Final Approach

It is now 37 days since the injury occurred and just 5 more days until surgery. I have to admit that deep down I am still very worried about the long term prognosis for my knee. And although I have the highest possible level of confidence in Dr. Stone, there is still a small part of me that is scared senseless of the surgery itself. Committed optimism is just not that easy to come by right now.

I’ve been through nine physical therapy appointments and I’ll have one final pre-op session tomorrow. My physical therapist has been exceedingly helpful and considerate, not at all the sadistic tyrannical stereotype I had heard about from others. That said, I’ve been told that pre-op PT is just a dry run. Post-op is where the real work is required. We'll see. When I started PT three weeks ago I was still in quite a lot of pain and I was well short of being able to pedal through an entire stroke on a stationary bike. By my third appointment, I had gained a bit of range so I set the seat as high as I could reach and after a few warm-up swings I slowly forced the pedal over the top of the stroke by rotating my hips in the opposite direction. Tears came pouring out of my eyes with the gush of pain and the release of the wide range of emotions I had been diligently covering up since Christmas night. It wasn't until that moment that I realized how much it would mean to me to be able to pedal a bike again, if even just barely.

At this point, the pain in my knee, although constant, is mostly quite tolerable except in the area of the MCL. The mild visible swelling has improved to the point where the right knee now looks nearly like the left knee, except that I have shaved bare the general vicinity of the right knee to enable the placement and painless removal of the electrodes during PT. My range of motion has gradually increased, at least in part a result of the reduction of swelling. I can now extend my leg to within 3 degrees of straight and I can bend it to within about 10 degrees of full flexion. Walking is getting better, although I’m still quite obviously limping and occasionally I get sharp shooting pains through different parts of my knee if I don’t step just right. I’ve been using the hinged brace but it doesn’t seem to really help – other than to protect me from an accidental hyper-extension. As the non-specific pain in my knee begins to subside, the pain from the sprained MCL is becoming more prominent and I am beginning to worry that the damage to the MCL may be much more severe than initially suspected. I am reasonably strong in extension (leg presses from about 45 degrees to straight), but flexion exercises cause a debilitating level of pain on the medial side of my knee. Again, probably the MCL. Advil, even in over the counter doses, provides a noticeable improvement in most of my symptoms but the surgery center has suggested that I avoid ibuprophen and the rest of the NSAID family for the week leading up to surgery to help reduce bleeding. I’ve already lost an inch from around my thigh and yet somehow I’ve gained five pounds. I suppose those two unwelcome trends are likely to continue in the short term.

I will try to post every day next week. I’ll be staying in the city at my brother-in-law’s where they have two ferrets that roam the house in search of weak and injured prey. I’m going to bring a long stick and take my chances. My surgery schedule, in case you’re following along, goes a little something like this:

Monday – Pre-Op, 11:15 am
Tuesday – Surgery, 7:15 am
Wednesday – Post-Op, 10 am
Thursday –PT, 11:30 am

After that I’ll come home and start PT sessions locally with follow-up visits to the Stone Clinic scattered throughout the calendar for the rest of the year.

I have never had any kind of surgery before and there is no way to describe how I feel right now. “Anxious” just doesn’t quite capture it. I’m trying desperately to focus on looking forward to the recovery process so that I don’t fall back and bury myself in the negative aspects of this injury and the many unpleasant 'what if’s' of next week. Dr. Stone’s assistant surgeon emailed me yesterday and gave me perhaps the best advice I’ve had yet. “Just think of it as a day off”, she said, “with a really good nap”. Geez, she makes it sound almost pleasant.

Surgeons

There is an important link between ACL surgical options and orthopedic surgeons, and it is this – while they may be competent with multiple techniques, each doctor has his or her own surgical preferences. These preferences can be determined by many factors including personal experience, initial and ongoing education, medical study results, associations with medical distributors, insurance company requirements and limitations, group practices, and the specifics of the patient and their injury. I believe that all doctors are inherently good people but it is worth noting that not all of the aforementioned factors are necessarily based on the best interest of the patient. The doctors I met with all said something like, “typically in a case like yours I use…” and then they went on to describe their recommended surgical specifics.

