He doesn't make mistakes: Cadaver grafts for ACL knee surgery

An orthopedic study, released yesterday, found a 24% failure rate in operations on young athletes who get a cadaver graft [from a dead person] in knee surgery to repair an ACL ("anterior cruciate ligament"). Many have discussed whether Tiger Woods should have this surgery. Here's the story of Keith, an avid amateur soccer player in California:

Having played an awesome game of soccer on Saturday the 15th, on Sunday July 16, 2006 I decided to help out a teammate and play for his team since they were short. The league that I play in have artificial turf fields. The league my teammate played in used various grass fields. On this particular day, it was an awful field of a junior high school. I had just recovered from a mild Achilles tendon strain to my right heel, so jokingly I stated "there's a hole out there w/my name on it, watch." 

Unfortunately, I was right, but had no clue what was in store for me. With maybe 10 minutes left in the game, the other guy playing forward w/me was on a breakaway. I was running with him, wide open, so he crossed the ball to me leaving me 1v1 with the keeper (who sucked btw). It was a simple setup that I've played through many times before: a quick cut to the side and pass the ball in. That's all I had to do. So, I did just that. 

Or attempted.

What happened, to my recollection, was that I tried to cut to the left w/the outside of my left foot. Somehow in my footing my left leg got stuck as if I couldn't lift it up quick enough. Maybe I stuttered in my steps while trying to quickly change my direction or something, but my leg was firmly planted as the rest of my body moved over it. Before I knew it, I was on the ground, my knee having bend backward and to the inside a bit and having heard a pop. I was in the most excruciating pain I've ever felt in my life, and as I was literally digging out clods of dirt and grass from the field I could only say two things, "f***" and "oh s***!" I didn't even move for a few minutes (from the ground that is). When a teammate shouted to the sideline "get some water" I blew up. "I DON'T NEED ANY F***ING WATER, WATER ISN'T GONNA HELP ME!" 

And it figures, because with my Achilles tendon strain, I bought and brought a bag of ice from Ralph's every game. The one day I don't do that is the day I tear my ACL, and some ice would have been nice initially. Anyway, when my teammates helped me up, I tried to walk and immediately my knee buckled. It was as if it were jelly, just no stability at all. The fact that somebody else said they heard a pop was a bad sign, but for the time being I had hoped that it was just a severe hyperextension. In high school I hyperextended my knee a few times and may have had Osgood Schlatter's disease (it was a debate, I had a lot of the symptoms but currently show no sign of ever having it).

My 1hr+ drive home was nervewracking because I started analyzing what could be wrong and what it could mean for the rest of MY season (screw my teammate's season!), and where the heck should I drive to. The urgent care I had intended on going to was apparently closed even though they have "24hrs 7 days a week" posted on their window. In tears from the pain, I made it to the hospital (having never been there before) and apparently parked the furthest distance from the urgent center as possible. In time I got a wheelchair and X-rayed, and 4 hours later (it was a long wait) was told to see an orthopedic surgeon. My leg/knee was in an immobilizer brace and a friend picked me up and took me home.




THE SURGEON

The next day, Monday July 17th, 2006, I went to Blue Cross' website and found the closest orthopedic surgeon to me and called. They had an opening if I could get there in 1/2hr, so I lucked out. The surgeon asked me a series of questions and prodded around my knee for a bit, injecting a giant needle into my knee and pushed out a TON of blood. The needle felt like it was going so deep so as to hit the bone, but it wasn't. Definitely painful while it lasted. I wish I could say the amount, because it was a lot even for an ACL tear, but must have been 4-6 CC's worth. He sent me off to get an MRI as it was the only way to tell for sure what was wrong. I had my fingers crossed for a "best of" situation, meaning I didn't want it to be an unhappy triad (torn ACL, MCL, and torn meniscus), but I wasn't gonna be happy with an ACL tear either. During this time, I had not only the immobilizer brace but was on crutches too. Anyway, a few days later I got the MRI results and sure enough...ACL complete tear. Unfortunately, my stupid surgeon was going on vacation to the Caribbean for THREE weeks! I wanted the surgery right away and this wasn't going to help. So, I painfully had to wait nearly a month in order to have it. At some point I got a hinged immobilizer brace which was a lot better than what the hospital gave me. This new brace had hinges which you could lock into various degrees of flexion and would be key mostly for after the surgery. So anyway, let's get to that already shall we?



