11 February 2012

How To Avoid Another Knee Surgery

On 1 February, 2012, I was scheduled to have knee surgery, but at the last minute I decided to cancel the surgery in favor of a more advanced treatment that requires no surgery. Here's a brief story to describe why I chose this route.

All of my knee problems began when I was in high school. I was a pole vaulter on the track team and during an early spring season track meet while warming up I landed wrong and experienced a medial collateral ligament (MCL) tear as shown in the image to the right. Prior to this injury, I never had any knee problems so this injury was a very big surprise. There was no surgery required for the injury, just immobilization. So after eight weeks in a brace from my hip to my ankle that utilized progressive motion during the last four weeks, my doctor at the time took my crutches and told me good luck. I was just a kid and completely inexperienced with knee injuries to know any better. Little did I know that this lack of proper rehabilitation would affect me for the rest of my life.

The following fall, I made the high school soccer team again and played soccer wearing a big knee brace. Because of the brace, people would come after me on the field to take me out and so I experience a number of sprains and strains throughout the season. But the very last game we played that year I twisted my knee badly and heard a loud pop. When my knee ballooned up in a matter of minutes to the point that I could barely bend it, I knew I had a bad injury. The result was an anterior cruciate ligament (ACL) tear. The image to the right shows an ACL tear, note that mine was a total tear and not a partial tear. Although I did extensive physical therapy, I wound up needing reconstructive surgery a few months later. At the time, this involved a large incision down the center of the knee so that a chunk of the patellar tendon to form a new ACL that was grafted to the femur and tibia by drilling new tunnels and using a chunk of the patella. At the time, it was pretty extensive surgery and damn painful. Essentially stealing from one area of the knee to fix another area of the knee.

After nearly five months on crutches and one month with a cane, I was already into some rigorous physical therapy involving cycling, swimming and weight resistance/training. In that time, I also discovered that literally the week after I had surgery, the doctors began doing a new type of ACL reconstruction. This new type of surgery was/is known as anthroscopy and requires only very small incisions making it much less invasive than the style of surgery that I had and, as a result, required much less recovery and rehabilitative time.

Through all the reading and research around knees that I have done since my first injury, I have also discovered that the immobility was the real downside to the old style of knee surgery. It left patients (including me) with a significant amount of atrophy or muscle deterioration. To this day, I have visible atrophy of the muscles in my right leg where all of my knee problems have occurred and it all comes back to the immobilization techniques used in my recovery.

Over the last 24 years since the ACL reconstruction, I have experienced zero knee problems. But in December of 2011, while playing indoor soccer, I experienced a knee injury and I new right away that something tore. A month later, I found out that I experienced two meniscal tears (one medial, one lateral) as well as a possible partial tear of the ACL -- what?! Yes, the one that I had reconstructed so many years before. Through my own research, the lack of swelling and the type and location of pain, I had already guessed that I had torn my meniscus, so that was not a surprise. But I was very surprised by the news that there is a partial tear in the ACL. But the doctors did tell me that they couldn't tell for sure if this tear occurred at the same time. The image to the right shows the meniscus and my tears are located near the rear of each meniscus.

So I decided to have surgery for the meniscal tears and during the surgery the doctor would determine if the ACL needed to be replaced. There were two options for the ACL reconstruction -- use part of my hamstring or use donated tissue from a cadaver. After researching both options, I decided I didn't want to steal from another part of my leg to mend my knee again, so opted for the donated tissue. My surgery would have been an anthroscopy which is good because it requires less recovery and physical therapy resulting in much less down time than I had when I was a teenager. As I researched and read about folks who had had meniscal tears fixed via the same surgery, I found many folks who had success with the surgery but I also found a surprising number of stories from people who said that their knees were worse off after such surgery. And they attributed these to a variety of issues including shaving the meniscus, stitching the meniscus and, in some cases, removal of part of the meniscus. For those who are not aware, the meniscus is a spongy, low blood flow tissue that pads the area in the knee where the femur meets the tibia. Injuries to this area can often cause arthritis over time and removal of any of the meniscus means less padding there. This is why you see folks who have had a bad experience with meniscal repair who walk so gingerly, especially up and down stairs. Given all of this, I didn't think that I had any alternatives, so I scheduled the surgery with the goal of being able to cycle this summer.

Only days before the surgery, my friend and neighbor informed me about an alternative to knee surgery called Regennex. Last year my neighbor had a persistent hamstring injury treated with a similar procedure known as Platelet Rich Plasma (PRP). PRP is a similar injection therapy for acute injuries that only uses the platelets from your own blood to promote healing. She experienced a full recovery to an injury that had been recurring for years. Needless to say, she is a fan. Regarding the Regennex treatment, she knows a woman who had the procedure last year and now is doing wonderful now. In fact, her case was even televised recently (see the video here: http://www.youtube.com/embed/DQ_H0yGLQh0?autoplay=0&). Being that the clinic where this procedure is being conducted is only a few miles from where I live, I decided to see if I could schedule an evaluation ASAP with the goal of avoiding surgery. A couple days later I was evaluated and found out that I was a candidate for this new procedure. Being that my first ACL reconstruction was essentially using the tail end of surgical techniques at the time, I didn't want to be in the same boat this time. I wanted to be on the cutting edge and to avoid surgery if possible. Also, knowing that I can have this new procedure more than once if necessary and that I can always opt for surgery at a later time if it truly becomes necessary, I decided not to have the surgery at this time in lieu of this new procedure.



