A Difference of Opinions

The Summer of Bone Grafts is finally over. Or close to being over. At least I think it is. I might visit one more doctor, and I’ve got one more test to undergo. Anyway, I’ll treat this blog post like Lebron’s “Decision.” I’ll tantalize you with some background and details, string you along for a bit, and then announce my decision at the very end. Of course, unlike Lebron’s shameless hour-long special, you can simply scroll down now to learn my future plans. You won’t hurt my feelings if you do. I promise I won’t stick a shiv in your back like Lebron did to Cleveland fans.

4 doctors, 4 different opinions. Actually, it’s 5 different opinions, though I didn’t have a fully informed visit with Berman back in April. Let’s recap. Back in April, the CT scan revealed that my tibia hadn’t fully healed. Turgeon’s immediate reaction: I need a bone graft, and the bone is borrowed from the iliac crest (ie, my hip). He believed the screws would remain in place, packing the bone graft and putty around them. The next day, I sought Berman’s opinion on Turgeon’s advice. Berman generally concurred with Turgeon’s approach. The only real difference was that he would replace the existing screws with 2 “flat-head” screws so, hopefully, the new screws wouldn’t protrude through my shin like my current ones do.

Over the next 2 months, I educated myself about bone grafts. I also spent a week in Maui, which was much more fun than reading medical journals. Anyway, I learned that 10-20% of patients who donate bone from their iliac crest experience some type of long-term complication. I also learned that a synthetic substance – BMPs – has a success rate almost as high as using your own bone. And, of course, using BMPs means I would avoid having surgery on my hip, too.
Armed with this information, I met again with Turgeon. This visit was as productive as an Israeli-Palestinian peace meeting. By the time I walked out the door, Turgeon had a lower approval rating than George W. Bush did when he left office.

First, I asked Turgeon to explain the exact surgical procedure he would perform. He would borrow some bone from part of my iliac crest (he told me the specific area, but I’ve since forgotten where), mix it with BMPs, then pack it in around the screws. He wasn’t sure how much of the nonunion area would need to be “cleared out.” The nonunion’s not like an empty sack; there’s some bone and fibrous tissue there. He would keep the screws intact. He feared that yanking them out would weaken the existing bone, similar to how removal of a nail might cause a 2x4 to splinter. Turgeon also said he planned to shave down the existing bone wedge inserted to elevate the patella. Despite several follow-up questions, I never fully understood why he would shave down the bone wedge.

I then asked Turgeon about BMPs. He reacted like somebody farted in an elevator. He simply dismissed the use of BMPs out of hand. No response. No discussion. Nada. Zilch. When I mentioned that several medical journals documented that 10-20% of iliac crest patients suffer long-term problems, he got extremely defensive. He scoffed at my information, questioning the legitimacy of the reports. Um, I wasn’t exactly relying on a 1974 study from Zimbabwe. Rather, most of the articles came from various national orthopedic journals, and one of the studies was co-authored by 2 local surgeons, including the dean of the nearby medical school.

My initial thoughts? He didn’t appreciate me – a non-doctor – questioning his surgical advice. At one point, he grew so frustrated that he made the absurd comment that, “Well, none of my iliac crest patients has ever developed any problems.” Really? None of them? Ever? At that moment, I decided I could no longer trust his opinions.

He did note that I wasn’t likely to shatter my tibia performing normal activities, something I was seriously concerned about. But he warned me that if I fired my quads suddenly – like, say, I sprinted to prevent my child from wandering into incoming traffic – I might yank the screws out.

The visit ended, and Turgeon simply told me to let him know what I chose to do.

Because I entrusted this man 18 months ago with a surgery that would – and did – change my life, you can imagine how frustrating and disappointing this experience left me.

I next met with Alan Jones. I read an article Dr. Jones co-authored that compared the use of BMPs to iliac crest bone grafts. Jones specializes in trauma surgery. Most of his patients are car accident victims rushed to the emergency room after their legs got crushed. While he was careful to note that a patient’s own bone is the best source for a bone graft, he believed that BMPs mixed with cadaver bone produce comparable results, with, of course, the added benefit of not needing to cut my hip. Plus, using BMPs also reduces the time spent in surgery, another bonus. Based on his review of the CT scan, Jones was concerned there might have been some slippage with the screws and cautioned that I needed to repair the nonunion. Jones also noted that he was surprised that Turgeon performed a Maquet for the osteotomy. He didn’t go into details, but he said Maquets were rarely done these days. This was news to me. I was not aware he did a Maquet; Turgeon said he was going to perform a Fulkerson.

Next up was Bob Scheinburg at Texas Orthapedic Associates. My sister-n-law works with Dr. Scheinburg (along with the last surgeon I visited, Mike Champine), and spoke highly of him. Scheinburg specializes in microfractures. Bob was pretty laid back. No matter what I decided to do, Bob told me I likely would have long-term issues with my knee. Not surprisingly, as a microfracture guy, he was critical of ACI. He didn’t think the new cartilage formed was any better than that created after a microfracture. That I expected. What I didn’t expect was his criticism of the Maquet. He took great pains not to criticize a fellow surgeon, and I really didn’t want to play Monday Morning QB, so I simply noted that I couldn’t change what was done.

Scheinburg took his own x-rays. He doesn’t think I need to undergo the bone graft. He noted that enough bone and tissue had filled in to keep the tibia intact. He also pointed out that it’s been 18 months since the surgery, and my leg hasn’t suffered any setbacks. His bottom line advice – do nothing. He cautioned that undergoing a bone graft would basically “start the process all over,” and there were no guarantees my quality of life would improve. After all, the bone graft had nothing to do with my knee. He also thought the screws could be removed, and wondered if removing them might improve things.

