Yesterday was the pre-operative appointment with the surgeon. First we met with the nurse who went over the paperwork with us. They made sure we knew where to check in and what time. Double checked medical history and ordered lab work.
Next in was the physician's assistant. She examines the knee and asked about the history of the knee injury. She also discussed the check in procedure and ordered the pain medication for after surgery.
Last was a meeting with the surgeon. He also examined the knee and went over the notes from prior appointments. He discussed the surgery and the different possibilities of what could happen depending on what they find when the get inside the knee. Basically they tell you they expect to replace the ligament but there is always the possibility they could discover other issues like issues with the medial plica or debris in the knee which once removed could eliminate the instability issues. So they plan for the open reconstructive surgery as the "worst case" situation but tell you they may do less depending on their findings.
At this time they discusses the healing process: 4-6 weeks for just arthroscopic or 3-4 months for reconstruction. The focus of the discussion was reconstruction so they discussed the brace and plans for PT. All was fairly vague because it depends on the individual ability to heal and the findings during surgery.
So the entire day was mainly complete paperwork, get blood work done and go over all possibilities and risks associated with surgery.
Next will be the actual surgery day on Tuesday March 23rd.
Tuesday, March 16, 2010
Tuesday, March 9, 2010
MPFL Surgery
In my initial post I described the events leading up to the decision for DD (Darling Daughter) to undergo reconstructive surgery of her MPFL (Medial Patellofemoral Ligament) due to reoccurring patellar subluxation and ongoing pain.
Here I will explain a little more about the surgery and some options we were given.
Autograft vs. Allograft
Our surgeon gave us the choice of harvesting a section of DD's hamstring (autograph) to use in the reconstruction, or using donor tissue from a donor/cadaver (allograft). DD's first reaction was to go with the autograft because the other felt creepy to her. The surgeon asked if she was a runner, which she is not, because he wanted to point out that with using her own hamstring she would lose about 5% of its efficiency and that would be a disadvantage when jumping hurdles, high jumps or other track events. There is also about a 1% advantage to the Autograft in the infection rate. However, research of the few related articles we could find on the web and talking to others familiar with the subject, DD decided to go with the Allograft, mainly because of the prospect of a quicker recovery and the athletic trainers all saying not to touch a healthy hamstring if she didn't need to. Using the Allograft (cadaver) means that a second open incision on the side of the knee to harvest the piece of hamstring isn't necessary, nor is the healing of the hamstring an additional hindrance.
Scheduling the Surgery
The next step towards scheduling the surgery was scheduling a CAT scan. Images of both knees were taken in order to make comparisons and take measurements for ordering the donor ligament. These are also used to ensure proper alignment of the knee and ligaments during the reconstruction. With a confirmed date for the CAT scan, the nurse who schedules the surgeries was able to set a date. This required the juggling of two schedules, because it takes two surgeons to perform the surgery. The date was set for March 23, 2010. DD was not happy with the date being 6 weeks out because she knows there is a long period of rehabilitation ahead and she wants to be back on the soccer field for the new season with club soccer. Six weeks also seems like an eternity while anxiety is building and you are living with daily pain.
The Surgical Procedure
The surgery will be both arthroscopic and open incision in nature. The arthroscopic portion will entail making 3 small buttonhole-sized incisions through the skin to pass through the pencil sized instruments. A small lens and lighting system magnify and illuminate the interior of the knee. The arthroscope is attached to a miniature camera that enables the surgeon to look around and to clean up the area. Any discoveries of small "floater" fragments can be removed and abrasions smoothed away.
The open incision will be a longitudinal cut, 3-4 inches in length, midway between the patella and the medial epicondyle. Through this incision the graft will be passed and anchored. Prior to fixation the knee will cycled several times from full flexation to full extension with the graft under tension. This pre-stretches the graft to eliminate any give. The attachment point for the reconstructed MPFL are the superior patella for the lateral attachment and the superior aspect of the medial femoral epicondyle for the medial attachment. Attachment techniques may include metallic interference screws, bioabsorbable interference screws and endo buttons. We were given a quick explanation of the surgery which will include drilling through the femur and looping the donor graft through and around but we will get more detail and a better description at the pre-op appointment, especially since we have had time to do research and can walk in with specific questions in hand.
Next up: Pre-Op
DD's next appointment is for Pre-Op on March 15, 2010. Meanwhile, she continues with physical therapy to build up strength in the muscles and tendons so she is as strong and fit as possible going into surgery. At this point PT has been reduced to once weekly because the therapists have said they have done as much as they can to get her ready and are limited with what they can do until after surgery. The days after PT are the most painful and it takes Advil just to get out of bed. I will post again after the Pre-Op appt to give more details and anything new we've learned before surgery.
