2+ Year Knee Update

2 years, 3 months is a long time. Think about it. Ellin had yet to smash Tiger’s Escalade with a 9-iron. LeBron hadn’t taken his talents to South Beach. Obama thought he could “change” the country. And Snookie was a term of endearment, not a pudgy reality star.

I also had 2 holes in my kneecap and a perfectly healthy leg.

Obviously, a lot has changed since then.

So let’s begin with the obvious starting point. If I could do it all over again, would I still choose ACI? I honestly don’t know. Before going under the knife, my knee didn’t hurt THAT badly. I could sense it was about to take a turn for the worst, but it wasn’t there yet. Today, my knee doesn’t hurt at all, which is a good thing, obviously. On the flip side, the lack of pain pre-surgery also meant that I never experienced the unbridled joy of having a pain-free knee, post-surgery. So when I say my knee doesn’t hurt today, I say it with a shoulder shrug, not the fist pump of a guy who just birdied 18 to win the Masters.

Unfortunately, the surgery also produced some unexpected drawbacks, completely unrelated to my knee. I went in with one problem, and woke up with a brand-new one.
The osteotomy didn’t fully heal. My tibia remains “somewhat fractured.” (By the way, somewhat fractured is an actual medical term). While the bone didn’t fuse entirely, however, enough bits and pieces did to hold the leg together. Dr. Champine described my leg as a “poor welding job.”

Now, the screws were inserted to keep the leg intact, and the surgeon had warned me the area surrounding the screws would be sensitive. At the same time, I was assured they could be removed once the tibia fully healed, meaning I spent that first year or so biding my time until the leg healed enough to remove them.

Well, I can stop waiting; the leg never healed. So the million dollar question today for me is: Has the leg healed enough for the screws to be removed?

Champine says, “probably.” He believes – and his partner, Dr. Scheinberg, concurs – that since the leg has held up for 2+ years, it’s “probably” not going to fall apart now. Of course, patients really don’t like when doctors use the word, “probably.” I like to measure risk. Can I catch VD from that Vietnamese “masseuse”? Probably, so I’m not going to ask for the happy ending. Easy decision. So even though my current choice also involves screws, this one is a bit more complicated.

Ok, quick intermission from my knee situation:

Over Spring Break, we road-tripped to Chicago to see family. My parents still live in the same house in which I grew up. After spending the week at my childhood home, I’m not sure what seemed weirder: sleeping in my old bedroom with my wife, or the lack of Michael Jordan or Paulina Porizkova posters on the wall.

By the way, did you know Illinois leads country in vanity license plates? Even minivans have them. I actually saw a guy driving a minivan with “Peters 64” plates. Advertising that you own a minivan? I thought you were supposed to be ashamed of them.

Ok, back to my knee update:

Thus far, I’ve chosen the conservative approach and opted against undergoing the surgery to remove the screws. Maintaining the status quo. By all accounts, this surgery is minor. A few days on crutches. Not a big deal in the grand scheme of knee surgeries, so I don’t fear the recovery. But I don’t want to risk the consequences if it turns out that the screws really were holding my leg together. If so, I would need some sort of bone graft to shore up my shin. And THAT’S a big f*cking deal.

To give you an idea of what’s potentially at stake here, I have no “daily living” issues. I can walk just fine. No issues with stairs. I can bike and use the elliptical machines at the gym. I avoid impact exercises – running, squatting, jumping or explosive plyometrics – but otherwise no functional restrictions. I’m plenty capable of jogging around the soccer field with the kids, even cutting without too much difficulty during scrimmages with 9-year olds. In fairness, I’m a slow, 38-year old dad playing with third graders, and these kids aren’t Brazilian. I actually weigh a bit less than I did pre-surgery, and think I might even regain my 2-pack abs by summer if I keep up my current exercise routine. Overall, I’m pretty content.

On the other hand, the screws in my shin remain sensitive. I mean, really sensitive. A little tap on my shin will drop me to my knees quicker than a hooker looking for a quick $20. Um, not that I have any idea what the going rate is for those types of things….
Until lately, the screws weren’t too big of a deal; I could tolerate them. During recent workouts, however, some of the basic leg strengthening exercises – short arc leg extensions; shuttle leg presses; even hamstring curls – have started to stress the outside of my shin. And guess what? The mere sensation that metal screws might rip through your leg like Mr. Kool Aid bursting through that brick wall is not a good feeling.

