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Monday
Jan142019

Blown - Life after my ACL rupture - 5

Back at it 9 months laterAlthough I’ve dismissed all superstition in my life as I’ve gotten older, there’s a curious tendency for health care workers to suffer complications following procedures performed ON them. I honestly doubt that the incidence of routine complications in this population is any higher than the general population but the phenomenon is, nonetheless, something we talk about often. And so it seems that I’ve become one such statistic feeding dubious credibility to this observation. 

9 months ago I underwent reconstruction of the anterior cruciate ligament (ACL) of my left knee using cadaver allograft after suffering an injury while skiing 3 weeks prior. I chose a surgeon recommended by a friend who knows and made it through the first part of the recovery in uneventful fashion. You can find details here, here and here. To describe the experience as profound would be an understatement for me. To be honest, the day to day minutia of recovery has consumed me for over 9 months, much to the chagrin of my girlfriend who has to hear about my knee dozens of times each day. It’s no exaggeration that I think about my knee at least every 5 minutes or sooner. To hear from friends going through a similar process in nearly the same time frame but who report nearly complete recovery at this point has become increasingly distressing for me. I started to get the sense that something wasn’t quite right with my experience. 

Sideways

Somewhere around 5 months post op, I started sensing some grinding and related mechanical signs in my knee that were accompanied by a persistent joint effusion (swelling) and loss of full extension. I tried to ignore it but as it became worse, I started putting the feelers out about what to do. I eventually obtained another MRI which demonstrated quite a bit of fibrosis (scaring) in the front of my knee around the patella as well as the suggestion that part of my graft may have failed. Soul crushing news, for sure.

After talking it over with a couple of surgeons, I elected to have another knee arthroscopy to clean things up and assess the state of my new graft. You can read part of the operative report below. Nothing really good here. A significant portion of my graft was shredded and had fallen into a position where I was more or less standing on it when I straightened my knee. The resulting reaction to all that shit was also blocking my full range of motion. For a surgeon who rarely spends more than 15 minutes performing routine knee scopes, the fact that he spent 50 minutes rooting around in my knee is telling.

 

After surgery, my knee predictably filled with blood. I noticed an improvement in my straightening right away and that has persisted over the last 10 weeks. The effusion has now resolved but the joint still feels a bit odd. Hopefully, this residual sensation is simply the result of the surgery and will continue to improve over the next few weeks. I’m back to squatting full weight again and can box jump 30 inches without too much difficulty. 

Reasons for Failure

There’s no way to know for sure why things are going sideways for me but I can offer a few possibilities that are described in the literature. Probably the most common cause of graft failure involves technique issues on the surgeon’s side. The placement of the tunnels through which the graft is eventually passed needs to match the native ACL’s foot print as closely as possible. This ensures proper biomechanical function going forward. Poor tunnel placement can lead to graft impingement in the femoral notch and abrasion of the graft tissue. Without getting too technical, my surgeon used a large graft (9-10mm) and there was some indication that it was rubbing on the wall of the femoral notch. However, the failure appeared to be on the opposite side of the graft so I’m not sure this finding explains things. In terms of overall tunnel placement, things look pretty typical in my knee without any red flags.

My new graft about to be pulled into placeAlthough I tried to progress my rehab under the guidance of my therapist, I was never able to meet one particular milestone - achieving full extension. I hammered this with all kinds of techniques for months and my knee still lacked around 10 degrees. Doing everything to get extensionAlthough some surgeons told me it doesn't matter, I could find absolutely nothing in the literature to support this. In fact, everything I read in both the orthopedic literature and the physical therapy journals insisted that getting full extension within the first 6 weeks was vital to ensure a successful outcome. Failure to do so compromised ultimate function, strength and likely leads to earlier patellofemoral joint osteoarthritis because of alterred mechanics. It wasn't until my graft partially failed and was cleaned out that I achieved near normal extension. There is quite a bit of disagreement within the surgical literature regarding the technique for tensioning the ACL graft at the time of surgery. I can't help but feel something was amiss in this regard with my graft. Hard to know for sure.  

