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.