Ok, time for the Second Intermission:

Just like a strong jawline or piercing blue eyes define somebody’s face, the random shops dotting the sides of the highways provide a glimpse of state’s personality. On my Spring Break road trip, I discovered that Missouri leads the country in adult video stores and firework stands, which says a lot about the Show Me state. In fact, sometimes there were 2 adult video stores next to each other at the same rest stop -- the porn version of McDonald's and Burger King. That made me wonder -- do truck drivers comparison shop at adult video stores? Do they broadcast over their CBs, “Breaker Breaker. This is Little Bear. The Bobby’s XXX in Joplin has a wider foot fetish selection than Soft Skins.” One of the adult video stores also advertised an adjacent "men's only spa," and even used a picture of a geisha. Why not just throw up a billboard that says, "Happy Endings Available"? And, oh yeah, the local Mizzou gas station is called, Kum and Go. I'm not kidding. And you can find them next to the adult video stores.

Ok, back to the blog:

While the screws have nothing to do with my knee, I can’t truly test my knee for fear of aggravating the screws. Perhaps if the osteotomy had healed, I would have a better appreciation for how well the ACI grafts worked. But the screws prevent me from playing, for example, competitive volleyball or taking jiu-jitsu lessons, which I envisioned as the true measuring stick of a successful surgery. And that’s disappointing. Grumble, grumble.

Here are some other observations:
• My quad remains a bit weak, and I really don’t ever see it gaining full strength. Not only do the screws limit certain exercises, but the osteotomy permanently altered my mechanics, making it difficult to isolate my quad and build up the “teardrop” muscle. You can only do so many straight leg raises.

• I still have a decent amount of crepitus, but no pain associated with any of the crunching. I planned on getting my knee scoped to clean up the crunching at the same time the screws were removed, but obviously that never happened.

• Every so often I experience a twinge of weakness on the inside of my knee. It’s more like a pinch, something that creates the sensation that my knee might give out. But the knee doesn’t. I’m not sure if there’s something slightly defective with my knee, or whether that’s caused by my lack of inner/outer thigh and hip strength.

So here’s where I am 2 years, 3 months after ACI. Part of me wants to tough it out by keeping the screws. I try to convince myself removing the screws just isn’t worth risking a bone graft and the attendant lengthy recovery. But man, my screws can be aggravated as easily as a sleep deprived new parent, and I wonder how much “quality of life” can be gained if they were taken out. I still haven’t made a decision, and probably won’t until my kids’ soccer seasons end next month.

Until then, I’d love to hear from others about their knee experiences, along with updates from other ACI patients who follow my blog. In addition, I welcome any ideas or suggestions on blog topics from my “readers.”

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.

Two OS Visits

Before I describe my recent OS visits – yes, plural; seeing two surgeons reminds me of that “famous” JCVD quote and movie trailer line: “There are two of them. Double the Van Dammage” – I wanted to share my bike riding adventures. A few weeks ago, I bought a friend’s old mountain bike. Other than a few bike outings on vacation, I haven’t ridden one since my sophomore year in high school; i.e., when I got my driver’s license and no longer needed a bike for transportation.

First, it really blows biking outdoors in the cold. And by cold, I mean anything under 50 degrees. The wind whipped my face worse than Vic Morrow cracked Kunta Kinte (not sure why that analogy popped into my head; it just did.) Pedaling faster to get home quicker just makes things worse. Yeah, I realize I’m a moron. But at the time, that logic made sense. Also, I’m a sh*tty bike rider. Just brutal. I need bumpers on the side of the trail, like those bowling lanes for little kids.

Bikes have changed dramatically from the ones I rode as a kid. My first bike was a New York Giants dirt bike bought at Sears (my dad got a steep work discount). With a massive banana seat and tires fatter than contestants from the Biggest Loser, that thing outweighed a tank. I remember getting trapped underneath the bike after a wreck, unable to lift that beast off me. Too bad they didn't make the LifeCall for that thing. You know, I've fallen and I can't get up? Anyway, I’m pretty sure the Army now uses its frame for body armor in Iraq.

Remember being fearless on your bike as a kid? It was like the Dukes of Hazard on two wheels. We would rocket over creeks off homemade ramps and launch ourselves down outdoor stairways. Now? I avoided even the 2cm crack in the middle of the paved trail. That twig smaller than my 4-year old’s foot? Too big to ride over. Yes, age and injuries have transformed me into a mega-p*ssy. It’s gotten so bad that just watching the X-Games freaks me out.