Finally, I met with Champine, who works in the same practice as Scheinburg. Like his partner, Champine was critical of the Maquet. After prodding my leg, he noted that I was tender around the screws, but not where the nonunion existed. Champine recommended a more cautious approach. First, he didn’t believe I needed a bone graft, again noting to undergo one would re-start the healing and rehab process. He cautioned that I didn’t want to “constantly chase surgeries, undergoing one to fix a new problem, which might lead to further problems and more surgeries.” He also wondered if the screws could be removed. He suggested that perhaps I could have a cortisone shot (or some similar numbing injection) near the screw to see if that eliminated any pain/sensitivity in the leg. If so, then perhaps that would rule out the need to fix the nonunion area. He also suggested I undergo a particular bone scan to determine the amount of bone versus tissue surrounding the screws. If the screws were embedded in enough dense bone, he believed the screws could be removed. He also assured me that I couldn’t damage my leg doing normal activities.

So that brings us to the moment of truth. What will Jim do?

First, I’m getting a bone scan shortly. Unless something unexpected shows up on the bone scan, I’m not going to have a bone graft. I plan on seeing how the leg feels over the next few months. I might try a cortisone shot near the screws. If the cortisone shot suggests the sensitivity relates to the screws and not the union, and if the bone scan reveals enough bone has filled in, I’ll strongly consider having the screws removed.

Keep your fingers crossed. Lebron took his talents to South Beach, and screwed the Cavs in the process. My talents remain here in Dallas, but maybe I’ll remove my screws.

Bone Graft Intermission -- the World Cup

I probably won’t have any updates on my bone graft for a few more weeks. I’m in the middle of meeting with 3 separate surgeons to discuss the pros/cons of using BMPs vs. borrowing bone from my hip. I already met with one, and he confirmed what my research suggested -- BMPs have a similar success rate as using bone from the iliac crest, with, of course, the added benefit of not needing to cut my hip. My new motto: why cut twice when once will do. The doctor also didn’t think there are any obstacles to using BMP on me. I’ll see what the next 2 surgeons have to say. I hope to make a final decision and schedule the surgery by the end of July.

Meanwhile, let me entertain you with my thoughts on soccer and the World Cup.

I love soccer. Growing up, I played competitive soccer. I’m also a big fan. I attended one of Pele’s matches for the Cosmos. I celebrated with the crazy Brazilians and Dutch after their classic ’94 World Cup quarterfinal match. I’ve been to the 200,000-person Maracana Stadium in Rio de Janeiro to catch a club match between heated rivals, Flamengo and Botafogo. And just like the circle of life, I coach my kids’ teams, just like my dad did for me.

Basically, I feel qualified – and comfortable – to say this: Soccer is NOT about to take off in the US.

People who insist otherwise are almost as annoying as those f*cking vuvuzelas. By the way, they’re horns, people! Calling them vuvuzelas doesn’t make them any cooler.

Anyway, I say this even after watching the US’s thrilling win over Algeria to advance to the knockout round. In my opinion, that game was just as exciting as Game 7 of the NBA Finals. After Donovan scored, I screamed so loudly that my dog sprinted around the living room looking for somebody to bite. But even this victory, and perhaps even if Team USA keeps advancing, won’t convert Americans into regular soccer watchers. Just ain’t happening.

And that’s ok. Let’s just embrace soccer as a niche sport, somewhere behind football, hoops, baseball and even hockey. Actually, it’s probably even less popular here than Mixed Martial Arts (the UFC).

Some soccer-lovers question why folks feel the need to point out soccer’s “place” in the American sports hierarchy, which they liken to soccer bashing. Simple. Many people, including soccer fans like me, are sick and tired of all the “American soccer has reached a tipping point” chatter. Dude, let’s just enjoy the current matches. I don’t need some false soccer prophet telling us that Americans are “finally ready” to love “futbol” as much as the rest of the world does. Loosely translated, they’re saying, “Hey hoosier. If these games weren’t exciting enough to keep you interested in soccer after the Cup, you’re an un-cultured caveman.” Yeah, that’s a good way to get people to jump onto the soccer bandwagon long-term. Thanks for ruining the moment, buddy.

Americans simply don’t want to follow this sport on a regular basis; soccer just doesn’t match up with “American sports.” I’m not trying to denigrate the game or the talent of soccer players (though most of them ARE douchebags), just making an observation.

First, the American culture will never accept soccer or soccer players. We’re a macho society. Guys who kick a ball? Pansies. Plus, Americans hate floppers, soccer players who agonize on the ground, insist on a stretcher to cart them off, and then immediately sprint back onto the field. It’s no coincidence a European – Vlade Divac – brought flopping to the NBA. But not even Paul Pierce getting carried off the court in the 2008 Finals compares to the worst soccer flopper. And don’t even get me started with the whining. Imagine Tim Duncan’s bug eyes on steroids for 90 minutes. Anyway, there’s a reason why every American movie features the star QB getting the girl, not the midfielder.

But our ambivalence with soccer goes beyond cultural objections. Soccer’s usually slow-paced; there’s not enough scoring; and the athletes aren’t nearly as spectacular as guys like Kobe or LeBron. Plus, Americans can’t stand sports in which playing for a tie is accepted. I’d rather get season tickets to the WNBA than suffer through some of these 0-0 draws.

And yet every four years during the World Cup, we hear the US is ready to embrace soccer. FINALLY! REALLY! We’re not kidding this time!