Here I will explain a little more about the surgery and some options we were given.
Autograft vs. Allograft
Our surgeon gave us the choice of harvesting a section of DD's hamstring (autograph) to use in the reconstruction, or using donor tissue from a donor/cadaver (allograft). DD's first reaction was to go with the autograft because the other felt creepy to her. The surgeon asked if she was a runner, which she is not, because he wanted to point out that with using her own hamstring she would lose about 5% of its efficiency and that would be a disadvantage when jumping hurdles, high jumps or other track events. There is also about a 1% advantage to the Autograft in the infection rate. However, research of the few related articles we could find on the web and talking to others familiar with the subject, DD decided to go with the Allograft, mainly because of the prospect of a quicker recovery and the athletic trainers all saying not to touch a healthy hamstring if she didn't need to. Using the Allograft (cadaver) means that a second open incision on the side of the knee to harvest the piece of hamstring isn't necessary, nor is the healing of the hamstring an additional hindrance.
Scheduling the Surgery
The next step towards scheduling the surgery was scheduling a CAT scan. Images of both knees were taken in order to make comparisons and take measurements for ordering the donor ligament. These are also used to ensure proper alignment of the knee and ligaments during the reconstruction. With a confirmed date for the CAT scan, the nurse who schedules the surgeries was able to set a date. This required the juggling of two schedules, because it takes two surgeons to perform the surgery. The date was set for March 23, 2010. DD was not happy with the date being 6 weeks out because she knows there is a long period of rehabilitation ahead and she wants to be back on the soccer field for the new season with club soccer. Six weeks also seems like an eternity while anxiety is building and you are living with daily pain.
The Surgical Procedure
 |  |
The surgery will be both arthroscopic and open incision in nature. The arthroscopic portion will entail making 3 small buttonhole-sized incisions through the skin to pass through the pencil sized instruments. A small lens and lighting system magnify and illuminate the interior of the knee. The arthroscope is attached to a miniature camera that enables the surgeon to look around and to clean up the area. Any discoveries of small "floater" fragments can be removed and abrasions smoothed away.
The open incision will be a longitudinal cut, 3-4 inches in length, midway between the patella and the medial epicondyle. Through this incision the graft will be passed and anchored. Prior to fixation the knee will cycled several times from full flexation to full extension with the graft under tension. This pre-stretches the graft to eliminate any give. The attachment point for the reconstructed MPFL are the superior patella for the lateral attachment and the superior aspect of the medial femoral epicondyle for the medial attachment. Attachment techniques may include metallic interference screws, bioabsorbable interference screws and endo buttons. We were given a quick explanation of the surgery which will include drilling through the femur and looping the donor graft through and around but we will get more detail and a better description at the pre-op appointment, especially since we have had time to do research and can walk in with specific questions in hand.
Next up: Pre-Op
DD's next appointment is for Pre-Op on March 15, 2010. Meanwhile, she continues with physical therapy to build up strength in the muscles and tendons so she is as strong and fit as possible going into surgery. At this point PT has been reduced to once weekly because the therapists have said they have done as much as they can to get her ready and are limited with what they can do until after surgery. The days after PT are the most painful and it takes Advil just to get out of bed. I will post again after the Pre-Op appt to give more details and anything new we've learned before surgery.
Sunday, March 7, 2010
Background on Injury
My 16-year-old daughter is getting ready to have knee surgery later this month to replace her MPFL (Medial Patellofemoral Ligament). While trying to research the type of surgery she was having I was surprised at the limited amount of information that was available online. We decided to create this blog for two reasons: 1. to give a place where friends and family can get up-to-date information on how things are progressing and 2. to provide information to anyone else who may end up in the same situation.
This first post will give the background and what it took to get where we are today. I think it is important to know the symptoms and other possible diagnoses that were considered.
Background:
My daughter is a soccer player and has played since she was 4 years old. In October of 2009 (club season) she planted her left foot to take a shot on goal when she was hit from the side and her knee "buckled." DD (darling daughter) felt the knee buckle and a sharp pain just on the inside, lower kneecap. We saw the knee give and noticed her limping. She came off the field just after the foul and began icing the knee which swelled quickly. After a short rest she felt better, still in pain but tolerable, so she finished the game.
In the weeks following DD took soccer lightly and tried to rest the knee. She iced it, took anti-inflammatory medications and stretched it a lot. She said the knee still hurt but seemed to be improving slowly.