I am currently undergoing the Regennex Stem Cell Plasma procedure. This procedure involves a series of treatments where they draw blood from my arm to get the platelets out of it and they take bone marrow aspirate from my hip to get the stem cells out out it. Then they combine these two compounds and inject it into the damaged areas of my knee to encourage it to grow new tissue and essentially heal itself. My hope is to experience minimal down time (I will only need to avoid cycling for a few days) and continue being active. For more information about the procedure, check out Orthopedics 2.0 - How Regenerative Medicine will Create the Next Generation of Less Invasive Orthopedics.

The one activity that I have begrudgingly decided to sit out on is soccer. I have always loved soccer and I still love soccer, but two of my three major knee injuries occurred playing soccer. As difficult as it will be to watch my wife and friends and kids still play soccer, I have decided it would be best not to play competitively anymore. I will continue to cycle, hike, run, swim and do nearly everything I love to do, just not competitive soccer.

Stay tuned and I will let you know how things turn out as I complete the rest of the Regennex procedure.

10 comments:

  1. Hey Bruce,

    I actually had very similar experiences to yours with my right knee. About 16 years ago I managed to tear off my entire ACL during an indoor rugby session. Only I did not know it. At the time I went to the doctor with a big swollen knee and he told me it is just bent too much and the swelling will go away, and it did.

    About a year later I went on a 5 week cycling & camping trip to iceland and noticed that when kneeling down to get into the tent I somehow dislodged my knee. I managed to manually 'popp' it back in several times. Suffice to say I consulted a different specialist soon after and he diagnosed the ACL tear. I got an arthroscopy where they realized I had torn my meniscus (they had to take 90% away) and I also tore off the ACL completely but it had surprisingly not deteriorated (as it often does). They sewed it back on to the bone with an artificial string made of a sugar material (the latest and greatest at the time). It was supposed to dissolve after about 6 months by itself - just in time when the ACL had reconnected with the bone. Of course it did not and inflamed badly in the knee. So another operation to remove the inflamed tissue was due about one year after the first. This time a normal cut rather than an arthroscopy. Of course followed by another 6 months of rehab.

    Then when that was done, I tore it off again about 1.5 years later. Another specialist, another arthroscopy. This time they cut out a bit of the hamstring which they braided several times and then attached to the upper and lower bone by drilling holes through them and using metal plates as counter parts. Sounds crude but it worked. I never had any problems with it apart from some minor knee pain every couple of years and the screws which I can feel under the skin ;).

    I went snowboarding and skiing several times since then and do the occasional fitness activity (nothing compared to what you are doing though). I guess if this were to happen today I would also go for the least invasive option given I had a couple of misses before they got it fixed.

    Cheers,
    Stefan

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  2. Hi Stefan! It's great to hear from you. I wasn't aware that you tore your ACL. Sounds like you've had a rough go of it as well, more surgeries than me anyway. My first ACL injury I blew mine completely as well. But when they did surgery, there was nothing left of it so they had to use a check of the patella tendon, drill through the femur and tibia and attach it with bone graphs and staples (I still feel one staple and bump it occasionally -- that smarts!).

    I'm not sure that I will be skiing anymore after my knee is healed again. I have decided not to ski this season, and just after we purchased non-transferrable ski passes. Instead, I will probably take up snowboarding as it is easier on the knees than skiing and my oldest daughter is interested in snowboarding, too.

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  3. that loud 'popping' noise sounds horrific!

    best of luck with the new treatment.

    br.

    baz.

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  4. Hello Bruce
    I’m 17 now and I have had the same problem recently, about a year ago while playing rugby while running I stepped quickly to the left and heard a loud pop from my right knee loud enough for people on the side lines to hear, I partially tore my ACL, tore my MCL completely and damaged some cartilage about 3 months later I had the reconstruction surgery. I was not completely ready to go back into sports but I love sports too much and while playing soccer I felt a click in my knee it wasn’t loud but was painful so I stopped playing... I think I might need another operation but I dislike operations... I just wanted some advice and wanted to know how this regenexx treatment is going for you and how long does this treatment take?

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  5. @liam, Check out the latest update about my knee and the Regenexx procedure:

    A Follow-Up on the Regenexx Stem Cell Procedure for my Knee

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  6. Hello, I am meeting with the Regennexx team on the 31dt of May/2016. Here are my concerns: how painful is the procedure? I hv full trust in the outcome but am really scared of the bone marrow extraction and the initial solutions injected in the knee!! Help. Advice. Evie

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    1. If you search my blog for the word 'regenexx' you will find all of my detailed posts where you can read much more:

      http://bsnyderblog.blogspot.com/search?q=regenexx

      Bruce

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  7. Hi Bruce! I'm a DPT student and am doing research on Regenexx to inform a group of PTs. I wanted to know what year or around what year was your original ACL tear in high school?
    Thanks in advance!
    Ariana -- Austin, TX

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    1. Hi Ariana,

      My original injury was a partial MCL tear in 1986. This was followed by a full ACL tear in 1987 for which I had surgery. Then in 2011, I experienced the meniscus tear along with a partial ACL tear. I then sought out the Regnexx treatments in 2012.

      Bruce

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