Well, guess what? It hasn’t happened. It didn’t happen when Pele played for the Cosmos. It didn’t happen after the US made the 1990 Cup. It didn’t happen after the US hosted the ‘94 Cup and advanced to the 2nd round. It didn’t happen in 2002 when the Yanks made a surprising run to the quarters. It didn’t happen when David Beckham joined the MLS. And it won’t happen after this World Cup, no matter how far the US advances. Please. Stop saying it’s gonna happen. You’re embarrassing yourself. For the past 20 years I’ve heard folks insist America was ready to embrace soccer. The boy didn’t even cry wolf that long.

Here’s my solution. Instead of demanding that we follow and discuss soccer like it’s a major sport, let’s treat it like a special event. That works, right? Let’s treat soccer more like the Olympics. There are lots of similarities, besides the every 4-year thing. Two years ago, I was mesmerized by Usain Bolt, and religiously followed Michael Phelps gunning for 8 gold medals, like I’m sure a lot of folks were. But am I going to follow track & field or swimming on a weekly basis? F*ck no. In fact, I don’t even want to see Michael Phelps hawking Subway right now. America should impose a rule requiring all swimmers to retreat to their aquariums 2 weeks after the Olympics.

Yet Americans dig these sports during the Olympics. The ratings are fantastic, as I expect the World Cup’s will be. Why? Because we watch them only every 4 years, capitalizing on the novelty factor. Combine that with jingoistic pride, and bingo, you’ve got gold.

Same with soccer. Every four years works. It’s infrequent enough to retain the novelty factor, and not often enough that Americans get tired displaying their patriotism. And we get to root against France. Never underestimate the value of booing the Frogs. That never gets old.

Personally, I think soccer’s best chance soccer of catching on here in the US has nothing to do with the actual game but with the changing demographics of the country. Most Americans will never give a sh*t about soccer, unless their kids are involved. But the fastest growing population segment? Hispanics. They’re immigrating here, and once they’re here they multiply like rabbits. And these people really, really like soccer, about as much as Texans love their guns. Of course, this influx of soccer fans won’t necessarily make US soccer more popular. Mexican-Americans – even those born and raised in the US – still tend to favor Mexico over the US. Hey, it’s better than nothing.

Soccer’s next best hope – a longshot, really – is the emergence of an American Pele. Some man-child who decides he doesn’t want to be the next LeBron but the next Pele. If an American somehow became the unquestioned world’s best player – a guy with dribbling skills that make Brazilians look pedestrian –Americans probably would rally around soccer. I call that the Tiger Woods effect. One guy is such a phenom that average folks tune in just to see what the big deal is. However, I can’t imagine a 6’5”, 235lb inner city kid choosing soccer over hoops or football anytime soon.

In the meantime, let’s enjoy the World Cup, and hope the US can make an unlikely run. But when the Cup ends, let me resume my normal sports obsessions (football training camp! Whoo hoo!) without a slew of “soccer is here to stay” articles. Just like the Olympic torch gets extinguished when the Games close, so too will American’s passion for soccer. But don’t worry, soccer lovers. In four years, there will be even more Americans waiting for the next Cup, including me.

Bone Graft Deliberations

I’ve been radio silent for much longer than usual. Earlier this month, my wife and I spent some time in Maui without the kids. Good times. For a short time, at least, my knee/leg issues didn’t hover like a guillotine above my head. It was just blue skies, cocktails and sand between my toes. Now it’s back to the gallows, er, reality. Anyway, while I was bummed to read about some of your setbacks, it was still nice to hear from my “ACI friends.”

Ok, I’ve spent several weeks researching the bone graft options, probably more time than I spent researching the ACI. Yes, there are synthetic alternatives to the iliac crest, and I’m furiously educating myself about them. When my OS first told me I needed a bone graft from my hip, I asked about other options. He acknowledged others existed, but was adamant they didn’t compare. In fact, he seemed pretty dismissive of them. And it’s true – everything I’ve read since my visit described the iliac crest as the “gold standard.” My second opinion OS also said the hip was the best graft site, and I don’t recall him mentioning other bone graft options. Critically, both surgeons downplayed the negative side effects to my hip.

My research, however, suggests a far greater % of patients suffer drawbacks. Anywhere from 10-25% experiences some type of chronic hip pain or serious limitations. I’m not gonna lie. That scared the cr*p out of me. Now, most bone graft recipients are older and generally undergo the bone graft to fix their spine, or repair a leg mangled in some horrific car wreck. It’s fair to say these patients were likely in worst shape. On the other hand, the failure of my leg to heal the first time suggests I’ve got weak bones, meaning my hip’s probably brittle. In any event, I’m steadfastly opposed to borrowing bone from my hip unless absolutely necessary. I’m scared I could create a brand new set of problems if my hip gets cut.

I’ve learned there are 2 less-invasive options than borrowing bone from the iliac crest. The first involves BMP-7, a type of osteogenic putty. Turgeon mentioned mixing this or similar material with the iliac crest bone graft, but nixed the idea of using it alone. BMP can also be mixed with cadaver bone.

The second option appears to be even less invasive. It involves a bone marrow injection from the iliac crest. I still don’t completely understand this procedure, but it appears the surgeon draws the bone marrow from your hip, and then injects it into the area of tibial nonunion. No cutting involved. Obviously, this would be the preferred route, though I have the sneaking suspicion this procedure remains somewhat experimental or won’t be covered by insurance.
I don’t know whether the TTO or ACI eliminates me as a candidate for either option. No clue. And I’m still trying to pin down the success rates for the different options. Some of the medical journals I’ve read suggest success rates for the BMP bone graft – whether alone or combined with cadaver bone – are 5-10 points lower than the iliac crest bone graft. I haven’t located comparable numbers for the bone marrow option.

