ACL Repair
Honey called Rory early the next morning as though nothing had changed in the last month and a half. “Hey Doc, I’m back in town, living above the clinic again. I’m down here in your reception office. Bonnie tells me you’re doing an ACL repair today. I’m ready to help. Are you willing to put me to work?"
“You bet! I've missed you, Honey. Katie said you were back. It was too late to call last night. When do you want me?"
“In an hour. Conrad just dropped Feeney off. I'll show Bonnie how to do this."
"Wonderful. Thanks." What a pleasant surprise to have Honey back, and wanting to start up as soon as she could, Rory though. Now he would need to drop Bonnie's hours back. Hopefully, this job wasn't so important to her that reducing hours wouldn't be a problem. The woman was nice and all, but she was taking too long to catch on to certain things he thought were obvious. He couldn't remember Honey needing such a huge learning curve, but maybe that was his fondness for her showing itself more than real memories. Homey was more inquisitive about things in general, always asking Rory to explain this or that idea. Bonnie never offered herself this way.
"Your hair's different, Honey," was the first thing Rory said after arriving at the office.
"I cut my hair, dyed it black, and straightened it."
"Yep, I knew it was different," Rory agreed."Is this bringing in a whole different person, personality, viewpoint? How much should I be worried about, how did Byron say it, a rabbit suddenly showing up dead in a pot of water on my stove?" He teased Honey, observing her to see if she was over her grief.
She shook her head and smiled easily. "It was my Mom's idea. I needed to become someone else so I could look back at the old person that was so unhappy."
"Did she do the same?"
"No, not this time. She did it a long time ago when my real dad died. It helped her, so she pushed me into it. She was right; it helped a lot."
"How long do you keep this dark look?"
"Until I'm happy again."
"No matter, I'm glad you're back Honey. You make these surgeries almost fun. Let's get the preop going. How many pounds does she weigh?"
"Sixty-three."
After listening to the heart, and running through an anesthetic checklist, Rory figured the dose in the computer and injected the dog.
Everyone was wearing scrubs. This was a big surgery where both Rory and Honey wore gowns along with their hats and masks, not just the scrubs Rory used for minor procedures. Bonnie was anesthesiologist and room nurse.
Feeney was set on the surgery table hooked up to tubes and monitors. Rory and Honey were scrubbing in, next to each other in front of the scrub sink.
“Thanks, Honey,” Rory said as he felt her perform the final tug on his surgery gown. “Oh, that feels so good,” he continued.
“What are you doing inside that gown, Doc?” Bonnie overheard him when she walked back to help.
“I hate starting surgery with my gown crumpled. It gives me a bunched up underwear feeling, but from the outside of my pants.”
“That goes for thongs too,” Honey said. “I don’t wear thongs when I have to assist in surgery. You can’t do anything if you’ve got that wedgie feeling because you have a thong on. Squirming simply seats it deeper.”
“What do you think Doc?” Honey asked as she followed him into surgery.
“I need Bonnie to cut the foot free of the stand so I can finish draping the leg.”
“No, about thongs. What do you think about them?”
“Let me think. I need to organize this first. Bonnie open the stockinet and dump it on my tray. Honey, dig out towel clamps from the pack.”
Bonnie held the foot up so Rory could roll a sterile stockinet to meet the place Honey disinfected with her scrub. After wrapping the foot, he put four towels around the other end of Feeney’s leg, midway between her knee and the femur, the upper leg bone. When he was done, he had a large sterile area of green cloth from behind the dog up to his neck with a stockinet and towel-covered leg sticking from it. Now Rory was able to relax, spread out, work comfortably. And with his arms encased within the gown he could let them settle on the table, something a surgeon cannot do if his arms are bare.
“Scalpel blade please.” He waited with his hands cupped for Bonnie to peel part the foil package, allowing the blade to drop into Rory’s hand without touching it.