Choosing a surgeon is a very difficult and personal thing. I sent a request for ACL surgeon recommendations to the cycling email aliases at work and within two days I had a list of 27 names. Some were known for treating high profile pro-sports athletes. One had performed numerous surgical repairs to Barry Bonds and was now under investigation for potential ties to the steroid mess. Some were in private practice, some belonged to groups. I sorted and evaluated them based on duplicate recommendations and the quality of their websites. Not exactly ideal criteria. In the end, I identified a small number of comparible details, most requiring entirely subjective assessment, and from there I made a list of five doctors.

It took about three weeks to get out to see all five doctors. Based on their collective comments, it seemed that I had a pretty typical ACL case, although there was a higher degree of collateral damage than they normally see. They all performed essentially the same physical exam and all agreed with the MRI Findings Report, the complete summary of which is as follows:
1.) Complete tear of the ACL near the femoral attachment
2.) Grade II MCL sprain, Grade I/II LCL sprain
3.) Sprain of the short head bicep muscle and vastrus lateralis muscle
4.) Suspect tear of the lateral patellar retinaculum
5.) Joint effusion with superomedial patella plica

Each of the doctors I saw had their own specific method and approach. The breakdown was as follows:
Graft Source: Allograft (5)
Tissue Type: Tibialis tendon (4), Patellar tendon (1)
Attachment Method: Transverse suspension (3), Endobutton (1), Interference screw (for use with bone-patellar-bone graft) (1)
Hardware: Bioresorbable (5) [note: the endobutton itself is titanium]

All of the doctors wanted nearly full range of motion in the knee and little or no swelling prior to surgery. They all would perform the surgery as outpatient (no overnight) either in a local hospital or surgery center. Only two required x-rays, and only two recommended pre-op physical therapy (PT). My feelings on those last two items helped me narrow the field. If there were another six ways to image the knee, I’d want them all. And if PT helps get the knee prepared for the surgery and subsequent recovery, then why would you not do it?

The last doctor I saw was Kevin Stone in San Francisco. Initially I was drawn to him because he was performing repairs of the native ACL, but after talking with him about it I decided against that approach. His extensive involvement in orthopedic research and the dozens of patents he holds for surgical tools and methods are convincing indications of his overwhelming commitment and competency. Finally, I was so impressed by the level of professionalism and compassion that he and the entire staff displayed that I could hardly imagine going anywhere else. He was geographically inconvenient, but still well within reach. He was “out of network” as they say in the insurance game, but I could cover the additional cost.

And so surgery was scheduled. February 5th.

He would use the bone-patellar-bone allograft. A slight donor source variation on the “gold standard” of ACL reconstruction methods. This is not to say that newer soft tissue graft methods are less successful, in fact there are plenty of studies that show that they have equivalent results. The BPB method, however, is the most common and in many respects the most straight forward approach. It seemed to me that having doctor Stone perform this operation would be a bit like getting Michelangelo to draw me a happy face. But then, why not. At least I was confident it would be a good one.

Choices

I'm a bit of an obsessive research junkie so naturally I spent every waking moment for two weeks drowning myself in the details of every available source of ACL related information on the internet. My objective was certainly not to become an ACL expert, but rather to become aware enough to be able to ask good questions. The fact is, doctors are the single best source for the latest and most accurate information on ACL injury (if you don’t believe me, ask any doctor). But conversations with doctors are typically much more productive if the patient already has a basic foundational understanding of the problem and the available treatment options. There are hundreds of ACL related sites on the internet and many of them contain marginal or outdated information. The key to doing internet research on the ACL is to find and stick to a few, good sources. ACLSolutions.com and the Orthopedics Associates of Portland for example both have excellent comprehensive sites.

If you are for some reason more inclined to break your leg than your ACL, then essentially the only thing you will need to decide is which color cast goes best with your shoes. ACL injury treatment, on the other hand, is much more complicated and requires some decisions to be made. The first and most basic is whether or not to have surgery at all. A torn ACL alone is far from life threatening. Although physical activity sans ACL has to be limited, the knee can be strengthened to compensate to some degree for the retired ligament. Some studies have apparently shown accelerated degeneration in knees without a functioning ACL due to increased play in the joint, but clearly the effect would depend on activity level. For me, surgery was a relatively easy choice because I want to remain active in ways that do require the stability that the ACL provides.