Assuming these numbers are accurate, a 10-point decreased success rate seems like an acceptable trade-off to avoid getting my hip cut.

While I sort out the bone graft options, I’ve scheduled a PT visit with the guy the 2nd opinion OS uses. My quad remains weak, even after 16+ months. I’m not sure why. Even though the nonunion in my leg probably limits how hard I can push things, I think an updated PT session might be helpful. Plus, I’ll get a third set of eyes to check out my knee. Even as I stare down another surgery, I remain hopeful that my knee might approach something close to normal if I can eventually build up my quad after I fix the tibial nonunion. I’m probably clinging to hope at this point, but still . . .

Two days after my PT session, I meet again with Turgeon. I plan to question him about the non-iliac crest options. Assuming he disfavors the bone marrow injection and the synthetic bone graft and/or lacks experience with these procedures, I’ll seek out another OS. The problem is that I probably need to get my knee scoped, too, though the knee scope can wait. I prefer to schedule both operations at the same time to avoid multiple surgeries and recoveries. But I only feel comfortable getting my knee scoped by guys familiar with ACI, which pretty much is limited to Turgeon and Berman.

I also want to get a sense for what it would take for my bone and screws to shatter inside my leg. A kick? Getting sacked by LT? Just bumping into the corner of the kitchen table? If I learn my tibia is a ticking time bomb waiting to shatter inside my leg, I’ll need to make a decision asap.

Welcome to the Bone Graft!

This time the title sounds like something from a Guns ‘N Roses speed metal wannabe. Perhaps a ballad by Metallica? Unfortunately, it’s also the next surgery I’m scheduled to undergo.

A few weeks ago, I met with Dr. Turgeon and Dr. Berman on consecutive days. Both offered the same opinion: I need a bone graft. In fact, Berman had stated back in December that I needed a bone graft.

Here’s the deal. The space above my tibia created by the osteotomy didn’t fill in with bone as expected. The medical term is, “non-union of the bone.” Basically, the bone splintered off by the osteotomy now forms a wishbone with my tibia. The two Home Depot screws are the only thing keeping the bone from snapping off. If that space doesn’t get filled in, there’s a decent chance the tibia or screws might shatter or crack, leaving fragments of bone scattered throughout my leg. Quoting WebMd, that would be a really, really bad thing.

The solution is to borrow some bone from my iliac crest (part of the pelvis), mix it with some protein-rich putty, and pack it into the open space. Just like that.

Sounds straight-forward, yeah? It’s supposed to be. In theory, of course. So let’s hope the surgery works as it should.

Now the bad part.

For starters, I’ll spend the night in the hospital, unlike the ACI surgery. Deep breath. My hip will hurt like a mother-f*cker, just like Bo Jackson felt after a 260-pound monster piledrove his hip into the AstroTurf. Worse, the pain will be felt immediately, also unlike the ACI surgery. Back then, the femoral nerve block delayed the pain 1 ½ days. Not this time. I’ll wake up really sore, and, I’m sure, really pissed off. I’ll need to load up immediately on some good-old fashioned meds. That means the family drug store will be back open for business. Whoo hoo. Let’s hope I can stop at the vicodin. I really don’t watch to mess around with the serious stuff, like morphine. Selling it, sure. Consuming it, not so much. Just kidding. I don’t deal morphine. Only Hillbilly Heroin.

How long will this surgery put me on the DL? Turgeon and Berman gave slightly conflicting recovery timelines. I’ll be on crutches 2-6 weeks, and in a hinged brace (not the mongo immobilizer I wore after the ACI surgery) for 6-10 weeks. I should be full weight-bearing soon after the surgery. My workouts likely will be restricted for 3-6 months, at least until X-rays show the bone has healed. I’ll probably have to channel my inner Michael Phelps and use the pool to keep in shape. Not good times.

The surgery will be huge for 2 reasons. One, obviously, is the need to repair the TTO. Hopefully the bone graft will firm up the tibia, eliminating the ultra-sensitivity and my fear that a 4-year old soccer player might accidentally kick me in the shin and turn me into Joe Theisman.

Second, and more importantly, Turgeon is also going to scope my knee. That’s right. I’ll receive confirmation whether the ACI graft worked. That’s even scarier than the bone graft. While the scope is the more “minor” surgery, it’s actually more revealing. I’ll learn whether all the rehab, pain, and uncertainty was “worth it.”

Now, as much as I’d like to know whether the ACI surgery “worked,” I wouldn’t get scoped just to check out the graft site. However, I’ve got a fair amount of crepitus, particularly at full extension, suggesting overgrowth at the graft sites and possible scar tissue which need to get trimmed. Interestingly, Berman mentioned that scraping away the overgrowth might stimulate further growth of cartilage and hardening of the existing stuff. A nice side benefit to the unpleasant surgery.

On the other hand, it’s possible the crepitus indicates that the graft hasn’t filled in or the new hyaline cartilage hasn’t matured yet, which would not be a good thing. I’ve also occasionally experienced twinges of discomfort on the inside part of my knee, so I’ll learn whether my Holiday Inn-inspired diagnosis of a medial meniscus tear is correct. And these past few weeks I’ve suffered a few random pinpicks around my knee, which scares the bejesus outta me. Because of my osteotomy issues, it’s tough to pinpoint the exact location of these sensations. Sometimes they feel like they’re coming from the medial meniscus area; other times from the patella; and still others feel like they’re at the TTO site.