Ok. I met with 2 surgeons last week. I had my regularly scheduled check-up with Turgeon on Friday, and then I met with a new OS just to get a fresh set of eyes to check out my knee. For the most part, their evaluations were similar. Here’s what each had to say.

When I met with Turgeon, my big concern – other than the usual, how is the knee healing – was the twinge of pain on the inside part of my knee. As I blogged about earlier, my google-educated diagnosis suggested a possible medial meniscus tear.

Turgeon doesn’t think my meniscus is torn. He didn’t rule it out, but after performing a variety of bends and twists he doesn’t think there’s anything seriously wrong. He also thought the knee looked pretty good, and suggested it was time to step up my activities. He told me to start pushing the envelope and scale back if my knee starts to hurt. In fact, he told me – gulp – that it was ok to start jogging, though I need to use baby-steps. For instance, he told me to slowly increase my treadmill walking until the pace reached a point where I had to start a slow jog. He suggested I maintain the jogging pace for short periods – 10, 20, 30 seconds – before reverting back to my walking speed.

Turgeon, however, is a bit concerned with how the osteotomy is healing. The x-rays reveal the bone hasn’t filled in yet. He wants to keep the screws in my shin until July. Normally, he removes the hardware between 12-18 months. In my case, if the bone had looked ok, he would remove the screws now because they’re protruding. But he wants to keep them in for a bit longer.

But the main takeaway is that the knee looks and feels solid. The crepitus is normal. I’ve got full range of motion and full extension. No pain in the ACI-repaired areas. I need to build up my quad strength, however, which should come with time and after some more intense rehab. That will be the challenge with pushing things – how far can I go without aggravating the knee?

He told me that as I push the knee, I’ll also learn whether the meniscus is torn. He cautioned that the MRI – last taken 2 months before I started feeling the pain – is an imperfect tool to detect meniscus tears. If the pain persists, he mentioned undergoing an MR arthrogram. Basically, the doctor sticks a needle into my knee and injects some type of dye. The fluid then seeps into the knee joint and shows any “contrasts,” or possible tears, etc. The pictures might also reveal any deformities with the ACI graft. This procedure is not without risks, however. A number of lawsuits allege that one of the substances in the dye – gadolinium – causes a number of harmful side effects. Plus, sticking a needle into your knee joint can’t be enjoyable. Unless you’re Bubbles, I guess.

Turgeon didn't suggest I get MR arthrogram. He knows I’m an information junkie, and wanted to share this possibility now so I can educate myself in advance. Of course, I hope the pain goes away, making the possibility of further testing a moot point.

Turgeon also told me that he’ll probably check out the graft site when he removes the screws. He could clean up any overgrowth or remove extra scar tissue, though, at this point, he doesn’t think that’ll be necessary. He used a bioglide sealant – not periosteum – to cover the graft, which has a better track record; less than 5% of patients with bioglide sealants experience overgrowth.

The following Tuesday I met with Dr. Joseph Berman in Arlington, Texas, about 30 minutes away from my house. Berman, I think, does the most ACIs in DFW, and works out of a specialized facility; it was even larger than Turgeon’s old offices at the Texas Sports Medicine Group. I brought all of Turgeon’s visitation notes and the two surgical reports, as well as both MRI pictures and the technician reports. I felt like a fledgling author delivering a rough draft of his novel to a publisher. Berman took his own x-rays while I was there.

I was very impressed with Berman and his staff. I sensed he felt a tad uncomfortable serving as a second opinion, not wanting to play Monday Morning QB-surgeon and question Turgeon’s actions. However, I think he realized that I was a pretty-educated patient and had a number of specific questions for him to answer, which made his job a bit easier.

Like Turgeon, Berman did not think I tore my meniscus. So much for my google MD. Also like Turgeon, he thinks my recovery is going well. He suggested that the pain on the inside part of my knee, along with the quivering sensation my knee experiences when doing single-leg squats, might be from my lack of core strength. My right quad is still noticeably smaller and weaker than my good leg. Berman thinks that with continued rehab my knee will strengthen and some of these issues will disappear. Berman does not suggest I start jogging yet. He told me he counsels ACI patients to wait 14-16 months before attempting impact activities. But he says biking, even mountain biking, is fine.