The second decision is to repair the existing ACL or reconstruct with new tissue. At least for now, this is almost a non-option as repair is very rare, with a short track record, and it requires near perfect injury conditions. There are also only a handful of doctors performing ACL repair. I happened to find one of these doctors, and I spoke to him about it. Although I was a reasonably good candidate for possible repair, after considering the possibility for a day I decided that I really needed to go with the surest option.

Within reconstruction, there are various treatment details to consider and all have their own risks and benefits. The four key options are as follows:
Graft Source: Graft tissue is either “harvested” from another part of the patient’s body (autograft) or graciously donated by a dead person who no longer needs it (allograft). The main concern with allograft tissue is the risk of disease transmission, extremely rare and potentially fatal. Donors are carefully screened and grafts are cleaned to the best extent possible, but complete sterilization by any current method does too much damage to the tissue.
Tissue Type: This is somewhat dependant on graft source. The most common autografts are patellar tendon and hamstring tendon. Allografts can come from various tendons including patellar, achilles, and tibialis.
Attachment: This is somewhat dependant on tissue type, but generally, holes are drilled through the tibia and the femur and the graft tendon is attached at the tibia with an interference screw. At the femur end, the graft can be attached in various ways including an interference screw, routed over a horizontal press fit pin, or run through a rope with a button on the end.
Hardware: Titanium used to be the standard for screws and pins, but it seems that new bioresorbable plastic screws have become more popular.

There are other details to consider but in general, I found that even the most personable surgeons will begin to tire of any discussion with a patient that goes much beyond the four listed above. Placement of the femoral tunnel is critical to the function of the knee, but the conversations I initiated with doctors regarding this topic were not very productive.

I formed some opinions on these different options before I went out to visit as many surgeons as my insurance company would tolerate. Thoughts from that tour next…

Perspective

And so it was that I had somehow managed to survive for four decades including the typical reckless stupidity of male adolescence, ten seasons of youth soccer, years of skateboarding, road biking, mountain biking, skiing, snowboarding, countless drunken stunts and dares, and a half dozen car accidents, two of which were severe enough to require ambulance transport to the hospital. And through it all, I had a handful of sprains, cuts, and bruises, two broken bones and a couple of degenerative cervical discs to show for it – nothing more. Not once in forty years had I ever managed to bend either of my knees in any directions other than those in which they were intended to bend. How truly amazing that particular statistic now seemed, given, in hindsight, my inability to avoid the recent violation of my knee’s design limitations.

Now for the first time I had an injury with permanent consequences. The one constant among people I have talked to with a reconstructed ACL is that their knee was never the same again. Some talked about functional instability and some described lingering pain that comes with too much activity or changes in the weather. A couple ACL vets told me about follow-up surgeries that were required to “clean up” debris and degenerative damage caused by the body’s response to the original injury. One doctor I saw said that he tells all of his ACL patients that their days of neglecting their knees or taking them for granted are over. “You will have to think about your knee every day for the rest of your life. How to exercise it, how to protect it, which activities it can withstand.”

After the ACL diagnosis was confirmed, I was emotionally all over the map. I tried to maintain stability on the outside, but internally I was hopeful, worried, angry, disappointed, frustrated, and deeply depressed, and often all within the same hour. It was very much as though a part of me had died – the part of me that was the healthy, naturally functioning knee. I spent hours dwelling on the details of the incident, and the surgery, and on all of the potential limitations and changes this could have on my life. I confided in close friends and, although I appreciated their words, no amount of well intentioned “you’ll get through this” support was enough to help me regain my usual sense of optimism and confidence. For weeks after the diagnosis I awoke every morning to the feeling of a bomb going off in my gut with the renewed realization of the injury. If I woke up during the night, there was little chance of going back to sleep. Worst of all, I felt in some way that I had let down my kids. I have always believed in the importance of being physically active with kids. This has consistently been one of my favorite parts of being a parent, and one of the ways that my kids and I have always been able to connect. Certainly I would now be falling well short of that kind of engagement for the next year at least, and to some extent, maybe long term as well.