I don’t want to envision the possibility that my knee still has unresolved defects, but I need to mentally steel myself for that possibility. That would be a really crappy thing to hear after waking up from surgery. Unbelievably demoralizing.

Regardless of what the surgery reveals, I’m facing another lengthy recovery. I’ve learned that rehabbing is a lot like practicing sports. And sometimes the hardest part of sports training is working on your weaknesses. Nobody likes doing stuff they suck at, me included. This is especially true for kids. For example, the hardest thing for young soccer players to do is kick the ball with their non-dominant foot. The kids often resemble newborn giraffes struggling to walk after leaving the womb. Well, after the surgery, I’ll be forced to re-train all those obscure muscles in my leg that will have atrophied for the second time in the past 18 months. Let’s be honest here. I hated exercising my legs when I was healthy. I really hate lifting legs when all I can do are a bunch of functional leg lifts with no weight. I’m a guy. Guys have massive egos. We like to lift heavy weights. Me Jim. Strong! Guys pick up the biggest dumbbells we can find– even if lifting them causes a hernia – grunt loudly, and then drop the weights to make the loudest possible noise so folks, especially chicks, can see we just lifted something enormous. For some reason, we think this is impressive. It’s not, of course. But we’re dumb. We just can’t help it. And after checking out who witnessed our feats of strength, we flex a few times in the mirror. That’s right. Check out the guns, ladies.

But lifting your leg with no weight? Lame. Really lame.

I haven’t picked a surgery date yet. I still need to discuss a few things with Turgeon. Berman recommended replacing the existing screws with a new, flat-head screw that won’t protrude as much. I also want to learn more about what Turgeon would do if the cartilage hasn’t filled in or hasn’t matured. And I have a few more questions about the incision near my hip, like which side of my hip? Same side as my knee?

Anyway, this wasn’t what I was expecting when I decided to roll the dice on ACI surgery a little less than 2 years ago. I can only keep my hopes up that the knee will continue to improve over time, particularly if the bone graft fixes my osteotomy issues.

The Osteotomy Blues

That title sounds like something B.B. King might sing about after visiting the ER. Ah, if only that were true. Well, I now know the source of most of my knee issues during the rehab. Or I should say, the source has now been confirmed.

A CT scan revealed that the bone graft from the osteotomy is not attached to my tibia. In medical terms, there’s non-union of the graft and the bone. The only reason the graft hasn’t floated away is because the two Home Depot screws are holding it together. Of course, these are the same screws that really ache and that I desperately want removed from my leg. Not surprisingly, this poses a major dilemma, which I’ll address in a moment.

Anyway, this discovery/confirmation explains my struggles to bend at the correct focal point; that my knee generally feels fine, but mechanically it functions differently, something I struggled to explain to folks, including Dr. T and Dr. Berman. I almost feel like the osteotomy defect has cheated me out a “true” ACI rehab experience. Ok, not really.

At least I know what’s wrong. And like the ending to the old G.I. Joe cartoons, “knowing is half the battle.”

So what does this mean? What’s next? Right now, I’m not sure. Presumably, I’ve got 3 choices: (1) do nothing, which means leaving in those f*cking screws and having an unattached bone wedge; (2) undergo a bone graft to fill in the “area of non-union” between my tibia and the wedge; or (3) see if the screws and the entire bone graft can be removed. None of these options is very good. All of them have drawbacks.

First, doing nothing means learning to live with the uncomfortable screws and a really sensitive shin. Plus, I can’t imagine having an unattached bone wedge inside my leg is a good thing.

Next, a bone graft means another major surgery. And several more painful months of recovery. And another several months of putting my life on hold. Not to mention there’s no guarantee the bone graft will work.

As for the final option, I have no clue whether it’s possible to remove the unattached bone wedge (along with the screws). In my non-medical mind, if it’s not attached, why not “take it out?” That seems logical, right? Besides, I don’t need the osteotomy anymore. The ACI graft has sufficiently matured, eliminating the need to alleviate the pounding absorbed by the patella. True, the osteotomy would alleviate pressure long-term, thus minimizing the risk that I’d re-injure my injury-prone patella. But since I don’t expect to play competitive sports anymore, I think the odds of a future injury are minimal.

Sometime soon I’ll discuss these options with Dr. T. And then I’ll seek out another opinion to be safe. Stay tuned.

14 Months

Dallas has had an unseasonably long and cold winter. It actually snowed for 2 days in mid-February. I forgot how much snow sucks. Holy f*ck. It’s cold. Sh*t gets wet. Idiots drive too fast on icy roads.

On the other hand, kids have a blast when it snows. They get to pelt each other with snowballs. Mine built a wicked snow-woman.

But grown-ups can’t enjoy snow like kids. At least I can’t. See, I immediately succumb to my childish whims. Snowball fights rock. Who doesn’t enjoy throwing sh*t at other people? Good times. I start out lobbing a few snowballs at the kids. I playfully duck a few of their weak throws. But things spiral downhill quickly. While I’m goofing around with my 4-year old, my 8-yr old crushes the side of my head from 3 feet away. Oh, it’s on. My competitive instincts immediately kick in, and I transform from mild-mannered Bruce Banner into the Incredible Hulk. I need to win these snowball battles, even if I’m competing against people too short to ride Space Mountain. And I’m not content just cracking people. Nope. I want to inflict bodily harm. Before you know it, I start packing a bunch of baseball-sized WMDs into my snowballs. Acorns. Rocks. Anything to weigh down those puppies. This leads to a predictable chain reaction. Eventually I cripple one of my kids, my wife gets pissed off, and then I get no nookie for a few days. Not good times. Like I said, snow sucks.

