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.

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