It was only as I got into the fourth week that I really began to find what I needed to deal with the injury. Perspective. “It could be worse”, although true, is not at all effective unless and until you really begin to realize that for a lot of people, it already is. I began to consider, and I mean really personally consider what it must be like for people who are wheelchair bound, or slowly going blind, or for the people who will go to their doctor today and be told that some part of their precious body is full of cancer. Sources of perspective are easy to find, the key is be affected by them. For me, in order to be affected by someone else’s situation due to injury, or disease, or poverty, or disaster, or war, I first had to personalize their condition. I found that in just five minutes of genuine focused thought I could begin to feel enough of what someone else might be experiencing to significantly alter my own perspective, even if I was still only able to be barely aware of the full reality of that person’s daily life. It has been uniquely empowering for me to be able to adjust my outlook and create an objective appreciation for my own situation and for the opportunities that I have to improve it. Of course none of this changes the reality of my injury, but it has definitely helped to prevent it from destroying my attitude.

Diagnosis

It was now the day after Christmas and I sat in the exam room of an orthopedic doctor - a hip, knee, and shoulder specialist. He looked to be about twenty-six, but maybe, I considered, he was just unusually diligent with the moisturizer. My knee had swelled moderately overnight but I could still stand on it without any problem. My range of motion in the ER the night before was almost 100% but now it was reduced to less than half – from about 20 degrees at extension to about 70 degrees at flexion, with extreme pain and pressure on either end of the range. I explained to the doctor what had happened and he helped me onto the table where he did some very controlled tugging and pulling. Then he said, “Well, your knee’s pretty loose, boss.” A short educational discourse on the knee followed, complete with generous helpings of medical acronyms and frequent bits of Latin to describe the likely scenarios of my condition and then, just before my mind wandered off for good he gave a firm yank on the mental leash with the words “probably recommend surgery.” I quickly ran back through his dissertation trying to locate the logical transition between “pretty loose” and “surgery”. Somehow he must have recognized the frantic search in my face because he said, “I know, it’s a lot to digest all at once.” I mumbled my agreement. He would of course need an MRI to be sure, but he said he was 80% certain that I had torn at least the ACL. He recommended rest, ice, and elevation, and then he said, “I know this doesn’t sound right, but try to move it once in a while.”

An MRI comes with two parts: 1.) Films, which I received immediately after the MRI was performed, and 2.) A report of findings, which was to be prepared within a few days. Despite having never seen MRI films before, I had done just enough internet research by that point to have a vague idea of the anatomy in question. The ACL can typically be seen from the cross section that shows the profile view near the center of the knee. In my case, where I expected to see the ACL, I saw nothing but a blur of pain and debris. Nothing else looked obvious, except for a lot of thin, jagged lines in the top of the tibia and bottom of the femur (bruising of the bones I was later told), and a line in the medial meniscus, which looked to me like a possible tear. Still, I held out hope for my ACL as I talked to other people who had been through the injury and I compared their symptoms to my own. I researched the surgical options for reconstruction and none of them were good. In order to get any sleep at all for those first few nights I clung with increasing dedication to the 20% uncertainty of the doctor and my own likely inability to accurately interpret the MRI. And then the following Tuesday I had a follow-up appointment and the nurse handed me the MRI report and left me alone in the exam room. My eyes skipped down to the report summary:

1.) Complete tear of the ACL near the femoral attachment.

I stopped reading but continued to stare at the paper. The words were short and simple and impossible to misinterpret. A week’s worth of devoted optimism and wishful thinking had apparently not been enough to change reality. And the reality was that my knee had been seriously and permanently damaged in a instant on Christmas day. To my surprise, dealing with the physical aspect of the injury, at least initially, would be only half of the battle.

Man Down

In case you have not already heard the story of the event that started all of this, or if you happen to be one of the increasing numbers of people for whom I have selfishly invented a narrative that involved snowboarding, skydiving, or running in front of a bus to save a crowd of children, following is a brief summary of the actual details as I remember them.

The Christmas festivities were essentially finished. Weeks of preparation had unwound just as planned over the course of an unusually beautiful December day and most of the twenty or so guests had visited, eaten, exchanged and opened gifts, and said their goodbyes. I retired the five cd’s of Christmas music that had been in repeated rotation for the entire day and dropped in some Earth Wind and Fire. It was around 9 pm and a few of us were in the family room, dancing around the tree when I jokingly requested of my wife that she not “get too grindy” with me given the present company. I should point out here that this off-handed comment had no real justification or cause, nor did it have any intentional impact on the developing plot, but none the less it unexpectedly became the catalyst for the next few critical frames of the evening.

