Arthroscopic Alley

Last updated August 22, 1996

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This page shows in graphic detail some of the things I've done to the inside of my knees throughout my years of skiing.

I consider myself fortunate to have had my skiing accidents after the invention of that most wonderous surgical instrument known as the arthroscope. For knees, three quarter-inch incisions are made: one on the medial (inside) side below the patella, one on the lateral (outside) side below the patella, and one on the lateral side above the patella. Small tubes are then inserted into the incisions, and the knee is pumped full of saline solution to expand it to provide working room. Using fiber optics, the surgeon is able to look for damage, and can repair it by using lasers or small tools inserted through the tubes.

Arthroscopic surgery is usually performed on an outpatient basis. You arrive, they work on you for a couple of hours, you go home. Crutches will be necessary for a couple of days, and you will probably feel good enough to return to work in about a week. Physical therapy may be prescribed to rebuild your leg muscles, typically 3 sessions a week for 4 weeks.

This Is Your Knee

There is an injury for every structure listed in the above diagram, ranging from the simple accumulation of scar tissue to the dreaded ACL break. Refer to the above diagram when examining the pictures below.

March 24, 1995

I saw my orthopedic surgeon that same afternoon, and he ordered an MRI that was performed on the following Monday. I went back to my ortho on Tuesday for the results, and the MRI showed a large bone bruise to the top-lateral side of the tibia. 60% of the time such bruising is associated with ACL tears, yet nothing else abnormal showed up on the MRI, and the knee was acting stable. So my ortho shot the knee with an anesthetic (not enough!), and then used a REALLY BIG needle to aspirate the blood causing the swelling. He then shot it full of cortisone and sent me on my way.

A week after that the knee felt good enough to return to work. But later that same night, it swelled back up again, and so some arthroscopic shoulder surgery I had scheduled for Friday, April 7, 1995 was changed to arthroscopic knee surgery instead. I was wheeled into the outpatient operating room almost two weeks to the hour after the accident.

A small hemorrhage whose bleeding was responsible for the swelling was found and repaired.

Cartilage damage was found on the underside of the patella, shown in the upper half of the above "before" images. Note especially the whispy white structure in the first image. This condition is known as "chondromalacia patella".

The patella damage was smoothed out by a laser, and the resulting smoother patella is visible in the upper-half of the above "after" images. If you look carefully at the first image, you can see a crater-like structure where the damage was. My ortho said it looked like it had been whacked by the round end of a ball-peen hammer.

The Anterior Cruciate Ligament was intact, thank goodness. ACL grafting is a 3-hour surgical procedure.

Both the Medial and Lateral Meniscus were undamaged.

This is a view of the Mumble-mumble Gap. I don't remember what my ortho called it.

I woke up about 90 minutes later, and my wife Julie drove me home something like an hour after that. Immediate post-op care included keeping the knee iced, elevated, and strapped into a Continuous Passive Motion machine that constantly (slowly) flexed and unflexed the knee. Crutches were only necessary for about the first two days, and I returned to work 10 days after the surgery. At a subsequent followup visit, my ortho prescribed use of an OnTrack knee brace for a month to help correct a small patella alignment problem. The previously scheduled shoulder surgery finally happened in June 1995, and both the right knee and left shoulder underwent 12 sessions (3 times per week for 4 weeks) of physical therapy.

How much did it cost?

Notes about this table

• "Initial Bill Rate" is the full-retail, what you would pay if you didn't have insurance rate.
• "Insurance PPO Rate" is the rate that providers contracted with my insurance plan for these services. Providers aren't supposed to bill me for anything greater than this amount, and if they no, nobody has to pay the excess.
• "Paid out of pocket" is the final cost to me after meeting my deductible and the insurance plan's annual out-of-pocket maximum.

Conclusions

• Don't participate in a sport like skiing unless you have good medical insurance! ;-)
• Stay within your Preferred Provider Organization (PPO) network. It's much cheaper.
• It would be nice if PPO providers would bill at the PPO rate instead of the full-retail rate. My ortho says this is too hard to do when as a provider you must deal with literally hundreds of different insurance plans.
• Who's subsidizing who? Conventional wisdom in the USA is that insured people are subsidizing the cost of providing services to uninsured people. But my table suggests the reverse, that providers forced to agree to strict PPO rates jack up their non-PPO rates (includes the uninsured) to make up for lost profits.

Addendum

The knee brace helped only slightly, not enough to justify the daily 90 minutes of special knee exercises that are required. At this point we did a standard MRI plus a kinematic MRI (a 6-frame "movie" of patella motion; I will put it on this web site once I acquire video capture capability). The kinematic study revealed that the medial aspect of my patella was making abnormal contact with the medial articular cartilage during an early stage of flexion. Therefore, a lateral release was ruled out, because that would have moved the patella into an even more medial alignment. Surgery is not an option any more, and I was given a new BioSkin knee brace for use during activities that bother the knee.

Interestingly, the standard MRI showed the same complete Group III tear in the posterior horn of the medial meniscus that was visible in the MRI after my March 1990 accident. My ortho had probed that area during the plica surgery of 1991 and found nothing abnormal. The twisty diagnostic manipulations my ortho does to the knee in his office don't produce any pain suggestive of a real meniscus tear, and so we're going to assume this is just some harmless anomaly that likes to be visible to MRI.

March 5, 1990

After returning home, the mild/moderate aching in my knees never went away. It was especially aggravated by prolonged sitting, such as sitting at my desk at work or in a movie theater. My general practitioner doctor could find nothing wrong with my knees, so I lived with it for 9 months.

The physically excruciating experience of my knees sitting through the 3-hour long movie "Dances With Wolves" convinced me it was time to get a referral to an ortho. He initially found nothing wrong, and sent me to physical therapy for a month. When the problem persisted, he sent me for an MRI which showed a possible cartilage tear in the posterior horn of the medial meniscus of the left knee, and so surgery was scheduled. Both knees were done arthroscopically at the same time on March 8, 1991.

No meniscus cartilage problems were found, but the above "before" images show the bands of scar tissue ("plica") that were present in the left and right knee respectively.

Here is what it looks like with the scar tissue cut away.

I only needed crutches for a couple of days, but having had both knees done at the same time, arm strength was very important for getting in and out of chairs. I was definitely glad to be recently married and have my wife Julie to take care of me that first post-op weekend. I returned to work 10 days after the surgery, and was in physical therapy for about 6 weeks.