I arrived at the same day surgery center at 5:30 am which is the time I normally arrive for my clerkship duties as a medical student. It's weird to sit out in the waiting room--at the mercy of the folks behind the doors and curtains rather than being on the other side.
Prior to the operation, my orthopedic surgeon and I had numerous discussions about the graft type for ACL revision.
She initially convinced me to have an allograft
given the fact that the patellar tendon
graft had already been harvested. However, after doing my homework, I read that allografts
are associated with a higher (up to 15%) failure rate than patellar or hamstring grafts
. While she noted that the evidence higher allograft failure rate has been found in studies that included younger (<25 years old), more active patients, I thought that I wasn't ready to retire to shuffleboard at the ripe old age of 30. There is also a finite risk of infection from an allograft which I found creepy the more I thought about it (Once you see Hep C cirrhosis, you know you never want it). So I first asked for a contralateral patellar tendon graft
(these are the strongest and adhere to bone best). However, she was concerned about the delay in rehab and mobility if the other knee was cut on the same day as the operation. We compromised on ipsilateral hamstring tendon if it was usable
. Given my history of 3 other procedures on my knee, she had a real concern that there would be too much scar tissue around the tendon--In which case, she would use an allograft. This was the first unknown
going into surgery.
Unknown number 2
going into surgery was whether or not my surgeon would be able to salvage the lateral meniscus
in the setting of a large tear of unknown origin. There was some concern that the tear worsened during my clinical
clerkships as the symptoms had progressed over time. My fingers were crossed for this one. If she was unable to repair it, about 90% of the meniscus would have to be removed during the surgery--essentially giving me arthritis
at 30 years of age.
Unknown number 3
going into surgery was the risk of a staged procedure
. Based on the Xrays, the surgeon felt comfortable that she could leave the posterior
) screw from the original reconstruction in place. However, she was concerned that the original tibial screw would be in the way of the revision screw for proper placement of the revision graft. This would necessitate a staged procedure whereby the original tibial screw and graft would be removed, the hole from the screw (tunnel) would be filled with bone cement
and after a month or so of healing, she would return to the knee to perform the ACL revision.
The last thing I remember before waking up in recovery was the anesthesia resident and attending physician using the cold ultrasound
gel and probe to perform the femoral nerve
block (FYI for you women, try to shave in the groin area on the side of the nerve block on the day of your procedure just so it's a little cleaner for the folks placing the nerve block). Then I was out.
I woke up in recovery in considerable pain as my surgeon and the ortho resident were trying to manipulate my let as the placed the huge hip-to-ankle knee brace
on my leg. Totally disinhibited from the anesthetics, I kind of squealed in pain. The next thing I recall is hearing my vitals alarm going off, and looking back to see that my oxygen saturation was 83% (very low) and the nurse yelling at me to breath. I suspect that they loaded me with tons of dilauded and put me in a little bit of respiratory depression because of the pain I had been in (I overheard the nurses talking about it too). In any case, the worst part about immediate post-surgical experience was the severe nausea and hypotension I experienced from the anesthesia (I was kicking myself for not explicitly requesting a scopolamine patch from the anesthesia resident before the surgery
). I was kept in recovery for 7 hours to overcome the effects of the anesthesia and pain meds before they would sent me home. The anesthesiologists were even a little concerned by the end of the day. Eventually, an older anesthesia attending offered me some coke (coca-cola) to revive me from the anesthesia. He said it sometimes works to perk up the highly sensitive patients.
The good news was that all of the unknowns going into surgery ended up having a positive outcome. The surgeon was able to use the ipsilateral hamstring tendon graft, she was able to repair the meniscus rather than remove it and there was no need for a staged procedure. Thank goodness!
I was sent home with a polar bear cryocuff and told to keep it going for the first 24 hours. My discharge instructions included the following:
--Weight bear as tolerated with knee locked in extension
(extension lock due to the meniscus repair)
for 2 hours three times/day. Increase 10 degrees per day to 90 degrees
--Norco 10/325 as needed for pain
--Docusate for constipation (from the Norco)
--Leave the surgical dressings on for the first 48 hours. After that, shower with protection over the incisions. No soaking of the wounds.
--Aspirin 325 mg PO for DVT
(blood clot) prophylaxis--FYI, I take birth control pills, making the risk for blood clots slightly higher so I was prescribed the full dose aspirin.
Fortunately, because of the femoral nerve block, I was not in significant pain for the first 48 hours. This is in contrast to the first reconstruction when I woke up the following morning in the worst pain of my life. I did take one Norco on the first postoperative day just so I could sleep through the day but that totally backfired as it made me horribly nauseous for 8 hours until I finally vomited--I flushed the rest down the toilet and threw away the docusate. This has happens every time I have been prescribed Norco or Vicodin and every time I get a prescription, I stupidly try it...
I should note that after the procedure, my foot was numb
along the medial
and lateral sides and under my heel for the first 4-5 days. Inititally, I had attributed it to the nerve block but the numbness persisted beyond the time that the nerve block should have lasted. I did some basic googlesearching and found that this is a relatively common side effect of the surgery due to some nerve injury during the procedure. Regardless, it got better and the signs when it was resolving was pins and needles for a day or so before sensation finally returned to normal.
I started the CPM at 25 degrees. I would increase it 3 degrees at each session (increasing only 9 per day but as I mentioned, I'm a little obsessive compulsive and liked that number). However, during the first two weeks, I definitely experienced a great deal of pain at the beginning of each CPM session and would sometimes ease into the new levels of flexion
by starting on the previous setting for the first 30 minutes before increasing the flexion. I also noticed that icing
the knee before CPM helped as it decreased some of the swelling and opened the joint
space a little more.
In any case, I really spent the first 48 hours after the surgery on the couch on the first floor of my parent's house (my fiance moved to a different state for a job 2 weeks before the operation so as a 30 year old, I had to move in with my parents to take care of me--le sigh). When I did get up to use the crutches
nothing within my knee was suggesting I should even attempt to bear weight so I kept off it.
Summary of this post:
--ACL revision with lateral meniscus repair (hamstring tendon with no need for staged procedure).
--Worst side effects from surgery due to anesthesia and pain medication
--Femoral nerve blocks are one of the best medical innovations of recent history (I love anesthesiologists) making the first 48 hours relatively painless.
--I (personally) would not even consider bearing weight in the first 48 hours given how I felt.