Steady the hand

When I describe the procedure to my friends, they always cringe at the part about drilling holes in the tibia through to the femur. Frankly, I do too. It seems to me the part of the process that dictates more than anything else, how well the knee performs afterwards.

This reminds me of the old salt my father found to help him drill a long hole into the rudder of his cat boat. The procedure called for using a long bit, probably about 1/4" in diameter about 12" into the rudder. The rudder is only about 3/4" thick. A long drill bit can often wander off course, so it takes a very fine sense of feel to steer the bit correctly so it doesn't break out either side of the rudder. My father was a little uncertain about doing it, but this old guy he found, this boat carpenter, held the rudder between his knees, seated the tip of the bit and drilled the hole perfectly, in one smooth stroke. This is how I imagine the surgery works -- it requires a steady hand, a good feel for the proper angles, and an intimate understanding how the knee functions, and needs to function with its new ACL.

Quiet the doubts

When I was thinking about the prospect of surgery, and given how good the knee has been feeling, I have noticed a tiny element of doubt sneaking into my mind now and then. I never had any swelling or significant pain after all. Now and then I feel a little twinge on the outside of my knee, and bending the knee too far causes some pain. But one part of me is comparing the gravity of the surgery I'm facing with the apparent lack of symptoms. Is it the right thing to do? It's a question of weighing post-surgical risks against what I want to be able to do with the leg.

Lately, the knee has been feeling a bit achy. Nothing too specific. But it reminds me that not doing something about it invites other problems to develop. That's one strong reason for going through with this. The knee can start breaking down over time if the ACL is left untreated.

For me the main issue is mobility on the tennis court. My quickness and movement on the court is a serious requirement and an advantage for me against other players in my age group. Where I may lack in shot making or situational play, I can often make up by getting to balls and maintaining balance and fluidity. If I elected not to have this procedure, I'd have to give up singles forever, and I'm not at all ready to do that.

Pre-op update

I spoke to my orthopod yesterday about a few pre- and post-op details. I had a few questions about what to expect post-op, like how quickly I'd be starting PT, whether a knee brace was covered by insurance, that kind of thing. These are my notes from the call:

• A surgical pre-test has been scheduled three days before the procedure. Not sure yet what's done at the pre-test, but I assume they cover all the day-of details, run some basic tests, etc.
• On the day prior to the procedure, March 8, I'll be fitted for a post-op knee brace and supplied (loaned, I would think) a CTM, which I understand to be a constant-motion device
• Dr. Peters I don't think is convinced the CTM is all that necessary but I guess it's part of the package.
  
• He suggested using the CTM a few times a day for 30 mins. to an hour, but that it was up to me. I got the impression that he didn't think it was that important.
  
• Swelling the first week or so is the main issue. Keep knee elevated.
• I'll be on crutches first 3-4 weeks and then walking freely.
  
• I asked him if I'd need to get fitted for a sports knee brace but he said he thought I wouldn't need one at all once I was fully recovered.
• Plan to start PT the week following the procedure, say Wednesday the 14th. He'll send over the prescription (for PT) to the Fallon PT clinic in Worcester. I should call to confirm and schedule prior to the surgery.
  

I've worked at Fallon PT before and wasn't too impressed. Tennis has been good to me, but also hard on the body, especially my shoulder. Right now, I'm dealing with a probable impingement issue that seems to be responding well to strengthening exercises. The physical therapist I'm working with now on my shoulder is John Pallof at South County PT in Auburn, and he is really good. The only draw-back is that Auburn is more than twice as far away as Fallon. We'll see how it goes.

There's pretty good info at eHealthmd.com on ACL reconstruction.

Second visit to the orthopod

I had my second visit with the orthopod last Monday, Feb. 12. Doctor Peters confirmed the ACL tear and mentioned that the pain I feel now and then on the outside of my knee is from a small tear in my meniscus. The goal of this session was to determine the course of action. But the question in my mind wasn't so much what to do (have the surgery) as it was when to do it (as soon as possible). The discussion about whether to have the surgery at all really hinged on the level of mobility and the type of activity I felt I needed to have afterwards. I said that there was no way I would consider skiing or playing tennis on the knee in its present state. It's just too unstable.