Anyway, we finally had a decent day. Spring-like, even. Probably hovered around 60 degrees. I went biking. This was a completely different experience than my last outing. I rode around White Rock Lake and back home, about 16-18 miles total.

The knee felt good the entire time; it felt fine afterward, too. I even managed to push off my bum knee a number of times to “stand up” during my bike ride. There really aren’t any hills big enough that require riders to stand up, but, again, the competitive juices kicked in and I wanted to be able to stand up, so I kept practicing every 5-10 minutes. The first few times I tried to stand up, I was unable to complete the loop. It was a bit embarrassing. I stood up, did a half revolution, my right leg weakened, and then I got stuck at the top, forcing me to sit back down. I was playing Jack-in-the-Box on a mountain bike. It reminded me of my first efforts trying to ride the recumbent bike after my surgery, when I struggled to complete a full revolution. But halfway through my ride around White Rock I managed to “stand up” for 10-20 seconds at a time. Interestingly, I didn’t have to sit back down because the leg hurt, but because I was completely winded standing up for that short period of time.

I enjoyed my outing, but I don’t understand uber-cyclists. You know exactly the kind of people I’m talking about. The weekend warriors that wear yellow jerseys and spandex, ride in packs, and bark out instructions like they’re in the middle of some Tour de France team time trial. And you know what? Spandex is not a good look for most of these chubby riders. But I did ease into their world a few times during my ride.

Several times, I had the choice of whether to pass someone or draft behind them. Tough call. When you pass someone, you get to bark out, “on your left,” like one of those biking douchebags. And yeah, I felt like a dork, but, also, strangely superior; like sitting in first class on an airplane and watching people trudge back to coach. I paused briefly during the pass to savor the moment. I needed to make eye contact. I wanted them to acknowledge their master.

But sometimes I chose not to pass people. Instead I hovered a few feet behind them, drafting like a NASCAR driver. Drafting is a lot like stalking, actually. You just follow somebody, making them feel uncomfortable by remaining in their shadow. But when I wasn’t feeling creepy, I pretended I was at some Olympic Velodrome practicing my drafting skills. Of course, there’s really not a lot of wind resistance to avoid at my embarrassing speeds. But it did provide a pretty sweet view of some of the hotties on the trail. And those were the riders I didn’t mind stalking….

My next checkup is in 3 weeks. Not much has changed over the past month or so. I continue to increase my workouts. My gimpy knee still goes into convulsions during 1-legged squats, shuttle presses, and heel touches. The inside of my quad remains hollow. I struggle to perfect good “bending form.” But the knee continues to get a bit stronger. Baby steps.

I’m most anxious to learn how the tibia is healing. I want the screws removed, but I’m not sure how the leg will respond once their gone. Dr. Berman recommended undergoing a bone graft. That’s something I consider an absolute last resort. I have no desire to suffer through another major surgery and recovery. However, I need to learn the potential risks of having a “weakened tibia.” Does that mean the leg might break during normal activities? Would it complicate my knee recovery? Stay tuned.

Where Are They Now, Knee Edition

I've always loved the “Where are They Now?” articles. It’s like catching up with a long-lost friend from junior high on Facebook. You also discover the answers to really important questions, like Which Biggest Loser winner got chunky again? Does Joanie still love Chachi? And, hey, whatever happened to Cousin Oliver? I always assumed he wound working on really cheap Indie films, bragging to everybody on set about the time he saw Marsha naked. Or maybe he dabbled in some fetish amateur porn like the creepy director in 8MM. God help us if Sam the Butcher played Machine in one of Oliver’s snuff films. Anyway, that’s why I love these articles.

Obviously, the status of my knee doesn’t quite drum up the same level of interest as Cousin Oliver’s career. But that won’t stop me from sharing. It’s been 6 weeks since my last update, and over 13 months since my ACI surgery, so I think it’s time for a “How is the Knee Now?” blog entry.

Alright, let’s start with the big picture. I don’t have any functioning limitations. I get around just fine. I don’t have any daily pain. And unless you analyzed my walking form like the Zapruder Film, you probably couldn’t even tell that I had knee surgery.

But the knee’s not 100%. My ultimate fighting career remains on-hold. Interestingly, different things bother me now than before I went under the knife, which both worries me and gives me hope. Let me explain.

Before ACI, the knee occasionally ached below the knee cap and behind my knee, near the spot where the knee bends and your calf ends. Now? Those spots are pain-free, though I haven’t “tested” myself with athletic activities. Of course, my previous occasional twinges of pain happened during normal activities; I didn’t need to play sports to trigger the discomfort.

Instead, the medial – or inside – area where the knee bends kinda sometimes bothers me when I push off; going up stairs sometimes causes a slight tweak. Nothing major, but it’s enough to make me “think” before pushing off, which serves as a constant reminder that the knee still lacks strength and stability. Going down stairs is no problem. I previously thought I might’ve torn my meniscus, but Dr. T and Dr. Berman disagreed. However, something still doesn’t feel right.

What does this mean? Strangely, it could be good news, because the ACI areas feel fine. And it’s also possible that my knee might return close to normal if this un-related problem goes away. At least that’s my hope.

So what might be causing the slight irritation on this new spot? Possibly the lack of muscle strength.

Right now, my entire quad and the surrounding muscles are still pretty squishy. The teardrop shape that usually forms between the quad and kneecap? Let’s just say my quad isn’t crying. I mean, the knee no longer looks like it belongs to a starving African child. But it seriously needs to bulk up, like a scrawny high school athlete getting ready to play college ball.

