Part four…Tendon Augmentation and Time For a Second Opinion, or Two.

Having spent five hours at the sports orthopedic hospital on Tuesday, I was not thrilled about coming back to see their foot and ankle specialist on Thursday. I knew it would mean starting from scratch, filling out more paperwork and more waiting, before we got the important conversation about surgery options. Sure enough, not only did I have to fill out paper, but somehow my file was not transferred from the referring orthopedist who I had seen in the same medical office not 48 hours before. Once I got everything straight, I was put in an exam room where I sat for close to an hour while I heard the foot specialist talking in the corridor. When he finally entered and we dispensed of my recounting details of the occurrence of the injury for what was now the fourth time, the foot doc interrupted to say that my rupture was very bad, bad enough that he felt there was no way to repair my Achilles with simple suturing and that he wanted to do an augmentation procedure. He felt that the best way to proceed was to remove my flexor hallucis longus (FHL) tendon, which runs from the heel to the “knuckle” joint of the big toe, where it bends, and weave this into the Achilles breach for support.

When I asked him what the negative ramifications may be, he said that I would lose some flexion and power in the push-off in the front of the foot. As an athlete, that didn’t sound like an attractive option; even if I am unable to play basketball again, I would still like to have power to push off to play tennis, or just run. I wondered whether I would even be able to negotiate stairs easily without that tendon. I asked if there were other options, and the doc said no, that was about it. He then left to go check on his surgery calendar for the next week so he could schedule me for the following week, and disappeared for close to another hour. Frustrated, I asked an assistant in the hallway to call the original orthopedist, who I had seen the other day. After about 15 minutes he re-appeared, with the foot man in tow. They reiterated the FHL x-fer choice and procedure, but when I looked into the eyes of the first doc, I couldn’t get what I could read as a 100% go sign. I like him and felt very comfortable with him; if we had gone through with the originally-scheduled routine AT repair on Friday it wold have been a done deal. But I didn’t feel confident in the foot man, and I didn’t like the way this new procedure was being thrust on me by him without any options. I asked that they do the surgery together as a team and they agreed, the first doc would do the achilles work and the foot guy would transfer over the FHL. I walked out behind them into the hallway where they could check the surgery schedule, and the original doc said he was available on the following Monday or Wednesday, but the foot man said he could not do it until the following Friday. That raised another red flag for me; I had read that ATR repair should optimally be done within 14 days of rupture, and this would take my surgery out to 11 days. I was facing a dire dilemma: I was ready to go and didn’t want to wait 8 more days, but this was Kerlan-Jobe, one of the world’s most pre-eminent sports orthopedic hospitals. And I wasn’t convinced abut the technique, or the doctor recommending it.

I decided to hit the internet that night. I also emailed and phoned a few other orthopedists. First I tried to learn as much as possible about FHL x-fer, but I could not glean much information. One of the articles I read said that I could lose between 20% and 30% of the power and flexion in the front of my left foot, which is my push-off foot in sports. I also began sending out leads to find another sports orthopedist in my area so that I could get a second opinion. The search was appearing futile, and as of Friday afternoon, I had not turned up a good choice. Then serendipity prevailed. I am somewhat of a “wine geek,” and one of the guys in my wine-tasting group works on a wine and spirits store. Feeling sorry for myself, I decided to drop in and buy a bottle of tequila. Though I rarely drink tequila at home, I thought this would be the weekend to do it, and after my fried recommended and excellent anejo we began talking about my injury. Out of nowhere, he asked if I remembered a guy who had been a gust at one of our group’s wine dinner this summer. He had great taste in wine, was buying bottles from my friend and, coincidentally, a sports orthopedist in the South Bay who works on some of the L.A. Kings and has achilles experience.

Five minutes later I was on the phone with the new doc, who told me to come down to his office, and 90 minutes later I met him face to face, carrying my MRI on a CD and my radiologist’s report.

(To be continued in Part Five…)

11 Responses to “Part four…Tendon Augmentation and Time For a Second Opinion, or Two.”

  1. Stephen: The FHL transfer is the procedure that they did on me. I am now 8.5 wks post surgery. I had to wait almost 7 wks after the surgeon originally said I needed surgery to have actually having the procedure done. If you google FHL transfer there is a wealth of information about there about the procedure and also a complete slide show of the surgery. I am afraid that you won’t find a lot of positive opinions about the surgery on the websites. I am going to give you one. Since the surgery I have NO pain. Or at least nothing over maybe a three on the pin scale and that was related to swelling (I did way too much walking at work and didn’t stay elevated like I was told and also from the boot rubbing my leg) I am now in two shoes and therapy and I don’t even have a limp! Granted I have only just started the PT but so far everything is going well. I have great ROM for being this early into it, I rode the bicycle with some degree of tension and had no problems at all with that. The PT told me that she had seen quite a few of these FHL transfers and they all did very well. I believe how well you recover will have to do with how much you put into your recovery and how badly you want it. The hardest part of the whole deal for me is accepting the timeline. A year to full recovery seems like an eternity, but everyone involved (docs, nurses, PT) have all told me I should have no problems with being 100%. I should be able to go back to everything I was doing before: mountain climbing, trekking, bicycling, racquetball and tennis. I hope that this gives you some encouragement.

  2. Stephen: My son lost his FHL tendon in a weird accident. This was almost 3 years ago so he is fully healed. He says that the only time he notices a difference in his foot is when he takes his shoe off and tries to bend his toe. (Doesn’t bend) Otherwise, he says he doesn’t even notice it is missing. He is only 18 and running around is a very important part of his life.