December 2, 2009...High School season had begun...another game, another collision in the box this time with the keeper. The keeper ran into the side of DD's left knee. DD felt a sharp pain but kept playing. In the next couple of days following the collision DD's pain increased, repeated swelling around kneecap and an occasional popping and/or cracking sound would happen which was always accompanied by a sharp pain.
DD went to the athletic trainer at her school to have the knee taped. The athletic trainer did not like the way the knee looked and instead had her ice and rest. After a couple days she told DD she would be unable to participate with the high school team without medical clearance. The asst. coach who is a medical doctor was asked to evaluate the knee and worried about a possible MCL injury so we were told to go to the Orthopedist.
First Visit to Orthopedic Surgeon:
Off we went to the first appointment with the Pediatric Orthopedic Surgeon. He was concerned with the swelling, pain and location of the tenderness. This doctor felt the MCL was fine but was fairly certain DD had a torn meniscus. He ordered an MRI and put DD on crutches and in an immobilizer until the MRI could be done. The immobilizer was due to increasing pain. DD was in pain all the time and the knee was popping often, swelling a lot, but it was the pain that was becoming unbearable.
MRI was done December 26th and the results were given at a follow up appt on December 28th. At this point we were told the MRI "was for all intents and purposes normal." DD was told to begin physical therapy immediately and have a follow up appt in a month.
Physical Therapy:
In the first physical therapy appt the therapist told us DD seemed to have a sprained MCL based on his physical examination. He had DD do exercises, stretches and so forth with that in mind. PT caused the pain to increase. DD did not feel she was improving and the popping/cracking with pain continued...sometimes up to 3-4 times a week.
Follow Up Appt with Orthopedic Surgeon:
Four weeks later we returned to the surgeon having had almost no success with Physical Therapy. At this time we were told that is was possible DD had problems with her Medial Plica. "
A medial plica is a remnant of an embryonic partition in the knee, and runs along the inner aspect of the kneecap. About 50% of the population has this remnant and the MRI did show there was a plica. Unfortunately the MRI does not show injury or damage to the plica so the only way to know for sure is to undergo Arthroscopic surgery to "look." At this time we were told we needed to see another surgeon since ours did not do this type of surgery. Plica removal is Arthroscopic surgery with a 3-4 week healing time and would prevent this injury from reoccurring in the future.
Second Orthopedic Surgeon Visit:
On February 9th we had our appt with our new Orthopedic Surgeon. He took X-rays on the knee and review the MRI and PT comments. He then did a physical exam on DD's knee and questioned her thoroughly about exactly what happened when the injury occurred and what symptoms she was having now. After all that we were told he did not believe she had an issue with her Medial Plica. He said it was very clear she had sustained a traumatic injury to the knee and sustained a "subluxation" on the knee cap - also known as a Patellar Subluxation or Kneecap Dislocation.
A subluxation means that the kneecap manages to get out of the socket partially, then comes right back into place. Often people will complain of pain and clicking. These people will often feel their kneecap shift around as well. This is the source of the popping DD was hearing which was following by sharp pain. The doctor upon examine could feel how "loose" the joint was and that the kneecap was "floating" around and not stable. The subluxation had damaged her Medial Patella Femoral Ligament (MPFL).
Two Options:
We were given two possible options to treat the injury.
First we were told DD could continue PT for another 3-4 months to strengthen the Quad and hamstrings to compensate for the injury. The MPFL would never be normal but PT could offer a surgery free option. We decided against this for two reasons. First, the 5-6 weeks of PT up to this time had offered no relief whatsoever and the kneecap was still dislocating regularly. Second, upon researching the option we came to find that PT alone following a traumatic injury of this type has a 44% failure rate and the only stories we could find showed athletes with traumatic injury almost always had to have surgery at some point due to continued problems with the joint.
Second option was surgery to replace the MPFL. This is the option we have chosen. This surgery has a 94-96% success rate (depends on source) for a full recovery. We felt this was a much better option and thus far both in our research and questioning others all agree this was the better option for long term.
The actual surgery is called a Left Knee Arthroscopic Lateral Release, and Open Medial Patellofemo. Surgery is scheduled for March 23rd 2010.
I will post again with specifics on the actual surgical procedure...
This first post will give the background and what it took to get where we are today. I think it is important to know the symptoms and other possible diagnoses that were considered.
Background:
My daughter is a soccer player and has played since she was 4 years old. In October of 2009 (club season) she planted her left foot to take a shot on goal when she was hit from the side and her knee "buckled." DD (darling daughter) felt the knee buckle and a sharp pain just on the inside, lower kneecap. We saw the knee give and noticed her limping. She came off the field just after the foul and began icing the knee which swelled quickly. After a short rest she felt better, still in pain but tolerable, so she finished the game.
