Choosing an orthopedic surgeon

[Nords]

Anyone here had a total ACL replacement/transplant, not "just" a rebuild? Any advice or regrets? Rich, are you aware of any evidence-based medical research into this?

Both of my knees have been without anterior cruciate ligaments for nearly six years, although I didn't get it diagnosed until July 2006. I've continued to do tae kwon do and heavy yardwork with custom-fit orthopedic braces for over a year. I've recovered from multiple sprains of the remaining ligaments, my full-squat flexibility is back, and my knees are stronger than ever. I feel occasional pain from damage to each medial meniscus and the knees stiffen up after 30 minutes of sitting but there's no more swelling and I've been ibuprofen-free for over a month. I'm two steps (and about 18 months away) from my black belt. Life seems pretty good and I expected to avoid surgery indefinitely.

One of the reasons I chose braces over surgery last year was reading & hearing many reports about lackluster results of rebuilding ACLs. After six years I'm not sure how much ACL I have left to work with and the crusty ol' orthopedic surgeon was reluctant to operate. With all the patience & bedside manner of a Marine drill sergeant, he expressed the opinion that he didn't want to "waste his time" rebuilding my ACLs if I was just going to keep doing martial arts. Well, fine, then, no surgery for me.

Over the last two months, though, I've had a problem with my right knee (the "good" one) four times. Each happened after considerable exertion, mostly without braces. The first time was just raising my right leg to step up into the tub-- something in my knee twitched (the way a neck tendon snaps) and suddenly I couldn't extend my right leg or put any weight on it. I thought the pain was coming from the lateral collateral ligament. About two minutes later something snapped back into place and everything was fine-- no problems, no pain. A couple weeks later and a month later the same thing happened with the same results.

The fourth time was last Thursday's dinner when I tried to stand up from my chair. This time, however, things didn't "snap back" into place and I spent the rest of the evening with a bent leg and a bottle (of ibuprofen). The night was uncomfortable and next morning wasn't much better so I got an appointment with the local clinic's duty D.O. Somewhere during his prodding & twisting, the snapback happened and everything was fine again. Whew.

This new doctor, a 30-something surferdude right on my wavelength, says that it's my right lateral meniscus grinding and "locking up" with what's left of the cartilage. He was horrified ("Hey, Dr. Jones, Dr. Smith, you wanna come see this?") by how lax & flexible my knee joints are. He agrees that martial arts can be a risk, but he thinks that my knees are so floppy that I'm taking a far greater risk just walking around... and randomly grinding my remaining cartilage on my frayed meniscii. Orthopedic braces are "safer" but they're two pounds each of neoprene & carbon fiber & Velcro straps-- way too hot to wear 24/7.

Luckily wearing the braces full time isn't a good idea either because knees atrophy quickly (patients actually get psychologically addicted to braces). Squats & surfing and even controlled martial arts will keep my knees strong but his opinion is that their laxity makes them a ticking time bomb. He wouldn't pick a definite number but he says that the crepitation is bad, osteoarthritis has already started, and I should be in constant pain. In 15-25 years I'll be facing two total knee replacements, maybe sooner if I keep having these "incidents".

Aside from wearing braces more frequently for exertion (all yardwork & honey-dos) he recommended ACL transplants. One source is a long, thin slice of your patellar tendon and another source is cadavers. (As you can imagine, each source has its issues.) The "operation" pretty much drills out & taps the femur & tibia, screws in the tendon, and glues it down-- perhaps with a little hardware to hold things in place. It's all done arthroscopically. A mere 6-12 months (each knee) later you're back on the road to recovery.

This isn't the kind of surgery where you fly to the Mayo Clinic or Hopkins and a week later fly home. Unfortunately this morning I read that there are only 48 orthopedic surgeons in the entire state and I've already crossed one of them off my list. No offense intended to the rest but the remaining talent pool might be kinda shallow.

So during the next month I'll have another MRI at [-]Crippler[/-] Tripler Army Medical Center and consult with another randomly-assigned orthopedic surgeon. I'm in no hurry and I'm hoping to hold off at least three more years until our kid's in college and we're empty-nesters. That'll give me plenty of time to [-]work through the five stages[/-] research the options and maybe even choose a rock-star orthopod.

Spouse has pointed out that if I'm going to be immobilized then it might be worth [-]vacationing at[/-] going to Bumrungrad. I wouldn't mind visiting there just to pay for a good set of MRIs, X-rays, and whatever other imagery they want [-]me to pay for[/-] to do. It'd make a heckuva second opinion.

Any other ideas? Anything else I should be researching?

