TITLE: A Second Round of Surprise AUTHOR: Eugene Wallingford DATE: June 03, 2011 1:46 PM DESC: ----- BODY: When we last visited this tale, 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 microfracture surgery or, if the lesion were a little bigger, perhaps the OATS procedure, 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 CARTICEL. 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 better than the typical cases. 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 osteochondral allograft, 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 makoplasty, 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. -----