THE SURGERY

Finally, the big day came: Friday August 25th, 2006. The process I was told would take about 1hr 15 minutes, which I found surprising, but I guess it's not that long for a non life-threatening surgery, heh. The method of surgery was an allograft: a cadaver graft, meaning some dead guy's Achilles tendon was used as opposed to a hamstring (or patellar tendon) autograft. My surgeon explained he preferred this method because it doesn't require cutting into your own body. Why heal from 2 places when you can do it from 1? Fortunately, despite his jackassery of leaving for 3 weeks, he's a very good surgeon in LA. I got extremely lucky by finding him at random!

 The morning of the surgery, I wrote a giant "NO" on my right knee as it is my healthy knee. The docs later laughed at me for doing that, because "he doesn't make mistakes." But hell, why take the chance? Anyway, I was told that after the surgery I would be sent home: an outpatient. I found that cool because who wants to be in a crappy old hospital? BUT, the surgery didn't go quite as planned. Apparently my surgeon's assistant was also assisting another surgery, so rather than 1hr 15 min, it was 4 friggin hours! But, it was a success. I woke up and they wheeled me out of the recovery room and into a room in the hospital...so, rather than being an outpatient, I was an inpatient and had to spend a night in the hospital. 

That night was the longest friggin' night of my life. I knew that surgery would be painful, but I figured that knee surgery was small in comparison to hip replacement, shoulder surgery, etc...WRONG! Sorry to say but you're gonna have pain and it's gonna be extreme. I was asking for morphine every 4 hours on the hour and didn't sleep for s***...kinda sucked. I didn't eat nor drink much while there either. The next morning was quite a task as it was time to go home. Time to go home after going through traumatic surgery and having no food in my stomach. It also meant moving with a recently-operated knee. A therapist-type guy came in and helped me out of bed (painful) and showed me how to go up and down stairs w/crutches. After a long process of getting me into a wheelchair, into and out of my mom's car, and into my bed...I was home. Aside from moving, there really wasn't much pain...from surgery and on I only took 3 Vicodin pills and honestly didn't really need them. This is to say that while laying on my back all day I wasn't experiencing pain. Getting in and out of bed (basically, when my leg wasn't laying in bed) hurt, but that's to be expected. Maybe 3 inches below my knee was, and still is to this day, numb because apparently they have to cut through a nerve, but the area is only 4x3 inches? Its not bad, but it's one of those things that I'd like to have back just because I'm supposed to. 

There are some other side effects of the surgery such as lightheadedness. Considering you're stuck on your back for such a period of time AND a loss of blood/traumatic surgery AND your usual eating habits have been changed temporarily, it's entirely natural, but I tried to sit up when possible to read, etc. 

So, my surgery was Friday Aug 25th, right? Well, Wednesday August 30th I was back at my surgeon's office for a followup, and my first day of physical therapy. I guess this leads us to our the next point...



THE RECOVERY

The goal of therapy is to achieve full flexion (bending) and extension. When I saw the therapist the first time, he just did some electro-pulse type stuff on my knee. I've done it before back in high school so it was nothing new. Because a little more than a month passed between injury and surgery, my leg muscles atrophied pretty bad. If there's one thing I've always had pride over, it was my muscular soccer legs, heh. My right leg hadn't changed, but my left was kinda chicken-legged. Most notably, my quads. 8 months later, my quads are still diminished...better than post-op, but still not to where they need to be. I'd like to say that my therapist didn't have me work on them in the early stages of therapy. He stressed that the hamstrings are really important because they're the muscles that aid flexion. But, I still feel like he neglected them when it was key because I'm only doing 15 lbs on my left leg...it's not that my muscles can't handle the weight, it's that the ACL is still weak at this point. Which is normal.

Advice: Look into other patients' stories thoroughly before choosing elective surgery.

Read a more grim story of a young athlete's knee surgery.

Thanks to Keith, and to Drs. Kurre Luber and Gene Barrett for their presentation at the 2008 American Orthopaedic Society for Sports Medicine's Annual Meeting.