 

[simple girl]

Hey Nords,

In terms of choosing an orthopedic surgeon, my advice is to call several outpatient physical therapy clinics and ask to talk to one of the therapists. Ask them who they would go to if they were going to have an ACL reconstruction. PT's know who the good surgeons are in the area...they see their surgical results all the time (note, some clinics don't see alot of ACL's - you may need to call around to find sports/ortho clinics). After you've asked several PT's you probably will start seeing a consensus/trend as to who is the best in the area. Also, one other strategy is to find out who is the orthopedic surgeon for your local pro sports team(s). They obviously only will choose the best.


I agree with your doc...since you are so active, you are putting lots of stress on your knees and you don't have normal ligamentous stability...so you are at high risk to injure the meniscus and develop osteoarthritis prematurely. In my experience, ACL reconstructions are done for those who expect to continue to be highly active (ie. YOU)...they can be deferred for those who won't place high demands on their knees.

Hope this helps!

 

[Moemg]

Nords ,
I've worked for sports medicine Orthopedic doctors for a few years and they do that operation on a routine basis .So If I were you I'd head to A top Sports Medicine Group .The Group I worked for handled the american Soccer Team ,the top tennis players ,The Pittsburg Pirates and the (boo ) Tampa Bucaneers .Look for a group similar to that .

 

[Rich_by_the_Bay]

Except to the person having the surgery, it's pretty routine among knee orthopods and many sports-oriented orthopods. Personally I have minimal knowledge in this area of medicine, so TIFWIW...

Here's something to thing about. If you have a fair amount of post-traumatic arthritis in the knees you may be looking at knee replacements down the road. While it varies widely, those are good for 15 years, maybe more, if not abused. So, as a mere hatchling you may be looking at a handful of those over the years.

The arithmetic supports deferring the ACL surgery as long as possible if your symptoms are mild (as it sounds they are). More arithmetic: Orthopod Sparky the Surfer Dude has 3 years of experience. Orthopod Sawbones the Curmudgeon has 30. Sparky has not had to revisit the long term results of his own surgeries yet. Sawbones has had his share of "oops" moments, conveniently at the expense of others before you.

Good luck whatever you decide. Good suggestion about asking the physical therapists who's good, and also the nurses on the surgery units.

 

[packrat44]

Good suggestion about asking the physical therapists who's good, and also the nurses on the surgery units.

Agree totally with Rich.

My DW is a RN (FIREd in Jun 07). She would always check with other RNs prior to any surgery for us or family members. The RNs who perform in the operating room and recovery usually have a good knowledge of how a doctor performs in surgery.

 

[TargaDave]

Nords,
One thing to think about as an alternative to surgery is prolotherapy:

Caring Medical - Sports Injuries - Surgical Alternatives to Knee Ligament Surgery

I had it done on my lower back after years of accumulated sports injuries and weakening scar tissue from disc surgery I had back in the 80's. It's basically a treatment for "ligament laxity". I went from barely walking 10 years ago to playing hard ever since (as the avatar shows). Same treatment also also cured me of a worsening carpal tunnel condition in my right wrist. Unfortunately people equate prolotherapy to acupuncture and other black-art treatments so it tends to get some negative press. Results are not instant and it's expected effectiveness depends on your exact condition. Also requires a very skilled doctor. The guy in the link is one of the best in the world at this. At least an option to think about.

 

[donheff]

Good grief Nords. Here I have been whimpering about my sore tendons from a busted wrist and you are leaping around on knee stumps. I second the recommendation on a sports medicine clinic - you definitely want docs who understand your [-]obsessions[/-] passions. But AFTER you get your black belt you really ought to consider going into wussy mode on the martial arts if that will destroy your knees. Look into something that you can get hooked on that doesn't tear them up so much

 

[Cb]

As you know I've recently had an ACL repair (cadaver graft) and abrasion arthoplasty on my femur to address a Grade IV chondral defect. Here are a handful of random thoughts to consider:

- a few years back I was pretty disappointed by my own primary care doc's response to my questions following lousy lipid profile #'s and started searching for a new one. I'd established a pretty good relationship with the company doc at work, and asked him if he knew of a primary care doc who was young, well educated, was a fitness buff himself, and was biased toward exercise/dietary changes rather than writing prescriptions. He referred me to an excellent doc (recently rated by colleagues as a "Best Doc In Cincinnati"). I've been pleased with every referral the new guy has given me...he's remarkably candid about the specialists in the area. An old guy like you needs a great GP.

- interesting tidbit - while Googling the 'rockstar' orthopedic doc (he's the Bengal's othro guy, as well as the UC Bearcat's basketball) my GP referred me to I learned that top-shelf NFL players rarely use the team doc for their post-injury treatment...over the past decade agents have steered them to out-of-town docs who are not beholden to the team owners.

- 'rockstar' orthopedic docs delegate. I saw my guy twice prior to surgery (closing the sale), and again 2 days after, but then he was mighty scarce for the next 2-3 months. Even though I was complaining mightily about the (typical, it turns out) slow receovery I wound up with Physician Assistants for 3 visits straight after working with the scheduling gals to make sure I'd see the doc himself. One appointment was even covered by the Assistant's Assistant.

