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.

Random Knee Thoughts, 8-Month Edition

My kids are back at school, which is nice. I’m a huge fan of routines and schedules. Other than that, not a heckuva lot has changed over the past few weeks. Well, I am coaching my almost 4-year old daughter’s soccer team, the Rainbow Warriors. Within 3 minutes at practice, one of the girls either (a) has to go potty; (b) complains that’s she’s hot/tired; or (c) wants to know when she can play on the nearby playground. Coaching 3- and 4-year old girls is like herding cats. Rewarding, but sometimes it can be a major beating, too. Go Green Death. http://www.patriotledger.com/sports/x575725578/-Green-Death-coach-resigns

Back to my knee. Using the marathon analogy, I guess I’m at the 16-mile mark. I’ve made significant progress, but then I realize, “holy sh*t! I’ve still got 10 more miles to go. Not to mention that a pack of Kenyans just lapped me.” All kidding aside, the knee feels like it’s inching closer to normal. Baby steps, people. Baby steps.

Over the past few weeks, I’ve stepped up the intensity of my knee exercises. At this point in the rehab, it’s more of the same. Basically, I just increase the number of reps, weight and difficulty. For example, I now do 25 step-ups on a 2-foot high stool with 25 pound weights in each hand, a far cry from doings heel touches on top of a phonebook back when I started my rehab. The gimpy knee remains much weaker than my good one; my quad remains squishy. And pasty. No matter how hard I try to isolate my bad knee, the good knee instinctively compensates. On the step-ups, for instance, the help usually arrives in the form of a small “push” off the floor by the good leg before elevating atop the platform. Luckily, it’s almost impossible to cheat on certain leg exercises, such as the leg press and the nautilus, 1-legged squat machines.

The knee still makes little clicking and crunching noises when I walk. It pretty much has been since the surgery. But it doesn’t bother me. The back of my knee also “pops” frequently, especially whenever I wake up first thing in the morning, or after my leg extends from a hyper-extended position. Again, no pain, but these can’t be good things. The crepitus usually signals overgrowth of the cloned cartilage. While not ruling out overgrowth, my OS noted that the new porcelain sealants usually prevent overgrowth. We’ll see.

The area of my knee that may or may not have a torn meniscus kinda aches, but still hasn’t limited my activities or rehab. I’m hoping MRI, Part 2 will reveal the extent of the damage. In a perfect (surgical) world, my OS could fix the meniscus tear at the same time he removes my screws. I’m not sure whether that’s possible, or even advisable. Or even whether, if the meniscus is torn, that I should wait until Spring 2010 to get it fixed, which is presumably when the screws will be removed.

That’s about it. Pretty boring update, I know. But that’s what you get at 8 months. Meat and potatoes.

An Impromptu 32-Week Visit and Firsthand Exposure to the Health Care Reform Debate

Last month I had an MRI of my gimpy knee. As I blogged about earlier, the MRI technician/specialist/whatever-his-title-is, thought he was checking for a torn ACL, not an ACI repair. Hey, mistakes happen, right? Well, he still wrote up a report. When I met with my surgeon last month, however, the report was not available. Instead, my surgeon told me he asked the MRI guy to re-do the report, which, I thought, meant focusing strictly on the ACI repair. Bad assumption, it turns out; more on that in a moment. Meanwhile, we reviewed the actual MRI pictures together, and Dr. T shared the good news that everything looked great. I still wanted the report, though. Dr. T said he would send me the revised report when it was available. He knows that, as a lawyer, I like written reports.

A few days after my appointment, I had yet to receive the “revised” MRI report. It turns out the guy never re-did his report. Instead, he simply noted on a separate cover sheet his mistaken assumption about my ACL. That’s it. Considering how much MRIs cost, that MRI probably wasn’t a good use of health care dollars. Consistent with today’s debate over health care reform, they’re not “my dollars” so, frankly, I’m not too concerned. Sad, but true.

Anyway, I still wanted a copy of the report. Even though it focused on my ACL, it nonetheless examined other parts of my knee, so that information would be helpful and I was anxious to review it. I finally received it about one week after my appointment.

Incredibly, the report failed to mention the ACI-repaired lesions on my patella and trochlear groove. At first, I thought this was yet another example of the technician’s incompetence. I don’t think it’s a stretch to say that the guy who mistakenly checked for a torn ACL would also miss a cloned graft, right?