He carved an eight-inch line centered on the knee, cutting the inside of the leg. Setting the blade down he picked up the Metzenbaums quickly cutting through the fascia, the silvery white tissue compartmentalizing the muscle groups and tendons. With the fascial attachments cut Rory pushed the skin from the stifle area, giving him good access into the joint capsule. Retrieving his blade, he tapped the joint with his forefinger feeling for a fluid bounce-back, telling him he had located the capsule.
“Ready?” Carefully he pushed the blade through the tissue, waiting for joint fluid to ooze from the cut.
“There it is,” was the indication he found it. “Can you dab the ooze?” He asked Honey. Picking white gauze from the surgery pack she sopped up the escaping bloody synovial fluid.
Digging into his tools, Rory retrieved his Metzenbaums. “To get into the knee joint I have to push the kneecap out of the way, so we need to scissors the joint capsule enough to loosen the knee cap setup.”
“Why?”
“The knee cap lies over the knee joint, the place we need to look at, and we can see inside after doing two things. First, I need to extend the capsular incision to the very top of the joint space. Watch how far above the actual joint the capsule goes,” he showed her. “It surprised me, the first time I saw how it is made, but that’s how we get the extra space to leverage the knee cap out of the way.”
“And the second thing?”
“Oh yeah, after you open the capsule enough you need to straighten the leg fully. That will give me enough laxity on the patellar tendon to allow me to pop the kneecap from its groove. Watch.”
Grabbing the leg above and below the knee, Rory placed his thumbs on the knee cap and showed Honey how to push it over the inside edge of the patellar groove. “Once you push the patella to the side you’ve got to flex the leg again. Otherwise, the tissue tension will pop it right back into the patellar groove. See how it quietly stays out of our way when we remember to place the knee back in flexion?”
Now the exposed joint was in front of them. “Take these gelpi retractors to open the space for me. The three other ligaments are still good, that's why it's still really tight in here, but we can work with it. I don’t want to cut any more tissue, the more I cut, the longer it takes to heal.”
“Why do you even look inside? You are doing an extra capsular repair, Doc,” Honey surprised him with the question. It showed him she possessed a good understanding of the surgical nuances. She wanted to know why he spent the extra time going inside the capsule when his repair technique didn’t require it.
“In case a piece of cartilage was torn off during the rupture. If we don't remove it, Feeney will still gimp on the leg in spite of my fabulous suturing. We call those joint mice. Having one is like having a rock in your shoe, it get's in the way of regular walking."
With the knee flexed open in front of him, Rory continued.
“You can see the torn cruciate right here. See the torn ragged edge on this small piece of floppy white tissue?”
“Oh yes, I do see it.”
“That’s the ruptured ligament. Its whiteness tells you ligaments don't have blood supplies. Hence they take forever to heal. I leave them alone, of might trim off long strands. After that, I explore the joint for any joint mice.”
Satisfied he decided to go to the next step. “Hand me 2-0 Vicryl please Bonnie.” He asked. Then he remembered something she said. “Did you say you wanted to wear thongs to work?”
"I didn't," Bonnie replied nervously.
Rory chuckled. No, Honey did. "What were you saying?"
“Not to work, just going out, it gives me a feeling of sexy from within, especially wearing dresses when I get the feeling I’m not wearing one.”
"Until it climbs up when you're in a public place you can't adjust," Bonnie replied. "I hate them, not to mention the fact my GYN doc said NO. They are a bacteria buffet and are just too close to both orifices. Bacteria are easily ping-ponged between the two. No matter how immaculate you may be able to keep yourself, you can't be 100% clean 100% of the time. I just found them to be too uncomfortable to wear. I love cotton bikini cut panties, even string bikini panties are fine, and so you can have pretty, and sexy and lacy without having panties stuck in your crack all day. Just say NO.”
“Now that I’ve finished sewing the capsule back together, it’s time to string the extra capsular setup,” Rory needed the others to focus on him.
“I’m ready for the drill Bonnie.” He waited in silence as she placed a wrapped bundle on the instrument table. Rory dug into the deeper layers to retrieve his sterilized Makita Drill.