- my surgeon said my cartilage was in such lousy condition as a result of having a loose knee for two decades following my ACL tear and old-school repair. I may have been lucky to have re-injured this spring before the cartilage had deteriorated more.

- The ACL replacement is a piece of cake. He said guys my age (48) generally do better with cadaver grafts rather than robbing our own tendons, though he'd take a peek at mine to see if they were sufficiently stout to whittle on. They weren't.

- the abrasion chrondroplasty (bone-grinding to stimulate the formation of scar or 'pseudo-cartilage') probably added 12 weeks to my rehab. During post op visits the doc (and his PA's) were very pleased with the tightness of my knee joint with the new ACL, and not a bit surprised by the sharp pain I experienced whenever I'd load the knee in the grind zone. It was pretty frustrating watching ACL-only (and total knee replacement!) patients at rehab going up and down steps, jogging on the treadmill, and hopping around a few weeks out of surgery while I was still on crutches six weeks out trying to regrow cartilage.

- abrasion chondroplasty and the more popular micro-fracture techniques to regrow cartilage are temporary measures...it helps for 2 - 10 years, depending on how quickly you use your knees up. My doc and the physical therapists tell me that even the stationary bike and elliptical will accelerate the deterioration of the pseudo-cartilage, so I've devised a circuit-training weight routine that keeps me in the aerobic zone for 30-45 minutes stright 4X per week with minimal knee loads/cycles (recall the lipid profile mentioned above)

- from what I read, total knee replacements are wonderful things. I met a guy in his 70's who just had his 2nd knee done. He said "Just do it...I should have done mine years ago...my knees basically changed my whole personality...I was angry all the time, couldn't sleep, didn't want to go out, etc..."

- Trouble is TKR's typically only last ~15 years because the bone/artificial joint interface eventually deteriorates, and they can only cut back your femur far enough to do a second installation. I hope there is progress in the next decade allowing a third replacement...longer-lasting bone/joint interfaces, or maybe less cutting for each installation?

- Fize yew I'd track down a workholic general practioner / weekend athlete with a 32 inch waist and big shouders who's ~10 years younger than you for this referral and others to come.

- Find a great surgeon, even if you have to go to SoCal.

- Follow the post-op & rehab to the letter...let them know you're a man of leisure so there are no work-related constraints to your recovery.

You might want to read "Younger Next Year"

Amazon.com: Younger Next Year: A Guide to Living Like 50 Until You're 80 and Beyond: Books: Chris Crowley,Henry S. Lodge

The authors outline a pretty thorough approach to diet and exercise for old doods, but one of the more compelling suggestions they make is that if a reader finds that the comprehensive diet/exercise/meditation routine they recommend is just too much trouble, and just wants to know what is most important, they say to "keep your legs under you" as you age, because once you wind up in a wheelchair things start to go south in a hurry.

Cb O0

 

[NewBones]

Nords,
I agree with you. Choosing an ortho is not easy.
I recently had a hip resurfacing surgery. No insurance from my employer and no money to be able to handle the bill myself, I chose to go to India for the surgery to avail of what has been termed "medical tourism". The hospital facilities could easily pass off for a 5-star hotel.. The surgeon had done hundreds of such surgeries. And they treat you like royalty
It's been 6 months since I returned from India and I'm obviously happy with the results. The best part is I saved so much.
Good luck!

 

[NewBones]

BTW, here's where you can learn more about medical tourism.

Good luck..

 

[pfpelican]

NewBones... I see you in the testimonials...right above the link for an estimate for hip resurfacing. Do you get anything from referring people to this site?

 

[Nords]

Thanks again for all the advice, everyone, and especially for all the blow-by-blow details, Cb. I had a page of questions for the doctor and he was struggling to get out of the exam room.

I've finished an MRI and a consult. I could start an entire new thread about medical bureaucracy and HIPPA paranoia but my complaints are probably a nitpick next to the typical patient experience.

BTW if you want to feel good about your physical condition, let alone your mental attitude, you should go hang out in an orthopedic surgeon's waiting room. I think I should also invest in the medical tech companies that sell casts, braces, crutches, wheelchairs…

A neighbor works for Kaiser's physician-recruiting branch and volunteered her networking skills. Out of Hawaii's other 47 orthopedic surgeons, I think I hit one in the top three. Dr. Kan is recommended by Kaiser's local chief of surgery. He's 47 years old, played on the San Diego Chargers, assisted with medical support at the 1992 Olympics, and helps coach a high school football team. He and three of his partners rebuild the UH volleyball & football teams.

