Jun 23, 2018

leg reconstruction

Hey! It's been a while, so I'm here with a different kind of post. It's now been 5 months since my surgery and 10 months since I wrecked my leg (8/18 accident, 10/6 first surgery, 1/23 final reconstruction), and this post is on how a bunch of doctors (and my biology!) made me a new leg.

Note for squeamish people : basically every photo after this is a bruised or stitched-up or otherwise wrecked leg. I have the more 'scary' surgery photos hidden behind a spoiler button, but skip this post if medical photos make you uncomfortable.

It turns out all the accessible-route signs are above eye height if you're on crutches. It's probably even more out-of-sight if you were in a wheelchair.
So 10 months ago I fell off a bouldering wall at the gym. I hit the mattress with my left knee at a funny angle and heard a loud pop on impact (the same as when you open a sealed jar). I immediately knew I fucked up, even though it didn't hurt that much. To my surprise, I could walk on the leg so I hoped it might've just been a sprain. And x-rays from urgent care the day after showed nothing broken, so the doctor also thought it probably wasn't a big deal (they gave me a brace and told me to go ahead and walk on it)

Left leg super swollen compared to right

Bruising underneath the knee

Of course when I got the MRI results back, it was pretty clear I actually wrecked everything. The two major things were completely tearing an ACL and more importantly tearing half of my patellar tendon.

The MRI scans are really cool, too. If you haven't gotten an MRI before, you (the patient) can request a CD loaded with software to flip through axial, frontal, and side views (MRIs come in stacks of image slices). I also used this great website to compare my images to both healthy and injured knees.

Note: I am not a doctor. I backsolved knowing the radiologist's report and after being told exactly how/what/where was broken. Don't make armchair diagnoses without a medical degree.

Some quick MRI facts: My images are T2 weighted, so hydrated things appear lighter. Air is very dark. Muscles are supposed to be a neutral gray, and tendons are very dark. Fat is super bright.

Quick cheat sheet on knee anatomy
(from www.healthpages.com)

Focusing first on the ACL - this is one of the ligaments that runs diagonally inside the knee joint. It keeps the tibia bone from sliding in front of the femur, and is important for rotational stability.

On the left is a side view of the knee and on the right is the location of that image slice in frontal view. The normal ACL runs through a notch in the femur and connects to the upper bone at the back. There's... not supposed to be an air gap. (green circle)



If there's an air gap then that means the ACL is completely torn and retracted (think broken rubber band) somewhere. I backed up a few slices and found it curled against itself.


The other major injury was the patellar tendon. The patellar tendon below the kneecap and the quadriceps tendon above work to extend the leg. My fall partially tore it (transverse tear, like opening a sideways zipper)

Below is what the tendons should look like - completely black, solid strips.


And here's the broken side. Compared to the intact quadriceps tendon, the patellar tendon here looks frayed (because it is!)


The patellar tendon is the more important injury, but its rehab interferes with ACL recovery. So, the first surgery just dealt with the patellar tendon and left the ACL alone. It's not like I would be running anytime soon anyway.

The surgeon grafted on a cadaver's tendon and sewed it to the intact part. Then we both let biology and PT take care of the rest.

bandages came off 3 days post-surgery. Still very swollen.

1 week. Swelling's down
The first objective for PT was to regain range of motion, which took a few weeks.

Started off with only 20deg of flexion

Quick progression 3 days later.
Got full 130deg a month later (though right leg can get to 150deg)
The second objective was to regain strength in the quad muscles. They atrophied while the leg was immobilized and I needed them to be strong enough to handle an ACL. (The stronger the muscles, the less stress placed on the ligaments and tendons)

An interesting discovery I made during rehab was how important re-training neural connections was to regaining control of my leg. The majority of the recovery felt like the scene from Kill Bill where she commands her toe to move:


I had regained most of my muscle strength early on, but there was a delay between commanding my muscle to move and the knee actually bending.

Human biology is really cool. My leg didn't really feel like an extension of my body until I got the attached neurons to properly work in concert. According to videos like this, the same premise should apply when neurons seamlessly interact with inorganic muscles too.

Anyway, at the end of January I was deemed functional enough to get more parts. For this procedure, the surgeon opted to use an autograft (results in a stronger ligament but is a more invasive surgery) from my right (intact) knee.

(For anyone actually closely following this blog, yes I did fit two woodworking projects between the surgeries. Good deadline motivation!)

Me before getting new parts

The ACL reconstruction is also really cool. Nearly all of it required just two small portals (I think they also reopened some of the previous incision scar since it was available)

Arthroscope images

Navigating to the femoral notch and finding the torn ACL and meniscus

Drilling and reaming an access tunnel through the femur to pass the new graft through

Feeding new graft (attached with blue thread) and drilling screw holes into femur and tibia.

Tapping hole, adding screw eyelet, then attaching and tensioning new graft.

And finally, here I am 5 months later!
I've now been cleared to bike and go to the gym, and hopefully begin running, pivoting, and otherwise return to sports by the end of the year.

This is likely to be a perpetual in-progress project - not much is really known about what affects outcomes of major joint surgery. The evidence is both depressing (high likelihoods of developing early-onset arthritis and other complications within 10 years) and optimistic (aggressive first-year rehab is key)

Note the four circular scars on the left leg (2 from screws, 2 arthroscope ports). 
I'm planning on a 1year update in August on this topic, and also a post next month on a related walking-gait side project. Hopefully I'll continue to be on the up-and-up and will have more cool things to show then!

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