This is especially true for the inside muscles that run from my knee to my quad. That part of my leg looks like a crescent moon. Plus, the area immediately above my kneecap resembles the chin of an elderly person. Thankfully I don’t have 14 different folds or wrinkles there, but there’s a bunch of saggy skin present.

I’m hoping that, as the muscles continue to develop and strengthen the overall knee, the twinges of pain around the inside of my knee disappear. That’s what I’ll focus on over the next couple of months; to see if the pain decreases as the muscle grows.

Ok, here are some more knee thoughts:

I still have crunching sounds in my knee. But it only sounds like popcorn when I squat or extend my knee quickly. No pain.

Whenever I almost “hyper-extend” my knee – basically straighten it out a tad bit beyond straight – the knee pops. It’s the exact same sound my knee makes when I first wake up in the morning, or when I stand up after sitting for a long period of time. Again, no pain.

My hamstring is pretty soft. I’ve started doing various dead lifts. Unfortunately, the major exercise to strengthen hamstrings – hamstring curls – seems to hurt my shin.

I struggle to isolate my right quad because, during 2-legged exercises, my left leg over-compensates. It just can’t help itself. My left leg has always been the dominant leg, even before the surgery. I continue to do 1-legged exercises, mainly the shuttle press and calf raises, along with a variety of step-ups. Lately, I’ve been doing step-downs and holding the bottom position (almost like a 1-legged wall sit) for 20-30 seconds. That seems to be helping. Of course, my leg trembles freakishly like it’s going into epileptic shock.

The knee feels better immediately after I exercise, i.e., when the muscle is tight/tense, which suggests to my un-trained medical mind that the lack of muscle strength is causing the twinges of pain near the medial meniscus. Again, that’s what I hope is causing the problem.

Sometimes when I walk my right leg is a bit “stiffer” than usual; my knee fails to bend the same amount as my good leg. Insert your own pirate peg leg or Heisman Trophy pose joke here. I wasn’t creative enough to come up with one.

I’m unable to “fire” my calf muscles, but that’s not from a lack of strength; more of a function issue. Calf raises just don’t feel normal. I think it’s because of the osteotomy; that raising onto my toes tugs on the shin bone, which irritates the bejesus out of the screws.

Let’s see, what else? The area surrounding the screws in my osteotomy remains sensitive. It doesn’t hurt if left alone, but god forbid I accidentally crack my shin against the couch or one of the 4-year old girls on my soccer team kick me instead of the ball.

The area on the lateral (outside) of my osteotomy bone wedge remains numb. Some of the nerve/nerve endings got severed or damaged during the surgery, which was expected. No real issues, though.

Because of the bone wedge, I still struggle to bend normally, like I can’t find my “bending focal point.” Hard to explain.

There have been other changes to my body. Before the surgery, I functioned just fine on 5-6 hours of sleep. I settled into a nice routine. I’d put the kids to bed around 8, spend an hour or so catching up on personal stuff, before plowing through the latest DVDs or stuff on DVR until 11-ish. Then I’d wake up sometime between 4.30-5.30am to exercise. And I felt great.

Now? I need at least 8-9 hours of sleep. No matter how hard I try, I cannot wake up early enough to exercise in the morning unless I hit the sack by 8pm. And since that’s never going to happen, morning workouts remain part of my dreams.

On the positive side, I continue to slowly regain what I call, “athletic mobility.” I finally can perform basic athletic movements, like dribbling a soccer ball or basketball. My difficulties now are with that third step explosion, the steps taken after performing the initial move. I can move easily enough to demonstrate the actual move, but can’t continue the move with any speed. For example, I can showcase a cross-over dribble to get past the initial defender, but lack the strength/speed to continue the drive all the way to the hoop. Call it the old man Iverson, only even slower.

I haven’t tried running, but I think I’ll be able to soon. As I continue to re-build my quad, I think I’ll be able conquer the slight hitch that rears its ugly head when my pace quickens beyond a leisurely stroll. I doubt I’ll ever challenge the Kenyans, but I would like to move faster than the elderly. Or at least be able to dodge traffic if a car decides to play Frogger while I’m crossing the street. But all of this is contingent on the twinges of pain disappearing as my quad grows stronger. Fingers crossed.

2010 -- New Year, New Way to Think

Full disclosure: this post is not about my knee, but about something bigger: our ability to think for ourselves.

As you welcome in the New Year with a fresh batch of recycled resolutions, I’d like to share the profound words of David Foster Wallace. Back in 2005, he spoke to the graduating class of Kenyon College. His speech was titled, “This is Water,” and it conveys Wallace’s struggles to define thinking and master empathy. His theme is captured in this little gem: “Think about it: There is no experience you’ve had that you were not at the absolute center of it.”

Wallace’s speech, I hope, causes you to re-consider how you view the world, or at least the small part of the world you inhabit. I hope it causes you to think before you speak; to seek information and form your own opinion, rather than follow the herd. Just like the mid-range jump shot, these attributes are a lost art.

In today’s partisan climate, people increasingly surround themselves with like-minded folks, especially the ones who are supposed to be “leaders.” Republicans only watch Fox; Democrats only watch MSNBC. Right-wingers listen to Rush Limbaugh; liberals follow Huffington Post. Issues are no longer debated. They’re not even spotted.

These days, you have to subscribe to multiple news sources just to get a (somewhat) complete picture. The media only reports stories with angles that reflect the viewpoints closest to their readers or reporters, failing to examine stories from all sides. It’s all about the angles. The source of your news says as much about you as your actual views. In fact, think about what your opinions would look like if you only listened to Bill O’Reilly or Keith Olbermann? While I realize they aren’t traditional newscasters, in today’s world most news is delivered this way. If your reaction to the mention of either of these guys is something like, “Man, that dude is so biased. Only a (liberal or conservative) would believe his cr*p.” Well, imagine how somebody with the polar opposite viewpoint reacted to that statement. Yup. They feel the exact same way about what you watch and read.

