MPFL Reconstruction Surgery
How the day of my MPFL reconstruction went, start to finish.
T-Minus 4 Hours
The night proceeding the surgery, I lay in bed wide awake, staring at my phone and the ceiling, a mess of nerves, wondering if I was indeed doing the right thing; on the surface I was having cold feet, though deep down I knew I was doing the right thing — delaying the surgery would mean keeping my knee’s vulnerable status quo of inevitable future dislocations and early onset arthritis from patellar instability. I was instructed to arrive to the surgical center at 9.30 with an 11AM surgery time, and although it’s only 5min down the road, I gave up at 7AM to take an extended hot shower. I hadn’t been allowed to eat or drink anything since midnight, and though I usually thrive on Americanos in the morning, even the smell of coffee didn’t appeal thanks to my nerves. My Dad and I arrived to the outpatient surgical center early at 9.15.
The receptionist asked if I’m here for a procedure and I responded, “unfortnately.” She probably hears that daily, but she still assured me that the pre-op and surgical staff would take good care of me. After about 10 minutes I was called to the check-in office to sign all the waivers and submit my insurance co-pay (I will be talking about the costs in a future post — this is a subject I could find no information on in my searches preceding the surgery).
This is the part where you explicitly consent to a given procedure, and I clarified a discrepancy in the verbiage that had been used in the week prior; on the phone, several of the schedulers calling to confirm and remind me of the surgery had used the term “MPFL revision” instead of “MPFL reconstruction.” A revision is a surgery to fix problems with an existing MPFL reconstruction; since I hadn’t had an MPFL reconstruction yet, this was the incorrect terminology, and this is the time to make absolutely sure your surgery center has you scheduled for the correct proceedure. On the paperwork I was presented everything was correct, but this isn’t the time to be timid since it’s your body and you must be your own best advocat; when I asked to confirm everything, the pre-op managing nurse was called in to confirm, and she already knew about the question — apparently my orthopedic surgeon, his physician’s assistant, and she herself had talked on the phone the day before to make sure everything was correct. She explained that when they looked into it they found that my surgery was correctly listed as an MPFL reconstruction in all the authorizations and pre-op paperwork, but it was a note in the scheduling department at the doctors office that had been mistyped as a revision. This was a simple mistake that wouldn’t have had any impact on my procedure, but caused me some confusion; even if the wrong verbiage had been used everywhere that counts, it would have been figured out in the OR and they’d have given me a reconstruction when they easily see I hadn’t had one. The point to take away here is to never be afraid to question and confirm things when it comes to your health; you are your own best advocate, and it’s better to take a few moments to confirm what you’re consenting to, rather than risk any potential for a mistake. There is no shame in asking questions when it comes to your health, even when the discrepancy is as small and unlikely as this. I put my John Hancock on the last few forms and exited back to the waiting room to be called to pre-op.
T-Minus 1 Hour: Pre-Op
After another 10 minutes of waiting, my number (for privacy) was called and I was taken into the pre / post-op area, weighed, and placed in a room. I used the bathroom one last time before changing into a hospital gown and hopping into the hospital bed. I’d been texting friends and family all morning, and I was on my phone non-stop until the nurses started actually prepping me. Between having the support of my friends, my Dad in the pre-op room with me, and the sheer fact that this was finally going to be over with, I finally calmed down — I was ready.
First things first, my pre-op nurse came in do the usual confirmations, checking my name and ID bracelet, and ask, yes or no, are you here for MPFL reconstruction surgery (yes!), on your left leg (very yes!); great, initial here and here (this is standard pre-op confirmation and had nothing to do with my inquiry during check-in). Next she had me use a sterile marker to write YES on the knee to be operated on; only the patient is allowed to do this, for liability reasons. I’ve seen other facilities write NO on the side not to be worked on, but this is how this center’s proceedures are set up. I was handed a cup with three medicines in it; Eliquis, a painkiller (I don’t remember which), and a third one I don’t remember — it may have been anti-anxiety, which is very common pre-op whether you’re nervous or not.