My feeling was, let's get as much mobility back as possible so I can have a chance to get a USTA ranking in the 50-55 age group, as well as be able to compete in singles at the 4.0 level. So, we agreed to go ahead with the procedure. The only remaining question was where to get the tissue to use for my new ACL. Dr. Peters explained that, because of my age, I was on the borderline for the use of an allograft (cadaver tissue) or my own tendon, probably a part of my hamstring. Finally, it was decided the allograft would be on hand as a backup. Sometimes it's used in combination with your own tissue. I don't have a problem with the use of the allograft. What I'm interested in is the highest statistical probability of long term success -- I don't care where the tendon comes from.

We also settled on the date: March 9: Three weeks from today. So now, I'm reading up on post-op recovery, rehab, and physical therapy.

In the beginning

Here's how it happened. As a Ranger at Mt. Wachusett, I go out on the hill two times a week at night to help the Ski Patrol with injured skiers and snowboarders, and to help maintain a certain amount of sanity among the nutjobs flying around like unguided missles. January 18th, I arrived and immediately went up the lift to help out at an accident scene on a trail called Smith Walton, or trail 5 as we refer to it on the radio. Just after going over the first pitch, I washed out on an ice patch, and in trying to recover my balance (instead of just taking the fall, as I should have) I hyperextended my left knee. I felt a small 'twang' in the knee, not exactly a pop. There was no twisting, wrenching, and nothing especially violent about the fall. I was not going very fast, either.

When I got up, I knew I'd done something, but it didn't hurt a lot, and I was able to keep going. I remember saying to myself, 'jeez I hope I didn't do what I think I just did.' From the accident scene, I skied down, following the Ski Patrol sled, taking the injured skier's own skis on my shoulder and skiing more or less normally, though a little unsteadily. Turning to the right was a little exciting. Later on, during a single run, I fell twice, which I almost never do, and realized something was up.

Taking a break for coffee, I noticed walking around in my ski boots that there was some definite pain on the outside of my knee, so I decided to quit for the night and put some ice on it. I'd read about ACL injuries, and while I suspected that could have happened, I wasn't convinced. I assumed it took a lot more violence to tear an ACL. The fall I'd had was almost incidental. I'd never hurt myself skiing and was having a hard time accepting the idea that I'd done something serious.

First doctor's visit

But I was concerned enough, never having injured my knees, to get it looked at right away. I was able to get an appointment with my family practice physician the next day, who gave my leg some tugs, noted that there wasn't a lot, if any, discernable swelling, and sent me on my way with the advice to ice it, stay off skis for 4 weeks, and not to worry. We figured it was a sprain.

The specialist

I was already scheduled to see an orthopod early in February to look at my shoulder, so I figured I'd have him take a quick look at the knee while he was at it. During the appointment, we spent 20 minutes talking about the shoulder, which I'd had some trouble with over the last tennis season. In October I'd elected to quit playing until I figured out how to alleviate the pain I was having. I had assumed that the problem was a small rotator cuff tear and that we would be talking about when to schedule arthroscopic surgery. As it happened, he didn't think it was a tear -- the MRI was inconclusive -- so instead, he offered to give me a cortizone shot and put me on a physical therapy regimen. Then we had a look at the knee.

Now, the knee had not really been bothering me at all. It never swelled up much. I could walk a straight line and do stairs without any discomfort at all. I figured a little rest and I'd be back in action. The one thing that nagged at me was that it felt unstable, like I could really do some damage if I stepped off a curb wrong.

He got me on the table, did a few manipulations of my good leg, and then moved over to my left leg. After about two seconds of examination, he told me I had a definite tear in my ACL. This was quite a shock to me at the time. He said he didn't need an MRI to confirm it, but that he'd order one anyway to determine if there was any other damage to the knee, which is pretty typical of an ACL tear, apparently.



The Lachman and drawer tests he did were dramatic. On my good leg, the calf moved forward slightly and stopped with almost a 'thunk.' On the bad leg, the calf moved forward twice as far, and stopped with a certain mushiness. So in a moment, my ski season and my 2007 tennis season disappeared before my very eyes. As I've been saying to friends, "I went in with a shoulder and came out with a knee."