He laughed when I asked if he could handle my knees, tae kwon do is fine with him, and he's in no hurry to operate. He showed me on a model how the tibia can move around a torn ACL to cause pain in the side & back, exactly my symptoms. It's minimized by consciously clenching the muscles around the knee before stepping up or down, and he agreed with even more weight training to strengthen the joint because the remaining ligaments won't take up the slack. I have enough meniscus (meniscii?) and cartilage to make it for a few more years if I don't run a lot. No worries.

Oddly enough, orthopods diagnose more torn ACLs by joint manipulation (laxity) than by MRI. He wasn't interested in more MRIs or other imagery (no need for Bumrungrad). Good thing, too, since Tricare only reimbursed $61 for a $227 MRI bill. He typically transplants ACLs as outpatient arthroscopic surgery with either a general anesthetic (preferred) or [-]heavy restraints[/-] a local. (Some patients have a problem when the drill bites through their femur & tibia.) They prefer slicing a strip off your kneecap tendons for their replacement ACLs instead of cadavers. Meniscus/cartilage damage is trimmed as necessary. As with Cb, post-op is a lot [-]more brutal[/-] faster than I expected-- a couple hours in a recovery room, oxycodone (woo-hoo!), an orthopedic brace, icepacks, and a pair of crutches. A cold therapy unit can be used to chill & move the joint, but Dr. Kan says they've had reimbursement trouble and there's no evidence that it improves or speeds ACL healing. Physical therapy starts the next day, the crutches are returned a couple weeks later, and the brace is off after the first month. Move or die. Next patient! The first knee could be back to full strength within four months and the second knee could be done anytime after that.

He agrees that I can wait at least three more years, by which time my daughter and I should have our black belts and she'll be in college.

He said the reason that Hawaii has so few orthopedic surgeons is because Medicare equates Hawaii's reimbursement criteria with Arkansas. Of course housing is a tad more expensive and everyone's lobbying hard to change this, but he doesn't see himself retiring anytime soon. Rich, how in the world does reimbursement get set like this, and how is it fixed?

Cb, I told my spouse that your DW left town after your surgery. My DW is much more cheerful about the whole thing now.

 

[Khan]

BTW if you want to feel good about your physical condition, let alone your mental attitude, you should go hang out in an orthopedic surgeon's waiting room. I think I should also invest in the medical tech companies that sell casts, braces, crutches, wheelchairs…

I recall taking my mother to the arthritis doctor and observing the folks in the waiting area: canes, crutches, braces, walkers, wheelchairs.

 

[Alan]

I recall taking my mother to the arthritis doctor and observing the folks in the waiting area: canes, crutches, braces, walkers, wheelchairs.

I had to have back surgery 17 years ago and hanging around the neorosurgeons' waiting room was pretty depressing also

 

[Oliver]

Oddly enough, orthopods diagnose more torn ACLs by joint manipulation (laxity) than by MRI. He wasn't interested in more MRIs or other imagery (no need for Bumrungrad). Good thing, too, since Tricare only reimbursed $61 for a $227 MRI bill. He typically transplants ACLs as outpatient arthroscopic surgery with either a general anesthetic (preferred) or [-]heavy restraints[/-] a local. (Some patients have a problem when the drill bites through their femur & tibia.) They prefer slicing a strip off your kneecap tendons for their replacement ACLs instead of cadavers. Meniscus/cartilage damage is trimmed as necessary. As with Cb, post-op is a lot [-]more brutal[/-] faster than I expected-- a couple hours in a recovery room, oxycodone (woo-hoo!), an orthopedic brace, icepacks, and a pair of crutches. A cold therapy unit can be used to chill & move the joint, but Dr. Kan says they've had reimbursement trouble and there's no evidence that it improves or speeds ACL healing. Physical therapy starts the next day, the crutches are returned a couple weeks later, and the brace is off after the first month. Move or die. Next patient! The first knee could be back to full strength within four months and the second knee could be done anytime after that.

Hi Nords,

When it comes to physical therapy, I would explicitly ask what is the optimal amount of physical therapy given your goals, if cost was no object. Sometimes the amount of physical therapy you get is determined more by insurance than what is optimal. Maybe a visit to Thailand would be in order after burning though the max amount of PT that is reimbursable.

Oliver

 

[Nords]

When it comes to physical therapy, I would explicitly ask what is the optimal amount of physical therapy given your goals, if cost was no object. Sometimes the amount of physical therapy you get is determined more by insurance than what is optimal. Maybe a visit to Thailand would be in order after burning though the max amount of PT that is reimbursable.

No complaints here.

I usually get six weeks, which is probably typical, but during that time I pump the staff dry on techniques, reference books, and equipment preferences. By the time they're done with me I'm doing it on my own.

My tae kwon do instructor has been a big help, too. He's usually interested in the latest balance & stability [-]toys[/-] tools so he has a large inventory of wobble boards/balls, foam pads, medicine balls, and weights.

But your advice on Thailand is worth following no matter how much PT I get!