Next was the anesthesiologist who went over my health and prescription history, drug allergies, checked my heart rate, blood pressure, and other vitals before asking about my history with anesthesia (I find it very easy and relaxing, but some people experience nausea — if you’re one of those people, fear not, because they control nausea with Zofran, and will send you home with a huge prescription of it regardless of how good you feel waking up). All that checked out, so she moved on, “Next I want to talk with you about some options to ease post-operative pain.” I stopped her right there and said, “yes, we’re absolutely doing the nerve block! Just please make sure I’m knocked out for it!” She went over the rare risks and side effects that she’s required to, and I signed my consent for them to perform two different blocks located in the knee and leg. This was both surprising and expected; all of the literature I had read mentioned a femoral nerve block, which is not what was being performed (I unfortunately don’t recall the exact names of the nerve blocks performed). Instead, like the gentleman I’d talked with in the grocery store several weeks earlier explained, they do a block lower in the leg, and they do so in a twilight anesthesia state where you aren’t aware of what’s going on. This is exactly what the anesthesiologist said they were going to do, as a femoral nerve block (located on the thigh adjacent the groin) disrupts function of the quadriceps. She explained that the nerve block will eliminate 80% of the pain, and the remainder will be controlled with IV and oral painkillers. With all this settled, she left to attend to other business until it was time to come apply the block and get me ready.
Another nurse got my IV line inserted into the top of my hand; to boot, this was the most painless IV insertion I’ve ever had, probably becuase of his technique of inserting the needle only far enough to securely enter the vein, then forwarding the catheter, rather than advancing the needle further in first. I’ve always been fine with needles and IVs, but this really impressed me, so props to this nurse! Another nurse used an electric shaver with a vacuum to remove and dispose of my leg hair around the surgical site — it tickled. After all this activity, I was left alone with my Dad for a little bit, so we waited.
A little later, the anesthesiologist came back in with an assistant pushing an ultrasound machine, which they would be using to ensure exact placement of the needles administering the nerve blocks. As they lowered the back on my bed I was asked me to raise my leg and place it into a small cradle so it would be easier for them to work on. At the same time, they delivered a dose of sedation that hit me fast and hard. So hard that the room zoomed out of existence and I was vaulted into a vibrantly colored tesseract, not unlike that seen in Interstellar. It felt like I was flying (I mean, I *was* flying high…) for what felt like 10 minutes. Somewhere in the middle of that I felt the slightest tickle on the underside of my leg, like someone brushed a finger against me; I can only guess this was one of the two nerve blocks actually being administered, but that is the only sensation I felt until I came to, landing in the bed, what felt like about 10 minutes later.
The sedation was like nothing I’ve ever experienced; I don’t know if it was technically “twilight” anesthesia, but if you are worried about the nerve block, don’t be — quite frankly the sedation was relaxing and enjoyable. I came out of it quickly and easily over the course of a few minutes, though I didn’t feel any effect to my leg.
My Dad and I had a few minutes by time I was coming off the high, and I knew with that my surgery time was quickly approaching. I asked my Dad to take a picture of me. I put on the biggest smile I could manage for my pre-op photo.
T-Minus 0: Surgery
The anesthesiologist and her assistant were gone when I came to, but a nurse came in to take my vitals one more time, followed finally by my orthopedic surgeon, who greeted me warmly. I said it was great to see him again, and addressed him as Mister instead of Doctor — the sedation from the nerve block had me drugged, relaxed so that I knew I was looking for “doctor” but couldn’t find the word, and used “mister” instead. He checked my leg, made sure it was my left, and signed his initials to confirm.