Here’s a challenge. Try watching one of those programs exclusively for 2 days, then switching to the other one. Just grit your teeth. Maybe half of the stories will be the same – the current health care vote, a bombing in the Middle East, etc. – except they’ll be covered from diametrically opposite angles. The other half of the program will address stories the other show doesn’t even mention. And yet people who watch just one of those shows are expected to get a complete picture of the issues? They’re supposed to debate things intelligently, let alone civilly? Um, yeah. Didn’t think so.

This dichotomy has trickled down to the local level, as our communities have become echo chambers, little cocoons of isolated thoughts and viewpoints. Neighborhood “for sale” signs should also include notices like, “Democrats only” or “Liberals need not apply.” Society has reached the point where “diversity” needs to be expanded beyond skin color or religion. Things don’t appear to be changing anytime soon. Remember last November when we were supposed to have moved beyond red states and blue states? Well, it looks like Obama’s ascendancy was a mirage, a temporary flash of hope. I can’t say I’m surprised, though I admit I had hoped things would change. But the venom spewed over the past decade wasn’t really about Bush, despite what was written for the past 8 years. George W. just happened to be an easy target, a caricature of ineptitude. The problem was how the rest of us debated stuff.

Fox holes used to be the last line of defense for the brave. Now? They’re refuges where folks willingly hunker down with sycophants. Who loses when people put on blinders and cannot have their views challenged? Everybody.

Which brings me to Wallace’s graduation speech. It’s not too late for society to become a bit more open-minded, a bit less hostile, and I think his words will help. For 2010, don’t just promise to lose weight or spend more time with your family, admirable goals. For the next 12 months, vow to step outside the box. To listen, before deciding. To contemplate, before reacting. To gather information, before offering a knee-jerk opinion. To try to see things from another perspective. You’ll be pleasantly surprised.

Happy New Year (and now I’ll step off my moral and philosophical soap box and return to knee updates.)

(Below are excerpts from Wallace’s speech; the full text can be found here. I highly recommend reading it) http://online.wsj.com/article/SB122178211966454607.html)

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Thinking this way tends to be so easy and automatic it doesn't have to be a choice. Thinking this way is my natural default-setting. It's the automatic, unconscious way that I experience the boring, frustrating, crowded parts of adult life when I'm operating on the automatic, unconscious belief that I am the center of the world and that my immediate needs and feelings are what should determine the world's priorities. The thing is that there are obviously different ways to think about these kinds of situations. In this traffic, all these vehicles stuck and idling in my way: It's not impossible that some of these people in SUV's have been in horrible auto accidents in the past and now find driving so traumatic that their therapist has all but ordered them to get a huge, heavy SUV so they can feel safe enough to drive; or that the Hummer that just cut me off is maybe being driven by a father whose little child is hurt or sick in the seat next to him, and he's trying to rush to the hospital, and he's in a way bigger, more legitimate hurry than I am -- it is actually I who am in his way. Or I can choose to force myself to consider the likelihood that everyone else in the supermarket's checkout line is just as bored and frustrated as I am, and that some of these people probably have much harder, more tedious or painful lives than I do, overall.

Again, please don't think that I'm giving you moral advice, or that I'm saying you're "supposed to" think this way, or that anyone expects you to just automatically do it, because it's hard, it takes will and mental effort, and if you're like me, some days you won't be able to do it, or you just flat-out won't want to. But most days, if you're aware enough to give yourself a choice, you can choose to look differently at this fat, dead-eyed, over-made-lady who just screamed at her little child in the checkout line -- maybe she's not usually like this; maybe she's been up three straight nights holding the hand of her husband who's dying of bone cancer, or maybe this very lady is the low-wage clerk at the Motor Vehicles Dept. who just yesterday helped your spouse resolve a nightmarish red-tape problem through some small act of bureaucratic kindness. Of course, none of this is likely, but it's also not impossible -- it just depends on what you want to consider. If you're automatically sure that you know what reality is and who and what is really important -- if you want to operate on your default-setting -- then you, like me, will not consider possibilities that aren't pointless and annoying. But if you've really learned how to think, how to pay attention, then you will know you have other options. It will actually be within your power to experience a crowded, loud, slow, consumer-hell-type situation as not only meaningful but sacred, on fire with the same force that lit the stars -- compassion, love, the sub-surface unity of all things. Not that that mystical stuff's necessarily true: The only thing that's capital-T True is that you get to decide how you're going to try to see it. You get to consciously decide what has meaning and what doesn't. You get to decide what to worship...

***

And I submit that this is what the real, no-bull- value of your liberal-arts education is supposed to be about: How to keep from going through your comfortable, prosperous, respectable adult life dead, unconscious, a slave to your head and to your natural default-setting of being uniquely, completely, imperially alone, day in and day out.

***

And the world will not discourage you from operating on your default-settings, because the world of men and money and power hums along quite nicely on the fuel of fear and contempt and frustration and craving and the worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom to be lords of our own tiny skull-sized kingdoms, alone at the center of all creation. This kind of freedom has much to recommend it. But of course there are all different kinds of freedom, and the kind that is most precious you will not hear much talked about in the great outside world of winning and achieving and displaying. The really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able truly to care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day. That is real freedom. The alternative is unconsciousness, the default-setting, the "rat race" -- the constant gnawing sense of having had and lost some infinite thing.