Blown - Life after my ACL rupture - 3
Friday, April 27, 2018 at 01:29PM 
Gotta wait awhile for more days like thisThe deal is done. Commitment made. Time to get on with the business of healing and returning to normal. But first, I'll share my impressions with the surgical experience and the first few days of recovery.
I didn't sleep much the night before surgery. I was literally tortured with the graft choice decision. It wasn't an easy choice due to lots of pros and cons but ultimately, having younger tissue and sparing my hamstrings made the most sense for someone my age. My surgeon admitted after the fact that he'd never done an autograft on someone over 50. So, there it is.
Summit Center Surgery Center, Flagstaff, AZThe ambulatory surgery center experience was smooth. I was the first case so it was pretty quiet when I arrived at 0615. The intake for the nurse was easy as my medical history is super boring. Good way to be in this situation. I met with the anesthesia provider and he offered me some preemptive narcs and an adductor canal nerve block to help with the post op pain. Since a big part of my job as an ortho PA is taking care of patients' post op pain, I wanted to experience what this procedure had to offer in terms of unpleasantness. At the same time, I didn't want to be some sort of hard-ass douche bag either. So, I compromised and took one of the pre-op Norcos and deferred the block until after the operation. It's no biggie doing it after the fact.
I met with the surgeon and confirmed that I wanted a cadaver graft. He went to the freezer to pick me out a fat, young piece of tendon that would allow him to do the magic. They wheeled me back into the OR and were pushing the Fentanyl before I even wiggled onto the operating table. Man, that shit hit me like a ton of bricks. Hard to believe people main line that drug for fun. A couple of deep breaths followed, the Propofol went in and I was out. I have no recollection of the next 30-40 minutes. In addition to reconstructing my ACL with the new tissue, he also cleaned up and trimmed my degnerative medial meniscus. The good news was that my articular cartilage was/is healthy. No arthritis....yet. Below are some pics of the fun.
Dr. Moezzi in the throws of putting me back together
My new ACL, prepped and ready for implantation
Pulling the graft into positionI received general anesthesia and slowly came out of it once I was back in recovery. I had a bulky dressing on and a knee immobilizer to keep my leg straight. It would also allow me to weight bear as tolerated without my leg buckling under me. As the fog lifted, my friend Kristy was there with my morning latte. Most excellent. I've had general anesthesia a few times before and never had any issues with nausea. This time was no different. I'm lucky. I've seen patients barfing their guts out for hours after waking up. You simply don't want to be that guy.
My ticket punched for the pain trainOnce I was out of the clouds, the situation in my knee became clear....a bomb had exploded inside! Since everthing costs money, I inquired as to the expense of the nerve block. I vaguely remember someone coming back and saying $200. I pulled the trigger. The anesthesiologist came by with a long needle and the ultrasound machine. I got to watch as he guided the needle to the sweet spot and infiltrated the local anesthetic. Now, everyone of my patients getting a total knee replacement gets one of these and most of the time they're thankful. Quite often, the pain relief is both profound and immediate. For me, not so much. I was disappointed. Truth is, some of us are just wired weird. I like to think that it helped some but there's no way to know. The one noticeable thing, however, was that my shin was numb for 12 hours.
Once I was moving everything and holding down my coffee, I got my final instructions, shook my surgeon's hand and headed home. I crutched into the bedroom and plopped down. Now the fun begins. Holy shit. The ache coming from my knee was relentless. I remember my buddy Andy Dorais, who went through the same thing a month prior, saying he really had no pain. Never took a pain pill. I wanted to be that guy, too. But after squirming around for an hour I dropped my first Norco 7.5. I felt like such a wimp. After an hour of no relief I dropped the second one and 600mg of Ibuprofen. I waited and waited. After another hour everything got better and I passed out for a 90 minute nap.
Kristy was all over me seeing what I wanted, food, drink, etc. I managed some of her delicious dinner and got back on the couch, stuggling to find a position that was comfortable. The instructions were to leave the knee immobilizer on in order to keep from developing a flexion contracture where my knee wouldn't go straight down the road. But there was no way I was going to be sleeping with that thing on. Plus, the compression cold therapy machine couldn't do its thing with all that shit on my leg. I even unwrapped the dressings to remove some extra padding leaving the base dressing intact and rewrapping with the ACE bandage. I also brought some serial compression devices from home to help with Deep Vein Thrombosis (DVT - blood clot) prevention. I crawled into bed with all this on.
I took another round of Ibuprofen and two Tylenols but decided against the narcs just to see what happened. Of course, I feared that the block would wear off in my sleep and I'd wake up hating life again. But, thankfully, that never happened. I slept for an hour at a time, waking up to pee and stretch. Since I was being non-compliant with the brace I felt like I needed to be vigilant with the straightening several times a day and night to make the difference. It worked out fine.