Like Turgeon, Berman is concerned with my osteotomy, though he offers a dramatically different solution. He would remove the screws now and do a bone graft to fill in the tibia. If the bone hasn’t filled in by now, he says, it probably won’t. A bone graft is a pretty serious – and painful – procedure, and the recovery lasts 3+ months.

We also spoke, somewhat at length, about the ACI process in general. He told me that the Israeli surgeon who pioneered MACI is a friend of his. I informed Berman of the CBS Today feature piece on Dara Torres’s ACI knee surgery (in my earlier post, “Celebrity Knee Surgery,” I noted that the press release announcing her surgery was vaguely worded; it didn’t specify which procedure Dara was having. I speculated it was ACI, and it turns out that's what she had.) If I was Berman, I would find a way to turn Dara’s very public ACI surgery into a marketing effort, assuming that’s ethical. It’s like rainmaking for doctors. Anyway, here’s a link to the CBS story on Torres:

http://www.cbsnews.com/stories/2009/12/14/earlyshow/health/main5977298.shtml

I also told Berman about my blog, and gave him the link. Not sure if he’ll check it out, or if he’ll enjoy my sense of humor. I also spoke with one of his nurses about my blog and my recovery experiences. I had mentioned I had swapped messages with one of Berman’s recent ACI patients (and blog follower), Char. Hopefully the info I passed along helps.

So, where do things stand now? Interestingly, the pain on the inside part of my knee has disappeared over the past few weeks. The leg actually feels ok right now, though I still think something’s amiss with my meniscus. I’ll probably try speed walking, and might even progress to a point where I jog a few steps. But I plan on waiting at least another month or so before I begin jogging. I also plan on regularly doing weighted leg raises again -- something I stopped doing -- especially the ones lying sideways to build up my abductor and adductor muscles. I think that might be the best and least painful way to build up my inner quad strength. And I wonder if the increased strength might eliminate the meniscus pain.

I next meet with Turgeon around Spring Break, unless the pain in my inner knee re-appears. We take x-rays every visit, and, if the bone does not appear to be healing, I’ll ask Turgeon’s opinion on how to address the problem. I want to avoid a bone graft, if possible. I really don’t want to endure another crippling surgery, especially now that I’m somewhat normal again.

In the meantime, happy holidays.

12-Week Update

Almost 3 months have passed. Lots of ups and downs. Lots of changes. Reminds me of that Beatles’ song, A Long and Winding Road. Anyway, it appears I’ve reached that point in my recovery where progress happens glacially. Instead of celebrating accomplishments like driving a car or ditching my crutches, I have to be content with 2 degree increases in my flexion. That’s like winning the World Series one week, and then trying to get excited about playing in the old man softball league.

The other downside, of course, is that material for my blog is diminishing. It’s tough to fill an entire post about graduating to 4-inch step-ups from 2-inch ones. But I’ll keep trying. I’ll probably transition to brief, bullet-point updates like this one. As always, I’m playing these developments by ear.

• The knee generally feels ok. People keep asking me if it “hurts.” Not really, though the knee gets tired and achy if I don’t rest or ice it regularly. The osteotomy, however, bothers me. The two screws in the tibia are visible when I wear shorts. Seriously, you can see slight bulges, like speed-bumps, on my shin. I don’t expect people to stare at my legs, but they kinda stand out like a third eye. The lateral side (ie, the outside part of my knee, not to be confused with the medial, or inside, part of my knee) sometimes feels like it’s stretched so tight that it’s gonna pop through the skin. I hope that doesn’t happen. It would be really weird if metal screws burst from my leg in the middle of the grocery store aisle. Clean-up in aisle four might be a bit embarrassing.

• 1-legged step-ups and 1-legged mini-squats (no deeper than 45 degrees) are killing me. It’s as much mental as physical. I’m convinced my knee will shatter if I bend any further. But I also have to remember not to push it. The knee is still healing.

• You know how your body twitches slightly during a morning yawn? Well, my gimpy leg convulses like it went into epileptic shock. Very freaky, and not in a good, freaky way like an insane stripper.

• My flexion continues to increase slowly. It reached 125 degrees on Wednesday. I hit 121-122 degrees with no problem, but Judy crunched my leg another 3 degrees. One of these days I’m gonna start crying. Or punch Judy in the face really hard. Not sure which.