In the following moment I began to turn to my left, thinking that everything was all well and good in Christmas dance party land but in response to the grindy comment, my wife had already launched an impossibly advanced and tragically ill-fated rodeo maneuver, deciding in a whim of festive holiday spirit to jump up and onto the front of me. The move would surely have been mildly amusing and would have fit right in with the feel of the carefree scene had it not been for the destruction that resulted. Before I realized what had happened the impact of her slightly off center, thigh-high arrival had deflected my right leg inward, rearward, and downward in a textbook combination of forces that instantly hyperextended my knee and drove my femur off the tibia and into the next zip code. She managed to break her fall to the floor using the back of her head and I somehow landed on top of her, my knee awkwardly snapping back into place as I instinctively curled my body toward a fetal position. She was definitely going to be left with a generous headache but I could tell by the searing surge of pain and by the speed with which the blood was rushing away from my face and hands that something inside my knee had gone very wrong.


I desperately pulled myself up on the couch and summoned for a bag of ice and a bottle of Advil. For the next few hours I did my best to cover the pain and think good thoughts as I winced and twitched and fought off recurring waves of nausea. When I finally got off the couch I was able to hobble very slowly and gingerly for about ten steps but when I got to the kitchen my knee bent backward with no sign of warning or resistance, sending me crashing onto the counter and into my first true realization that whatever was wrong was definitely not going to fix itself. With that I finally gave in and was driven to the local ER just before midnight. There we found out that the MRI machine has evenings off so they gave me a set of crutches and a straight leg brace and told me that I had better call an orthopedic specialist in the morning.

The next day I began my journey toward a painfully detailed understanding of the human knee, and what it really means to destroy one.

ACL Basics

In the event that you are blissfully unaware of your ACL's or their purpose in your life, well then, congratulations and count your blessings. Over the course of my life, I've watched just enough professional sports to learn everything I thought I would ever need to know about the ACL - it's inside the knee, it appears to hurt like hell when you break it, and doing so can be the end of an otherwise promising career. That's why I never played any pro sports. Too dangerous. The fact that I've never been quite big enough, strong enough, or athletic enough is entirely beside the point. Of course as I recently discovered, you don't actually need to play with the pros to do pro-level damage. Turns out, if you hit it just right, you can ruin your knee right in the comfort of your own home.

But before I get to that story, let's get everyone up to speed on the tissue at issue.

The ACL (Anterior Cruciate Ligament) is a critical ligament in the knee that runs from the back of the femur, through the middle of the knee to the front of the tibia. Under normal operating conditions, it helps prevent the knee from bending backwards and provides rotational stability. Partial tears are possible but most reported ACL injuries are complete tears. In that case, the knee is allowed to move in directions that it was not intended to move. Short term instability and long term degenerative damage are the result. Even a partial tear in the ACL has difficulty healing in part because the blood that clots at the sight of the tear (in an attempt to create a bridge of sorts on which new cells can grow) is repeatedly washed away by the fluid in the knee. A complete tear will never heal on its own. In some cases, a fully torn ACL can be repaired but this is very rare, and typically requires that the tear is right at the bone. There are only a few surgeons in the world even attempting full tear repairs. In the vast majority of cases the ACL is instead "reconstructed", that is, the damaged ACL is cut out and new tissue is attached to the knee. This is obviously a pure “gut and replace” operation, but somehow that doesn’t sound quite as nice as a "reconstruction".

Although ACL reconstruction is a relatively common, highly successful operation, it does not make the knee like new again. The replacement is not routed the same as the native ACL but instead installed in such a direction that it can approximate the stabilizing forces of the original. The replacement graft will never provide quite the same degree of stability as the pre-injury ACL and although a successful graft will eventually revascularize and regenerate, it will not contain or regrow the nerves which help the brain identify and control the movement of the knee. The purpose of reconstruction is solely to regain some of the mechanical stability in the knee necessary for certain activities and to limit the unstable movement that contributes to further damage and long term degeneration issues. Even after the most successful of ACL reconstructions, the knee is never quite the same.

In short, it's not a good idea to tear the ACL.

The ultimate goal of course is to rebuild and strengthen the surgically altered knee in ways that will help make up for the shortcomings of the reconstructed ACL. The rest of the entries to follow herein will describe my own ACL injury, the ensuing surgery, and my viciously held aspirations for recovery.