The next day went alright. I spent most of the day in bed doing the full court press on swelling and icing. I got up a few times to stretch and test things. I still had a lot of pain with full weight and odd little moves. My quad was not really interested in doing much. No big deal. That night I decided to take one Norco in hopes of better sleep. I chased that with 400mg of Ibuprofen again. Slept fine.
Day two was better. My mobility was good and weight bearing tolerance was higher. I still couldn't trust my quad for shit so I continued to use the crutches. We opted for a dinner out since I was feeling up to it. My friends have a 4 and 6 year old so getting away for a couple of hours keeps the parenting psych high. I wore my brace to the restaurant and it was actually really nice having the support and security. One thing is for certain, you don't want to blow your graft tripping over the curb or something stupid like that. Once at the table I removed the brace and let my knee bend and stretch. All was good.
That night I only did the anti-inflammatory and Tylenol. No big issues aside from the bouts of stretching and peeing. One thing about being a sea level dweller and recovering from surgery at 7,000 feet, the diuresis of acclimatization continues. Up, down, up, down...luckily, the toilet is two steps from my bed!
Early goal is to get it straightThe next morning marked the 72 hour point from surgery and the green light to remove dressings. I wanted a shower and I wanted the cold machine closer to the action. I got a post-op appointment with the surgeon and his assistant. He told me that "nobody looks this good" at this point so that was encouraging. Of course, I'm sure he says that to everyone. But he seemed genuinely happy with everything. We did a couple of xrays to confirm hardward position. His exam suggested everything was nice and tight. He told me not to stress much about motion for another week.
3 days post-opToday, post-op day 4, all is good. I can actually take some steps with full weight and no pain. I can fire my quad a bit although not enough to trust my knee completely. I'll continue to have at least one crutch under me at all times. I think by day 8 when my flight back is, I'll be ready to travel. I have a pair of high speed, low drag compression panty hose (yep...sexeh as fack!) to wear for the flight in addition to the compression devices. I used miles for a first class seat so I hope for a smooth transition back to AK.
ACL reconstruction in General
Reader Comments (11)
Oh man, Brian. I'm sorry to hear about your injury. As you said, it just sucks. But I can't think of somebody better equipped to navigate all the decisions, and train hard during recovery than you. You will ski again, you will stand on the tops of peaks again, and when you ski down it's going to feel so good!
If you can believe it, my wife and I both injured our ACLs this season, in low speed falls on easy pistes. In February my wife completely tore her ACL. She just had surgery last week, and is recovering well. In April I partially tore my ACL and MCL and brusied my tibia. Two orthopedic doctors independently advised me against surgery, so I'm focusing on rehab. It feels like the right decision--my knee is very stable. At the same time, I know that I did damage my ACL. On the MRI you can see intact fibers stretched all the way across the knee joint, but you can also see some frayed/cloudy damage. That makes me worry about the future, but I'm just going to have to take it day-by-day. Maybe I can postpone the point when I hear that pop for another few years.
One of the things that I sympathize with in your posts is the awful cascade of feelings immediately following the injury. I suffered an awkward twisting fall, sort of a side slip mechanism with compression. It hurt immediately, but as I sat there on the piste holding my knee, I was not cursing because of the pain, but because I knew that all my plans for the next season and year were gone, or had changed.
I can also sympathize with the sort if sickening memory of replaying the fall and the feeling in my knee. I'm getting better at blocking it out, but I don't really like to think about it.
One thing you don't mention is the sort of self-judgement that follows such things. As a decidedly intermediate skier, I still feel like it was my fault that I injured myself, that if I was more skilled it would not have happened, that it was simply my lack of ability that lead to my fall, and so on. Of course, the fact that skiers of all ability levels injure themselves doesn't do anything to lesson my judgement/guilt. I'm working on that.
Assuming that the rehab continues in a positive direction, I have two goals for next season: 1) get as strong as possible, and 2) get professional instruction to improve my skiing so that i have less chance of falling.
There is one silver lining in all this: as my wife and I work through our injuries together (with our 8-year old daughter's help) it's brought us all a little bit closer!
Thanks for writing these posts--I wish my wife and I had this resource when we were weighing options for her surgery.
Hang in there!
Hey Bruno,
Thanks a ton for your thoughtful comment. It's crazy how many people I know are going through this this season. And I'm sorry to hear about you and your wife's injury. Obviously, her path is set and moving in the right direction. Yours is less clear, as you pointed out. I think your chosen path is the right one, even if it's fraught with some anxiety about the future. There is the potential for some healing response in your ligament since some fibers are intact. You can only hope for that. But after pain resolves you get back in the weight room and get as strong as possible. What else can you do? The added skill you seek will serve you as well. That "pop" is an odd sensation and one I hope you'll avoid.
It's funny about the PTSD you refer to. I have the whole episode on POV GoPro. I'm going to edit it down to the 5 stages of grief or something like that. The transitions I make in those 15 minutes are quite noticeable. Stay tuned for that, if you can bare it.