Next thing I know I was being wheeled down the hall to the operating room. We get into the room and I’m babbling about floating through space like in Inception; still high from the sedation, I once again was thinking of one thing and mixing up the words with something related, but incorrect. The OR nurse asked me to slide from the hospital bed to the OR table, which was a padded bed table with no sides, slim at less than two feet wide, and had extensions for my arms. It vaguely reminded me of the table in an execution chamber, though I had long left fear in the dust; I was ready to get my knee fixed. I commented on how skinny the table was, and the nurse told me everyone is surprised, but don’t worry, you’re in good hands and won’t fall off. The anesthesiologist said hello again, and introduced me to all the staff who were present, though some were still making their way in. I said hello and nodded to the OR student observer I had consented to watch my procedure, and the anesthesiologist explained that she was going to be using both IV and gas administration of my anesthesia today. She placed a comfortable oxygen mask on me which also had a mouthpiece inside, as another nurse took my wrists and strapped them down to the arms; I wasn’t expecting that, but it makes absolutely perfect sense for stability on the table, and accessibility while the operation takes place — don’t let this freak you out if restraings make you apprehensive and they do this while you’re awake. Finally my orthopedist came in and said hello, smiling as he pulled up my MRIs on the monitor. He asked if I’m ready to get to work, and of course I said yes. With that, the anesthesiologist leaned over me and asked, “Ok, you ready? I’m going to give you the anesthesia and you’re going to start to feel drowsy, ok?” I told her to send it, and it was about 10 seconds after she said, “Ok, here it comes” that I started to feel the room spin. Usually I can feel it travel warmly up my arm, through my vein to my chest, but not this time. I told her, “Yup, here it comes. Oh, it’s definitely working now.” And with that, the room collapsed, and the downward spinning spiral dropped down the drain into peaceful, unaware sleep.
T+Plus 1.5hrs: Waking Up
As with all anesthesia, I woke up groggy, under warm blankets, back in the same recovery room I had spent most of my morning in. My Dad was sitting in the same chair, and there was no indication anything had actually taken place, except that my leg was wrapped up in thick wound dressing and a leg brace — they did the correct leg; YAY!
The first thing I said was, “Well?” I wanted to know how it went. Did the surgery go as planned? Did the doctor have any complications? Did he find anything wrong that didn’t show up on the MRI? I asked my usual post-anesthesia question: how long was I out for?
My surgery went great. It was routine. There were no complications or anything unusual or unexpected that showed up. There was no torn meniscus, no loose bodies, no damage to other ligaments, and no damage to any cartilidge. The only thing wrong with my knee indeed was my completely torn MPFL. The gracilis tendon was successfully harvested and grafted to replace my native MPFL. The surgery took exactly the 1.5hrs I was scheduled for, no more, no less.
And here’s the answer to the million dollar question; how much pain was I in post-op? None. Zero pain. Amazingly, I also still had feeling in my leg, and full function of my quad; I could lift my leg right there, no more effort than pre-operatively! I had heard the quad would be disrupted by surgery, but this didn’t happen at all; I had either heard wrong, or gotten lucky!
The doctor had already been in to debrief my Dad about the surgery before I’d woken up, and my Dad hadn’t caught most of what he said, so I’ll explain the other details about my surgery which I found out at my 12-day-post-op follow-up appointment, here.
My orthopedist uses two suture anchors on the patella, rather than the tunnel method of anchoring, because patellar tunnels place the patient at lifelong risk for patellar fracures, whereas suture anchors (which are similar in design to drywall molly anchors) provide an equally reliable bond, with more safety, and faster and easier application than drilling tunnels. The gracilis tendon is fed down between the 2nd and 3rd layer of the retinaculum and anchored to an adjustable tension set screw embedded anatomicaly in a tunnel in the femur. The gracilis tendon is 3–4x stronger than the native MPFL, and the sutures on the suture anchors are 20x stronger than the ACL, which is 10x stronger than the MPFL. After 3 months, the bone completes forming a bond with the autograft tendon. In other words, the new reconstructed ligament is stronger than the original in every way, and if you manage to break it again, you probably have bigger problems than just that ligament. Be confident it is strong.