  3. Smish and Wilddog,
    Hey guys. Thanks for the comments.
    As you will see when I post my next “chapter” (hopefully tonight), I chose to go ahead with a different augmentation procedure, an allograft augmentation, and had my surgery on Tuesday.
    Maybe if I had known about this website beforehand, I would have opted to stay the course with FHL x-fer, but I’m very happy with the way things turned out.
    I really like the doctor I decided to go with and the way he has proceeded so far.
    Thanks for checking in. Hopefully we can stay in touch as I finish getting my “blog” up to speed to where I am currently.


  4. Stephen: Is the allograft augmentation the same as a “graft jacket”?

  5. Hi Stephen
    I’m at 5/12 weeks post op from a reconstruction surgery utilizing an FHL transfer and so far so good. The reason I required the transfer was that I didn’t have an acute rupture (no pop or sensation of being hit in the calf) but rather a progressive deterioration which was misdiagnosed by the podiatrist I originally went to for treatment. So I was walking, more like limping, aroung with it for over 3 months untill I had the surgery. I’m thinking malpractice suit but that’s for later.
    Did you have an acute rupture and if so I think it’s unusual for a tendont ransfer to be required for the repair. I think you did the right thing in seeking another opinion since it’s important to have confidence in your surgeon. Besides why would it take two doctors to perform the procedure? I understand your concern about future limitations as to functionality since running anjd cycling are very important to me. My doctor is confident that with time I’ll be running again and I’m going to take him at his word.
    Here’s a link to what the procedure looks like
    I beleive an allograft is using a tendon from a cadaver rather than your own. I asked about going that route but my docter was against it.

  6. Bob and Stephen,
    I too had an FHL transfer along with an achilles debridement. I had a team of doctors but then I was in a teaching hospital. I can’t imagine needing two doctors to perform two fairly straight forward procedures. I had not ruptured my achilles either but had extensive damage due to cerebral palsy from birth. I can’t help but think it’s a money thing with the two doctors? I had a pulmonary doctor visit me twice in the hospital asking me if I was using my nasal oxygen thingy. He never stayed for more than a minute and when I asked him why I needed it he said he was just “consulting”. Anyway, it’s always smart to get a second opinion, very proactive. Good luck with your recovery.

  7. Kris,
    Thanks for your comment.
    My original dr., as ports medicine orthopedist is trained and was well-prepared to do a simple ATR repair himself. Once the FHL x-fer was indicated however he felt a consult with was in order with his colleague, a foot specialist who has experience in the technique. The foot man could have done the ATR repair and the FHL x-fer himself, but if you read my blog you will see that I asked for my original dr., with whom I felt much more comfortable, to be in the OR with the foot man. As I said, the two of them were then going to do the procedure as a team.
    There was absolutely zero money issue at all involved.
    But, as I was saying, I chose to get a second second opinion and decided to go in a different direction, which I will be blogging about in my next “part.”
    Hope your procedure went well!


  8. Bob,
    To answer your comment above:
    Sorry, sounds like you had a rough deal. My law days are behind me, but I’m not sure you have a malpractice case. That might be better for the practicing attorneys!
    If you read my blog, you will see that I said I had an acute rupture of my AT playing hardcore basketball, on TOP of a chronic achilles tendinitis progression. My AT exploded, and was left in gelatinous strands apparently from previous degradation. The worst of both worlds. Augmentation with another tendon was absolutely necessary. As I was saying, the first sports orthopedic hospital I was with, the prestigious Kerlan-Jobe clinic, was giving me only one option: FHL x-fer. After what I read and heard from others, I wasn’t convinced I wanted to go that way, and sought out another opinion. When I next blog, I will explain the very informative and informed opinion I was given, the discussion of all the options, and the ultimate choice in procedure I chose to follow.
    As to why there would be two drs., either read my blog or look at the answer I just gave Kris above, it’s self-explanatory, it was my choice.
    Hope your recovery is going well.
    Just out of curiosity, how old are you?


  9. Stephen,
    Well, point well taken. I didn’t read your blog and had I done so I would have been better informed of your situation. Sometimes we react only to what we read on the surface of things and respond before really researching the subject fully. Again, I think you made good choices regarding your care. I have personally had too many experiences in the medical maze of musts and at times can be cynical. I was born with CP and according to the commercials, I can sue the doc who delivered me. He’s probably dead since I’m now 43, what now!?! Just kidding, I sued my mom instead. ( Shame on anyone who believed that)

  10. Kris,
    Glad to see you have such a great sense of humor. I’m sure that and a healthy dose of cynicism have helped you get through what must be a trying, if not brutal, harangue with the medical system.
    I am also sure what I am going through pails to the trials you have had, and I am honored that you are even reading what I have to write. I am doing this as an exercise to while away the recuperation hours and with the thought that perhaps it will provide some small food for thought for anyone in the future who goes through their injury on a path similar to mine. If I had been able to access information on a case with a history that mirrored mine, I would have been comforted.
    Again, I thank you and Dennis and everyone else who comments, although I do hope they would read my blog before they comment! It does seem though that the way this site is set up, some people are seeing these comments and responding to them without ever reading my actual blog pages. And I haven’t been able to update the blog faster than the new comments have appeared.
    Unfortunately, I cannot add a chapter to my blog tonight, as my laptop hard drive quit last night, and I am too tired to sit upright at this desktop computer tonight and write. I hope to hobble out tomorrow and get the laptop fixed.

  11. Stephen,
    Just finished reading your blog and must say, you have had a grueling time of it. I have a blog on this site too, aging with cerebral palsy. You would have to go back to october in the archive section to read my story. I am glad to have found this site as all of us understand and have genuine empathy for one another. A sense of humor, patience, and a high pain threshold are essential to recovery, but it helps to have others in the same boat as you to share experiences with. I’ll look forward to your next blog update.

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