Recovery from this is long but at least I'll be riding a bike soon. I will miss summits this summer and for the bulk of next winter. It's hard to believe that I might take a good ol' American ski vacation and ride lifts and ski groomers in February. I hate riding the cable as you might guess but it'll be good training. I used to live in Sun Valley a long time ago and they have the best mountain in the country for groomed skiing. I'll skin up and ski down and make the most of it. Shit, maybe I'll even get a pair of real skis. That would be something. Also give me an excuse to ski the Vulcans I've had for about 6 years.
Thanks for the reply Brian. I like you analysis: what else can I do? It's not like I'm going to insist against two doctors orders and get in there to remove whatever healthy tissue exists, as much as I might like clarity!
Lots of interesting points to discuss and anecdotes to share about the recovery, but I throw out a concrete question that I think many people struggle with, and that I am sure you have thought about.
When you are doing your rehab, and when you start skiing again, do you plan to use a brace, for example, some kind of Donjoy? Opinions, including between doctors, seem to vary widely.
What do you think
Bruno,
Certainly that's an important question to answer and I will address it thoroughly in the appropriate "recovery" post later. But your general impression of controversy is absolutely correct. There is no consensus. One very busy and smart ACL surgeon I spoke with once made the point that any force great enough to rupture an ACL is not going to be prevented by a brace of any type. On the other hand, there is something difficult to measure about what braces add in terms of proprioception about the knee that may help in some way. Honestly, I think I will use a brace for the first year back to skiing. One is unlikely to find any solid scientific evidence to support such a decision but it'll make me feel more confident. That's worth something. I will not be using any sort of brace until that time, however.
Awesome Brian--I was thinking something along the same lines. Please keep up the posts about the recovery when/if possible, and all the best. Keep working hard...even if that means just being patient!
HI Brian: such an informative series -- thanks for sharing your expertise & best wishes for your expedited recovery...
Hey Patrick,
Thanks for reading and chiming in. I wish I could speed up biology but, short of that, I'm doing the most I can to get my butt back in gear. Cheers.
Great to hear your resilient recovery!
Bria,
Great blog and very informative. Very much with the fast and light ethic though not anywhere near your level of achievement. Very sorry to hear of your injury, having something stopping you enjoying doing what you enjoy is a b... I trust that having the opportunity to answer stupid questions from the likes of me is a welcome distraction!
Although I hear about ACL problems I am still not sure of the mechanics of it. I assume the tendon joins muscle to bone? So to cause damage you need strong muscles? The assumption is that as you exercise the muscle and tendon should strengthen equally, but...if you work out in the gym is there any danger of over strengthening the muscle?
I came through Nordic skiing and still ski telemark, (ok I realise it is in someways limiting, but I enjoy the turn, and is that not what it is all about? ) Why I raise this is the thought that telemark skiing may help protecting the joint on two fronts. There is more movement, so better a exercise, and of course harder so a better work out. Also with a bent knee is it more difficult to do damage to the joint.
Would very much appreciate to hear your expert opinion.
Cheers and a quick recovery,
Mark
Interesting questions Mark. Let's see what I can do here. First off, let's be clear about the nature of the tissue that makes up the ACL. It is a ligament rather than a tendon, as you mentioned. The difference is that a tendon joins a contractile muscle to bone whereas a ligament is a rather non-compliant tissue that connects bone to bone. In the case of ACL reconstruction, the tendon part of the muscle-tendon unit is sacrificed to replace the torn anterior cruciate ligament. In that way, tendons have similar characteristics to ligament.
As for the mechanics, the ACL keeps the tibia from translating forward under the femur. The ligament is most at risk when the knee is fully extended (0*) to about 30* of flexion. As the knee flexes further, there is less tension on the ligament unless additional force is placed pushing the tibia forward in relation to the femur. The ACL also restricts internal rotation of the tibia to some degree.
I don't think that the position of telemark skiing is necessarily protective but the free heel may decompress some of the forces needed to blow your knee. I haven't dug down on this and this is just my sense of things. A quick Google reveals little stratified information specifically about ACL ruptures in telewackers. I could be wrong. Certainly, when I was tele skiing in the late 70's through the 90's, the gear got heavier and heavier and less forgiving. The benefit of the free heel, if any, likely goes down as the stiffness of the boot goes up.
Certainly, the telemark turn is physically more difficult and the quad size of tele skiers is nearly mythical. But there is some belief in the ortho world that a disparity between quad and hamstring strength, so-called, "quad dominant", is a risk factor for ACL disruption.
Honestly, being skilled and strong is likely helpful but not ultimately protective 100% of the time. Fatigue likely plays a roll in ACL injuries. Avoiding the backseat is clearly protective and NOT falling backwards is a good thing to strive for.
Thanks for saying as much, Bren. Stay tuned for more.