TITLE: A Second Round of Surprise
AUTHOR: Eugene Wallingford
DATE: June 03, 2011  1:46 PM
DESC: 
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BODY:
When we
<A HREF="http://www.cs.uni.edu/~wallingf/blog/archives/monthly/2011-04.html#e2011-04-30T10_05_29.htm">
   last visited this tale</A>,
I had learned that my right knee suffers from a condition
known as OCD and that my life as a distance runner was likely
over.  Depending on the size of the lesion and the state of
the bone tissue, there are several potential reparative and
restorative procedures that my surgeon could take.  But
running was almost certainly out of question.

After doing some research, we decided to do arthroscopic
surgery to try to repair the lesion.  My surgeon hoped
that he would be able to do
<A HREF="http://en.wikipedia.org/wiki/Microfracture_surgery">
   microfracture surgery</A>
or, if the lesion were a little bigger, perhaps the
<A HREF="http://aboutjoints.com/patientinfo/topics/oats/OATS.html">
   OATS procedure</A>,
which transplants good cartilage to the lesion for regrowth.
If the lesion were too large for either of these procedures,
there was one more option, the first step of a newer
technique known as
<A HREF="http://www.carticel.com/patients/treatment.aspx">
    CARTICEL</A>.
The expected procedures, microfracture or OATS, would require
a recovery period of six to eight weeks, during which I would
not be allowed to put weight on the knee but would be doing a
lot of motion therapy to stimulate blood flow and tissue growth.

I went in for arthroscopy last Wednesday, May 25.  It had been
thirty years since I had undergone surgery, to repair the
rotator cuff in my left shoulder, and this experience was quite
different.  Medical technology has come a long way in thirty
years.  We did the operation at an outpatient surgery center,
which was much more comfortable than the typical hospital.  I
was in and out in about four hours, despite being placed under
general anesthesia.  I went to sleep and woke up comfortably
and even recall some of the conversations I had with nurses as
I left the post-op room.  The surgeon spoke to my wife after
surgery, but I was still out cold.  That evening, I was home
resting comfortably.

The surgery was one of those good news/bad news things.  The
good news was that my recovery would be faster than we had
planned.  The bad news was why: the surgeon was not able to
do either microfracture or OATS, because the damage to my
joint is more extensive than we thought.  It looks to be
more degenerative than the result of a specific trauma,
which fits how it presented
<A HREF="http://www.cs.uni.edu/~wallingf/blog/archives/monthly/2011-05.html#e2011-05-03T16_26_52.htm">
   better than the typical cases</A>.
So, instead he removed some loose cartilage, including one
large piece, and cleaned up cartilage on both sides of the
joint.

For the last week, I have been doing physical therapy, using
lots of non-weight-bearing motion to loosen the joint and to
strengthen other muscles in the leg, so that they can take
pressure off the knee when we return it to full use.

Yesterday I went in for my post-op appointment with the
surgeon, to gauge the state of recovery and to discuss next
steps.  He showed me pictures of the inside of my knee from
the scope and explained why he could not do the procedures he
had planned.  The reasons came down to two.  First, the
lesion is wider and deeper than we had hoped, and microfracture
and OATS only work on shallow wounds of a few centimeters at
most.  Second, there is also damage on the tibia across from
the lesion on the femur.  This is known as a "kissing lesion"
and means that any new tissue growth at the bad spot on the
femur would be damaged whenever I walked and the knee joint
closed.

The next thing for us to try is a partial knee replacement, in
which he cleans up the damaged area and fills the lesion with
a piece of something.  Basically, the options are again two.
One is called
<A HREF="http://www.arthroscopy.co.in/index.php?option=com_content&view=article&id=54&Itemid=66">
   osteochondral allograft</A>,
which uses a bone and tissue plug taken from a cadaver.  The
second is to use a synthetic implant made of the plastic and
metal.  The surgeon suggested that I may be a candidate for
<A HREF="http://osteoarthritis.about.com/od/kneeosteoarthritis/f/MAKOplasty.htm">
   makoplasty</A>,
which uses computer visualization to help create the implant
and an interactive robotic arm and to place it in the lesion
and attach it to the femur.  That sounds incredibly cool.  I
have to be sure not to let my fascination with the technology
unduly influence my decision!

At this point, my wife and I have some research to do, to
decide what, if anything, we want to do next.  I am on the
young side for even a partial knee replacement, but medical
advances are improving the longevity of the procedures'
effectiveness.  My surgeon is sensitive to the fact that, as
a relatively long guy, I probably want to live a more active
lifestyle than an unrepaired joint is likely to allow.  It is
a big step for me, whatever we choose.

In any case, the surgeon says I need to continue working
diligently on physical therapy, to build up the muscles both
in the knee and, more importantly, all the other muscles and
joints in the leg.  If I don't do more surgery, these muscles
are essential to supporting the damaged knee; if I do opt for
more surgery, these muscles need to be as strong as possible
to support the knee during recovery and rehabilitation.  So,
off to therapy I go.

If any of my running friends are still reading, I can add
this: given both the size and character of my lesion and the
way it presented, the surgeon is unable to say to what extent
my heavy mileage affected the condition.  Clearly, heavy
mileage delivers a lot of repeated trauma to our knee joints.
But with no previous pain or disruption to my running, it
seems almost as likely that my running delayed the onset of
the bone necrosis as that it caused it.  I seem simply to
have been unlucky genetically in this one regard.
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