This anesthesia must have been a little deeper of a sleep than I’ve had before, because it took me a while to fully come out of it; I kept falling asleep and waking up, fighting the anesthesia remaining in my system to regain alertness. I don’t know how long it took to wear off this time, but I do remember waking up one time to hear an argument about the post-op physical therapy regimen, which my dad wasn’t understanding. It’s ok; it’s written down clearly. Eventually I did finally stay awake, groggy as I may be, and the nurse gave me ginger ale, and kept trying to give me saltine crackers for nausea I didn’t have — I have never been nauseas from anesthesia, and frankly those crackers would make me nauseas from dryness on a good day; no thank you!
After finalizing some discharge paperwork, explaining my exercise regimen, and discussing the cold therapy unit I was sent home with, I was helped to get my clothes back on and stood up to switch to a wheelchair. The nurse wheeled me down a back exit to a ramp where the car was ready for me. They offered to help me in, but I stood, took three hops on my right leg, and carefully slid my bandaged, braced left leg across the back seat and I was in the car, no crutches used.
I texted friends and family that I was out and everythign had gone much better and easier than I expected. First stop was the pharmacy. I didn’t feel any pain still execept a little soreness if I really poked at the cushioning, but I had been given a presciption for Percocet and Zofran, and wanted to be sure I was on top of the pain management. I had been instructed to begin the Percocet as soon as I got home, regardless of if I felt pain or not; between friends and other online stories, everyone, including these doctors, explicitly instructed me to stay ahead of the pain; take your pain meds every four hours regardless of your pain level — don’t ever get behind your pain, because it’s very difficult to catch back up. I fell asleep waiting in the pharmacy drive-thru, but woke back up when pill bottles were tossed in my lap. Still no pain. Next stop; well, you take a guess what the next stop was. You already know what I’m about to say…
And with that, it was time to go home, get inside, and plop down for a long while. My orthopedist assigns MPFL reconstruction patients to 3 weeks non-weight bearing, but no time to think about that right now; I have a Double Quater-Pounder to eat, and Facebook statuses to update. Remember, it’s now almost 5PM and this is my first meal in 17 hours.
The rest of the day was relaxing; talking groggily with friends on the phone about how it went easier and less painfully than expected, distractedly watching Netflix, and finally, enjoying a much needed cup of coffee.
T+Plus 6hrs and Beyond: A Note on Pain (Or Lack Thereof)
The Percocet made me drowsy for about an hour after taking it, and takes about 30min to kick in. I found that my knee didn’t have any throbbing or stabbing pains like I’d expected. Instead, the mild pain I had was just soreness around the incision sites which was irritated by movement and especially standing. The Percocet takes the edge off, dulling the bit of pain I did have. The pain and sensations I have experienced have slowly changed as my surgery heals, and I’ll explain the pain in more detail in a future posting, however I want to emphasize that this surgery was far less painful than I expected, and far less painful than some injuries I’ve experienced. The initial MPFL tear in May was probably 20x more painful than this surgery. Nevertheless, many accounts I’ve read online say that this surgery is excruciating, however I’m here to tell you that my experience couldn’t be further from that. Just take your meds, trust the meds, trust your doctors, and get on the road to recovery.
Think of it this way; I was on Percocet for only 4 days with this surgery, but I was on it for 14 days at the same dosage when I had two wisdom teeth removed and developed dry socket. After that I dropped down to Advil and Aspirin. Take that into consideration.
I do think I have a higher pain tolerance than some, but I know I don’t have the highest pain tolerance. If you’re worried about pain, you’ll have to be the judge. Perhaps what also helped me was how worried I was about the pain; I expected more, and received a LOT less — could this possibly be a twist on the old “underpromise, overdeliver” adage?
Stay tuned for more updates about my MPFL Reconstruction experience, and how the later stages of my recover went. In the evening after my surgery day, I made my way to my bed and zonked out for a long, recharging sleep. Just don’t forget to set your alarm every four hours — wake yourself up to take your pain pills, and don’t forget and skip, for tomorrow the nerve block wears off… (don’t worry; I couldn’t tell a difference from when the block was working vs when it had worn off… but more on that later).