Poorly designed rehab can also be a culprit. The obvious one is when a patient subjects the graft to enough force that it simply ruptures full-on. Early cutting or unexpected mishaps can lead to this issue. I can safely report that I experienced no such traumatic events. However, I was aggressive in my progression of cycling duration after the first 5 weeks, or so. I joked on Instagram about my rehab, using the hash tag #noncompliantpatient. I’m not aware that there is such a thing as too much cycling but I suppose it’s possible. On the other hand, I couldn’t help but reflect on what elite level athletes do to get back to sport within 8 months. I reasoned that their volume is ramped up pretty quickly. 

The third issue that can rarely come up and remains something I think about is the phenomenon of pseudo rejection of the donor tissue. There is a low-grade immune reaction to the tissue that some patients experience causing a slow degradation of the graft. It’s often accompanied by a persistent joint effusion which is something I dealt with all along. I’m not aware that there’s any way to test for such a thing. So, I’ll just continue on my way and hope that the process of graft destruction has ceased. Since I have access to easy (and free) MRI evaluations, I might get another in a month or two to see what’s going on. 

What’s Next?

The failure of at least part of my graft creates quite a bit of uncertainty going forward. The obvious question about whether it’s enough to do the job remains unanswered. There was little evidence that it was incorporating yet so I’m a long way from it being “healed”. Will it just suddenly fail when I’m 15 miles from the road? Can my partners trust me not to be a burden on future missions? Will they want to be bothered? Should I blow off skiing altogether this season? And if I do, how will I know that the graft won’t simply fail next season? These are all interesting questions that remain to be answered. Going forward will be an adventure.

A few things can be said about this situation. For certain, most patients do NOT get a follow-up MRI and still fewer have a “second look” surgery and have the luxury of finding out the state of their reconstruction. One wonders how many grafts are abnormal. There’s no doubt that this situation is going to screw with my head when I start skiing again. Obviously, starting off at the resort and testing things will be the first step. I’ve committed to wearing a functional ACL brace to begin with even though little concrete evidence exists that proves they make a difference. I’m going to try a slightly more supportive boot to perhaps give me additional confidence. I’ll also simply slow down in funky conditions.

Something not quite right with the quad innervation.The good news is that my left quad continues to improve. I had some funky atrophy of my VMO that was persistent due to the range of motion issue I was having. Fixing that seems to be having a beneficial effect on the muscle overall. I’m squatting over my body weight now and adding more demanding one legged work like lunges and Bulgarian split squats. Since hamstrings help quite a bit with knee stability and assist the ACL in preventing unwanted forward tibial translation, I’ve added some specific strengthening in that realm that I’ve never done before. 

Getting my VMO back onlineI have two goals with all this focus. One is obviously avoiding rerupture of this graft. Second, should the graft fail, perhaps finding out that I can perform without it. There is certainly a segment of the population that can perform at a high level in spite of being ACL deficient. Apparently, the gold medal winner in the moguls from the last Olympics is missing his ACL in one knee. Super Bowl quarterback John Elway famously played his whole career after high school ACL deficient. So, it can be done and at a very high level, indeed.  

Serious posterior chain work.Pending ultimate graft failure and a relative intolerance to it, my other option is to have a revision surgery. It’s hard for me to entertain another surgery and the year long recovery such an operation would require. I’ll avoid detailing the considerations of another reconstruction but suffice it to say it’s complicated. That said, Lindsey Vonn did well after her third go and won an Olympic medal. 

Sense of Loss

Throughout this whole ordeal I can’t help but have moments where I feel a tremendous sense of loss. For nearly 57 years, I had avoided significant orthopedic trauma in spite of taking considerable risk in the mountains. But in one short moment, everything changed. Of course, I realize that in the grand scheme of ortho trauma, mine is relatively mild. But knowing the natural history of ACL injuries and multiple surgeries, I know what’s ahead. Significant arthritis, increasing dysfunction and possible total knee replacement are all on the table. Add to this the looming possible failure of the primary procedure and it’s hard not to be discouraged sometimes. I’ve been completely committed to my recovery, working hard and 100% engaged nearly every waking hour. To have it all be for naught and contemplate starting from scratch, well, it completely guts me. Honestly, I do my best to not think about that at all. I’m starting to ski now, wearing a brace and trying to move forward like everything’s going to work out. 