“I need to drill four holes through the tibial tuberosity,” he explained to Honey. “But first I need to scrape off the fascia and clingy tissue that gets caught up when the drill bit spins.” He grabbed his scalpel blade and deftly removed clingy tissue from both sides of the tuberosity, the point of bone underneath the kneecap.
“There is obviously a large enough legion of supporters and wearers who keep the business of butt-floss afloat, but I like to think there is more than one woman like myself wondering why any female would voluntarily subject herself to wearing such paltry underpinnings,” Bonnie continued.
“Bonnie, I need the fishing lines,” he was ready to proceed. "These pre-made ties are the same material fishing lines are made with, but I pay a lot more for these because they come attached to circular needles made specifically to help thread the string behind the sesamoid bones.”
“This is the hardest part for me,” he complained. “It takes me forever to find the correct anchoring sites.
Dogs have two tiny bones called sesamoid bones in the back of their knees. This surgery uses these guys as anchor points, but it's difficult to push the needle at the right angle needed to skewer the small space between the teeny sesamoid bone the back of the femur.
Surgery can only work when I set the suture in a narrow band of tissue between these teeny tiny sesamoid bones and the back of the femur."
“Here goes,” Rory warned, as he tentatively worked the huge needle through muscle and fascia, blindly feeling for that sweet spot between a small bone he could barely feel, and the back of the femur.
“Oh, it came through the first time,” he said surprised.
“But will it hold? This is the real test.” Gathering both string ends in his right hand, he held the leg on the table with his left and yanked on the line, hard. He repeated this at least six times. It didn't give way, proving it was in the correct place.
“I guess I’m lucky today.”
“What were you yanking on?” Bonnie asked.
“The line has to hold for years. If I don’t set it right, it will work itself out. So, if I can't yank it loose I know I’m in the right place,” he said, tugging it two more times for effect.
“Some say they never worry about their state of wedgie because, you know, in a thong, you’re always immersed within a blissfully feeling like you’re not wearing any underwear at all. ‘Like you’re free,’ I’ve been told. Where I get stuck is in how paradoxical the freedom is,” Honey still liked g-strings.
“Now we take the top line to thread out through this first drilled hole,” He focused and jiggled his fingers to work the semi-soft nylon through the drilled tunnel. “Tell me when you see it. Oh, I can feel it. That’s the answer, just use bigger drills, that helped this step go quicker.”
“Now we need to turn the line downward to thread it back to me through the second hole.”
Honey was paying attention. She grabbed the emerging piece of suture, pulling ten inches of line towards her.
"Ready to tie the sling?" Honey asked.
"No, I like to sling both sides, which is why I use two suture kits," he explained. "After we string up the other side, I'll tie both loops while holding the knee in a flexed position. That creates the sling effect that supports the knee.”
Rory was pleased with how smoothly the procedure was going. “You’re good luck for me, Honey,” he offered.
“It’s your skill, not me, Doc. Don’t cut yourself short.”
“Well still, you seem to anticipate my next move, you’re right there like we’ve down this together before. It’s your skills too.”
“Well good for us. Let’s start a mutual benefit society.”
“I know I’m stepping into dangerous waters here, but G-strings have to be optional,” Rory decided, chuckling as they scooted past the other to switch back to their original sides.
“Now for the final check, we’ve got to see if we reduced the drawer motion. If not we have to go back and tighten the strings.”
“Remember how I showed you the drawer sign at the beginning?” He asked Honey
She nodded.
“Well put your finger here, I can’t elicit it anymore. We’re done! It’s time to sew out. Bonnie, I’ll need 3-0 Monocryl on a cutting needle. Honey, I want to put in a running subcuticular but need you to keep tension on the string as I move forward. Ready to grab?”
As before it took half as long because of her pre-emptive assisting. “Ok, let's place the Robert-Jones watermelon bandage. Honey, I need brown gauze and a roll of cotton.”
After unrolling the material around the leg, Rory finished using an elastic dressing that pulled the wrap into a tighter and tighter bandage. “There it is,” he said triumphantly, showing all he constructed the bandage just right by thumping it four times. “Hear that, sounds like a watermelon.”
