>>   --Knee

Arguably this doesn't belong in the "Ultimate" section, but since the injury is Ultimate-related, and since I don't want to create a separate category for it (this web site maintenance stuff can be a pain), this is what we've got.

Knee arthroscopy

In late February, 2002, I had an operation to try to fix a chronic problem with my right knee, a problem I've had since about 1989 and which has gradually been getting worse for all that time. It was diagnosed several times as "patello-femoral syndrome", but that turns out not to be right, I actually have a "chondral defect", missing or damaged articular cartilage at the bottom of the femur.

I had a kind of stop-gap surgery called "microfracture", performed by Dr. Warren King. I should get two to eight years of pain relief, depending on luck and on what activities I do.

Here's a write-up of the operation itself, originally written for my parents and friends:

I had my knee operation yesterday evening [Wednesday, Feb. 27, 2002]. Juliet and I arrived at the surgery center at about 3:30 PM, did some paperwork and waited a bit, and they took me into the prep room at about 4:00. I had to change into one of those hospital gowns, put on a hairnet, etc. They put an IV in me for drug delivery, marked the knee to be worked on with a big X and wiped it down with iodine, and put a stocking on my other leg. Then the doctor came in and answered a few questions, and gave me a little pep talk.

Finally the anesthesiologist came in to discuss options. She said almost everyone goes with general anesthetic, but agreed that local was an option if I wanted to do it. It seemed like there was no drawback to local, and many advantages, including being able to watch the operation and a much more rapid recovery from the anesthetic...she said they put you in a somewhat uncomfortable position while they work on you, and that some people are squeamish and don't want to be awake during surgery, but neither of those sounded too bad so I opted for the local. She said that at any point, they could put a mask on me and put me under.

At about 5:45 they took me to the OR, right on schedule, strapped me in, attached the blood pressure monitor and some other gear, and disinfected my leg with a solution that felt like it was below freezing. Then the doc came in. I asked "You feel OK, had your coffee, nice and alert, at the top of your game?" He said "I'm working on Doctor Pepper today, feeling good."

The anesthetist put me to sleep for about 30 seconds while the doc injected the local "block", as they call it, and then woke me back up. The position was not, after all, particularly uncomfortable, and they adjusted a monitor so I could watch what they were doing in my knee, so it worked out well. It's pretty cool, really---you get a great view with a little camera they stick in there. The doctor started by doing a quick look around the whole joint. At some places in the knee, like near the attachments of the ligaments, there's lots of fibrous stuff hanging around that is perfectly normal. He found the chondral defect right away---a big hole in the articular cartilage, with big and little chunks of partially detached cartilage hanging around it.

The doctor also checked out the menisci, which look very good---he cleaned up the edges just a bit, but said really they were in fine shape. He also found a nearly detached chunk of cartilage, about the size of an aspirin, stuck in place around...well, I think it was the base of the kneecap, but I'm not sure...and he grabbed that and pulled it out, and cleaned up the area with a sort of grinder. Then he went back up to the defect and started chewing away at it with the grinder---removed all the big chunks (they get flushed out of the joint by a continuous flow of water that they set up), smoothed the edges, and ground the remnants of the cartilage away from the exposed bone. During all of this, he occasionally had to push on my kneecap or manipulate my leg, sometimes pushing it or twisting it pretty far, but it was never really uncomfortable: the local really worked! I did feel the motion a bit, more in my back than in my leg.

After cleaning everything up, he started to punch holes in the exposed bone to get it too ooze out fibrocartilage. Pretty simple, really, just stick a pick into the bone and hammer on the end of it. This part, I could feel, and in fact it hurt pretty badly. After the first two, I had them put me under. It wasn't unbearable---it took less than 3 minutes for him to punch all of the holes, and I could have taken it if I had to. But I didn't have to! So they gave me the gas and put me under for about 10 minutes. From the time they stuck the tools into my knee to the time they took them out was only about 20 minutes. Almost all of it is on video, which they gave me a copy of.

The doctor came by when I was in the recovery room. Since I had seen almost all of the operation, he basically just said it had gone fine, that I should avoid unnecessary walking for the first month but could be fully weight-bearing immediately, and that he would see me next week. He also said the back of the kneecap looked good and he hadn't done any work there, which surprises me in retrospect because one of the photos (which I didn't look at until today) seems to show some damage to that area also, although admittedly I'm not 100% sure what I'm looking at. I'll ask when I see him next Thursday.

They've given me a "continuous passive motion" machine that flexes and extends my knee for me, that I'm supposed to use 8 hours per day (while sleeping is OK) to maintain range of motion in my knee. I'm supposed to keep my knee elevated all the time. Otherwise, I feel fine, no significant pain. I skipped work today, but plan on going in tomorrow. They gave my vicodin to take, but I don't need it so I'm skipping it. I'm taking ibuprofen, too, but mostly for the swelling rather than pain.

If all goes well from here on, I'll probably have substantial reduction in knee pain, which may (or may not) last 6+ years if I baby it, or maybe 1-4 years if I resume playing Ultimate a lot. After that, there are several things that could happen: (1) do it all again; (2) "articular cartilage implantation", where they would take out some of my articular cartilage, culture it, then smear it on the bad spot, where it would eventually regrow; (3) "mosaicplasty", which is kinda like hair plugs: they take plugs of bone and cartilage from less weight-bearing areas and implant them in the damaged area; (4) "total knee replacement". The terms can be searched on google(or your favorite search engine) if you want more info.

There are some other options too, but these are the most popular. My doctor is skeptical of articular cartilage implantation, feeling that it can't create the right bond between bone and cartilage, but the first long-term follow-up study just came out last week and the results look pretty good. He favors mosaicplasty.

Now the really painful part starts: trying to get my HMO to pay for the surgery. The doctor I used isn't on my "network", but since two of the guys in my network mis-diagnosed the problem and one of them doesn't know anything about treatment options and gave me several items of misinformation, I decided to use someone I know is good. The HMO declined my request for a referral, but I went ahead and had the good guy do it anyway, and I'm appealing the denial. My doctor says he doesn't think I have much of a chance. He said "I'll give you a stack of papers with my signature on them, and you can write whatever you want in my name if you think it'll help, but those guys just want to hang onto your money and it's hard to get them to let go." So, that's it! I have a follow-up appointment in 1 week, until then I'm just keeping the leg elevated and trying to stay off it.


Caption: this is a "before" picture of my knee. The lower/left portion is the femur, upper/right is the back of the kneecap. The white stuff is articular cartilage...it's a few millimeters thick. As you can see, it's torn up and parts of it are completely missing, exposing the bone (pinkish) below. The total area of the damage was about the size of a half-dollar. The surgery consisted of cutting away the torn-up cartilage, then punching holes in the bone to make it ooze out a protective substance called "fibrocartilage".

Fibrocartilage isn't nearly as strong as real articular cartilage, so this repair will probably only last two years (if I do lots of sports) to ten years (if I take it really easy). For the level of activity I anticipate, I think I'll be in the 3-5 year range.