Contemplating the first STEEP turn of the season. Gulp!The “easing back into it” thing didn’t last long as my knee actually feels best when I’m skiing, almost normal. The Donjoy brace I’m wearing doesn’t impact my skiing at all although the strap behind my knee beats up my skin after a longer tour. I’m finding ways to combat that. Going a bit slower on the descent and not skiing tricky snow in a fatigued state is also a tactic I’m employing. The fear of failure drives me in the gym to do all I can and be as strong as possible. Caution keeps me from hopefully doing anything stupid in the mountains. Stay tuned. 

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Reader Comments (4)

Brian! Damn, that sucks. No other way to say it. As someone with my own knee injury I can deeply relate. I’m going to focus on the positive here. From the doctor’s statement, “…The vast majority of his ACL was still intact…” That's good! At least most of it is still there! Of course, this might change, but as you advised me previously, what are you going to do? Do your best and keep going forward. The craziness/impossibility of starting everything all over if you need another surgery is understandable, and yet, I am sure that if you faced that reality you would just do it. It's not like you're going to stop skiing/running/cycling right? The picture of you skiing again really says it all...there you are, doing it, doing more, with your knee, than most people ever do, making the best of the situation. I think that in 2-3 years I am going to be reading about some great mountain adventures on this site.

Apart from those words of commiseration and support, I have somewhat the same feeling as you: my knee feels better after light skiing. I think that it really helps the nerves/muscles return to normal function, more than any physical therapy can. I have to balance it however, because too much stress sets me back.

Specific question: I understand that the data is non-conclusive, but what does the Donjoy give you? How does it help? Any advice about selecting among different Donjoy or other models?

Last: what do you know about posterior ankle pain/impingement. Does not seem to be the Achilles tendon (my feeling and the doctor's assessment)...perhaps bursa or fat pad or Os trigonum, but somehow seems like a deeper, sharper, bone pain, exacerbated by plantar flexion with load, and body rotation with load, relieved by motion, stiffens with inactivity. I know that I badly bruised the top and bottom of my tibia...could this be unresolved after 8 months, and could this be contributing? Ideas?

Just so you can share the irony/pain, my remaining injuries now are persistent patellar tendon irritation and this ankle thing...as one gets better, the other gets worse, and vice versa. Patellar tendon shows long term positive trend, ankle injury always flares up when all is going well. Ha ha....you can't win.

Good luck! Bruno.

January 16, 2019 | Unregistered CommenterBruno Schull

Hey Bruno,

Thanks for the thoughtful comment. It adds some great perspective when I'm mired in the minutia. Helpful, for sure.

The one thing that comes to mind with your ankle is some sort of OCD (osteochondritis dessicans) lesion on your tibial or talar chondral surface. An MRI would be revealing. Tough problem. Some surgeons would micro fracture it to stimulate some fibrocartilage filling. Others might suggest some sort of graft procedure. Certainly, you could find someone suggesting biologics like stem cells and the like but the data is shitty on those right now. Seems like a firm diagnosis is the first step. I smart, older (not too old) fellowship trained foot and ankle orthopedist is where I'd head.

January 16, 2019 | Registered CommenterBrian

Hey, have you spoken with Scott Johnston? I don't know him, but in his writings he's pretty excited about advances in knee replacement. Not sure if you're a candidate, but he is suggesting that recovery timers are decreasing and full activity including running is a real possibility. Might be worth getting a hold of him. I know you're in the business, but wouldn't hurt to talk to a serious mountaineer who's had the procedure.

January 24, 2019 | Unregistered CommenterTrent Smither

Hi Trent,

Thanks for the heads up. Yes, I know Scott a little bit having worked and played with his partner in crime, Steve, over the years. I also knew that he had his knee done a few years back and was doing well. After your recommendation, I reached out to him to get the full story so I could comment more accurately.

Honestly, his experience is not uncommon for motivated patients. My job is primarily joint replacement and I've averaged 350 knees/year for the last 5 years and I've done several hundred more over the preceding 20 years with other surgeons. The actual implant has changed little since it's original design in the late 60's but little tweaks in design and material has helped with function and survivorship. The real breakthrough came around 2003 when highly cross-linked polyethylene became the material for the bearing component. This virtually eliminated premature wear. I have lots of patients who mirror Scott's satisfaction but the majority are simply lower demand, for sure.

Right now, I'm a long way from being a total knee candidate. On the other hand, having an ACL rupture and subsequent reconstruction is a strong risk factor for needing one in the future. If I'm lucky, I'll be dirt napping by the time that becomes reality.

January 28, 2019 | Registered CommenterBrian

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