patell dot org

I have an abiding interest in technology and technological change. For quite a few years, I’ve been working on a project that I called “Technophobia,” which has subsequently metamorphosed into a number of other things. The closest thing I have to a hobby these days is building and upgrading computers: I’ve built several computers over the past few years, including the desktop and home server that I currently use.

But today I’m interested in a form of technology that I don’t think about as often: medical technology. That’s because I’m having a rather complicated bit of knee surgery in a few hours.

In 1986, I tore my the anterior cruciate ligament (ACL) in my right knee, when I failed to execute a flying snap kick correctly during a Tae Kwon Do class. I landed awkwardly, and my knee twisted. It was the single most painful moment of my life: I can still remember the feeling of pain shooting up my body from my leg through the top of my head, cleaving my tongue to the roof of my mouth for an instant. I left the class and rode my bike home. Over the next few days, the swelling subsided, and the knee felt better, though every now and then there’d be a funny clicking sound. I continued to play squash. I consulted an orthopedist at Harvard’s University Health Services (UHS), but his speciality was backs rather than knees, so he referred me to someone else. I got an appointment for January. I asked the first doctor if it would be okay to ski on the knee, because I had plans to go to Lake Tahoe with a college buddy. The doctor suggested that I be very careful.

Apparently, I wasn’t careful enough. A mogul took me and my knee out on the first run, and I went down the mountain on a body board. Eventually, I saw the knee specialist, and he told me that I had torn my ACL and probably my meniscus. In the end, he did a menisectomy and an ACL reconstruction, stretching a patellar tendon across the back of the knee to serve as a ligament. I was in the hospital for a couple of nights and then transferred to the infirmary at UHS for a few days.

Last year, after my knee had begun to ache more and more, I consulted an orthopedist here in New York. He happened to be Dr. Andrew J. Feldman, head of Sports Medicine at St. Vincent’s Hospital and team physician for the New York Rangers, the hockey team I’ve been rooting for since 1973. He said that I had a varus knee and the beginnings of osteoarthritis. He advised a high tibial osteotomy, in which the knee would be staightened out by removing a portion of the tibia, followed by an ACL revision. The alternative, he said, was a total knee replacement much sooner than was advisable given my age and level of physical activity. He described my symptoms so perfectly that I was convinced right away and began to take steps to apply for leave from teaching.

When I saw him again this fall, after having a scanogram and a full length x-ray done of the leg, he described my knee  as “a massive train wreck waiting to happen.” And, he said, “I can see the light.”

So today we’re going to do it. Click below and read on, if you like gory details. What astonishes me is that the ACL reconstruction that I had done twenty years ago, which kept me in the hospital for nearly a week, is now out-patient surgery. I suppose that’s a sign of both advances in medical technology and the changes in our health care system that have occurred during the past twenty years. This procedure is more complicated, so I’ll stay in the hospital overnight.

Okay, you want the gory details.

Dr. Feldman decribed my previous ACL reconstruction as antiquated and suggests that today surgeons would try to preserve more of the meniscus than they did twenty years ago. 

As a result of the meniscus loss, the knee has developed arthritis and is out of alignment (varus knee). It’s bowed outward in such a way that on the side without much cartilage, the bones are rubbing against one another. I have some meniscus left but an aggressive arthritic condition on the inside of the right knee that rules me out as a candidate for a meniscus transplant. And the ACL repair is failing.

So Dr. Feldman is going to do a set of procedures that will likely take about three hours. He’ll first investigate the scene of the damage with an arthroscope, cleaning out any debris around the meniscus and checking to see whether I still have any articular cartilage lining the bones. If there’s none or very little, he may try to perform a microfracture procedure, which involves drilling little holes into the bone to let some marrow seep out along with special cells that create cartilage.

Next, he’ll prepare for an allograft of an ACL ligament, using donor tissue (yes, from a cadaver). 

Then, the really fun part. He’d originally described a “closing wedge” high tibial osteotomy. But now, he says, it’s more likely he’ll do an “opening wedge” high tibial osteotomy, in which a wedge of donor bone tissue (yes, that cadaver again) is inserted to lengthen the knee. He says this is a more recent technique that creates fewer stress points in the knee. (Here’s a link to an article from the American Journal of Sports Medicine. If you have full text access and aren’t squeamish, take a look.)

And then he’ll do the allograft.

I’ll be in the hospital overnight (for observation and pain management). The knee will be fitted with a sheath that plugs into a water cooling unit, so that when I’m home it can be cooled constantly at a set temperature rather than iced periodically. (It’ll be running 24/7 for the first three days.) I should be able to begin rehab in a week to ten days. I’ll be on crutches for about 8 weeks. NYU has generously given me full medical leave for the term.

Stay tuned.