In the weeks following DD took soccer lightly and tried to rest the knee. She iced it, took anti-inflammatory medications and stretched it a lot. She said the knee still hurt but seemed to be improving slowly.
December 2, 2009...High School season had begun...another game, another collision in the box this time with the keeper. The keeper ran into the side of DD's left knee. DD felt a sharp pain but kept playing. In the next couple of days following the collision DD's pain increased, repeated swelling around kneecap and an occasional popping and/or cracking sound would happen which was always accompanied by a sharp pain.
DD went to the athletic trainer at her school to have the knee taped. The athletic trainer did not like the way the knee looked and instead had her ice and rest. After a couple days she told DD she would be unable to participate with the high school team without medical clearance. The asst. coach who is a medical doctor was asked to evaluate the knee and worried about a possible MCL injury so we were told to go to the Orthopedist.
First Visit to Orthopedic Surgeon:
Off we went to the first appointment with the Pediatric Orthopedic Surgeon. He was concerned with the swelling, pain and location of the tenderness. This doctor felt the MCL was fine but was fairly certain DD had a torn meniscus. He ordered an MRI and put DD on crutches and in an immobilizer until the MRI could be done. The immobilizer was due to increasing pain. DD was in pain all the time and the knee was popping often, swelling a lot, but it was the pain that was becoming unbearable.
MRI was done December 26th and the results were given at a follow up appt on December 28th. At this point we were told the MRI "was for all intents and purposes normal." DD was told to begin physical therapy immediately and have a follow up appt in a month.
Physical Therapy:
In the first physical therapy appt the therapist told us DD seemed to have a sprained MCL based on his physical examination. He had DD do exercises, stretches and so forth with that in mind. PT caused the pain to increase. DD did not feel she was improving and the popping/cracking with pain continued...sometimes up to 3-4 times a week.
Follow Up Appt with Orthopedic Surgeon:
Four weeks later we returned to the surgeon having had almost no success with Physical Therapy. At this time we were told that is was possible DD had problems with her Medial Plica. "
A medial plica is a remnant of an embryonic partition in the knee, and runs along the inner aspect of the kneecap. About 50% of the population has this remnant and the MRI did show there was a plica. Unfortunately the MRI does not show injury or damage to the plica so the only way to know for sure is to undergo Arthroscopic surgery to "look." At this time we were told we needed to see another surgeon since ours did not do this type of surgery. Plica removal is Arthroscopic surgery with a 3-4 week healing time and would prevent this injury from reoccurring in the future.
Second Orthopedic Surgeon Visit:
On February 9th we had our appt with our new Orthopedic Surgeon. He took X-rays on the knee and review the MRI and PT comments. He then did a physical exam on DD's knee and questioned her thoroughly about exactly what happened when the injury occurred and what symptoms she was having now. After all that we were told he did not believe she had an issue with her Medial Plica. He said it was very clear she had sustained a traumatic injury to the knee and sustained a "subluxation" on the knee cap - also known as a Patellar Subluxation or Kneecap Dislocation.
A subluxation means that the kneecap manages to get out of the socket partially, then comes right back into place. Often people will complain of pain and clicking. These people will often feel their kneecap shift around as well. This is the source of the popping DD was hearing which was following by sharp pain. The doctor upon examine could feel how "loose" the joint was and that the kneecap was "floating" around and not stable. The subluxation had damaged her Medial Patella Femoral Ligament (MPFL).
Two Options:
We were given two possible options to treat the injury.
First we were told DD could continue PT for another 3-4 months to strengthen the Quad and hamstrings to compensate for the injury. The MPFL would never be normal but PT could offer a surgery free option. We decided against this for two reasons. First, the 5-6 weeks of PT up to this time had offered no relief whatsoever and the kneecap was still dislocating regularly. Second, upon researching the option we came to find that PT alone following a traumatic injury of this type has a 44% failure rate and the only stories we could find showed athletes with traumatic injury almost always had to have surgery at some point due to continued problems with the joint.
Second option was surgery to replace the MPFL. This is the option we have chosen. This surgery has a 94-96% success rate (depends on source) for a full recovery. We felt this was a much better option and thus far both in our research and questioning others all agree this was the better option for long term.
The actual surgery is called a Left Knee Arthroscopic Lateral Release, and Open Medial Patellofemo. Surgery is scheduled for March 23rd 2010.
I will post again with specifics on the actual surgical procedure...
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