Apparently not. When I finally reviewed the report with my surgeon, Dr. T told me he actually spoke with the MRI guy, who told him he was surprised to learn I had undergone a cartilage implant. When he examined the MRI, he simply didn’t notice any difference in the consistency between the “old” cartilage and the “cloned” cartilage. Now, I’m hesitant to do the Tiger Woods double fist pump because of the guy’s earlier screw-up. But it’s hard not to be pretty stoked.

(Speaking of Tiger, why didn’t the CBS golf announcers state the obvious at the PGA Championship: Tiger choked on those last few holes. Period. Even Michael Jordan missed potentially game-winning shots. It happens. Yeah, it sucks when your off day just happens to be during the final round of a major in a year in which you hadn’t won one. But there’s no shame in that. Hey, even the best f*ck up. Ok, back to my knee)

The MRI report, however, did identify some areas of concern, which I discussed with Turgeon. Incredibly, it said I had a torn meniscus on the medial side of my posterior horn.

What the f*ck?!?!

For the past 7 months, I haven’t been preparing for my UFC debut or even playing pickup hoops. Nope. I’ve spent my time on the couch or hobbling around an office with a bunch of government drones. My craziest activity has been riding a stationary bike – not exactly the kind of situation that leads to torn meniscuses, you know.

Before I share my conversation with Dr. T about the MRI report, let me explain a few things about a meniscus tear before friends and family freak out. First, this “tear” has nothing to do with the areas of my knee repaired by ACI. Totally unrelated (well, except for the fact that multiple knee surgeries surely have made my knee more prone to injury). Next, in the world of knee surgeries, a meniscus tear is pretty minor. Usually, a simple scope cures it. I’ve actually felt a slight twinge of pain in this particular spot for a few months. Nothing serious, though. The discomfort rarely lasts more than a brief moment, and doesn’t impact my daily functioning. I mean, I don’t want to downplay a meniscus tear. But I’m not overly concerned, other than how I could’ve possibly torn it during my recovery. I’m still shocked.

Despite what the report says, Dr. T isn’t convinced my meniscus is torn. During our initial review of the MRI pictures, I recall he noted some splotches on the MRI of some minor concern. I’m not sure he was pointing to the meniscus. But during our follow-up, he showed me the affected area. There was some “grayness” there, which apparently might be indicative of a possible tear. However, it wasn’t large or deep enough, in Dr. T’s mind, to say definitively, “Yes, it’s torn.” He said the only way to tell would be if he scoped my knee.

Of course, my response was a subtle, “No f*cking way.”

I only want him – or anybody – cutting me open if surgery is absolutely necessary. And it’s not necessary to “scope me” just to see if it’s torn.

So, as of now, I’ll just continue rehabbing as usual. Actually, Dr. T wants me to step things up to improve my quad strength. He reiterated that everything looks fantastic with my knee; he’s ecstatic how things turned out. Now it’s time to put Lou Ferrigno to shame with my workouts.

We also took another X-ray of the osteotomy, something we do at every visit. My screws and the bone wedge continue to irritate me. The screws bulge from my shin like the belly on a 9-month pregnant lady. You can read the Black-and-Decker label through my skin.

Things have gotten better, but I still feel like the osteotomy is holding me back, even more than the actual surgery. After reviewing the X-ray, Dr. T isn’t surprised. While the bone has filled in just, he says it’s continuing to harden, and thus the bone remains sensitive. Normally, the hardware can be removed at the 12-month mark, but in my case he suggests waiting several additional months to give the tibia extra time to heal.

Next up is another MRI in October, at the 10-month mark. Dr. T mentioned this time they’ll do a bunch of other stuff to specifically focus on the cartilage. My first thought? Uh, why didn’t they do this type of review the last time? Is there a particular reason to do another MRI only 3 months later? Again, because I’m not paying (I don’t have a co-pay for MRIs), I’m not complaining. The extra information can only benefit me. But this just seems symbolic of the current debate over health care waste. Maybe the additional test is just covering for the previous screw-up. I’m not sure. But part of me – that speck of a conscience buried far deep inside and which rarely surfaces – feels a bit uncomfortable being a party to possible wasteful spending.

And then I remember how often insurance companies screw over patients, and those concerns begin to fade away.