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.
Friday, July 23, 2010
Friday, June 25, 2010
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.
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.
Thursday, May 27, 2010
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.
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.
Thursday, April 22, 2010
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.
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.
Friday, April 2, 2010
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.
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.
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