ANOTHER Knee Surgery
Is the SIXTH one the charm?
This Substack is about life in Vietnam from the viewpoint of a 10-year expat who spent his first 60 years in a low-context culture.
This is a long one with lots of pictures, so you may want to grab a cuppa or a beer before you get started. I’ll have a shot of Havana Club Añejo rum, thanks.
Warning: There’s few called-for f-bombs, so if you decide to continue reading and are offended, that’s on you. Not sure why I’m giving a warning; unless this is the first time you’ve read my work, you already know there’s a pretty good chance.
And we’re off…
At 7:30 a.m. Pacific Daylight Time on 29 April (the Tuesday after this posts), I will enter an operating room at Cedars-Sinai Hospital in Los Angeles for the SIXTH surgery and 8th procedure on my right knee.
I can’t tell you how much I hope this is the last one.
It all started…
Late in the afternoon of Saturday, 1 October 2016, as I was riding my beautiful 1989 BMW R100GS
in downtown Olympia, WA (USA), when my front wheel hit a damaged joint in railroad tracks that run parallel to the street.
As best they could figure, I went over the handlebars and landed — all 242 lb (110 kg) of me — solely on my right knee.
Passers-by called 9-1-1, and both Olympia Police and Olympia Fire Paramedics showed up pretty quickly.
They loaded me into an ambulance and carried me off to the hospital of my choice, St. Pete’s. There, x-rays showed that my knee had suffered what SpaceX would refer to as a
rapid unscheduled disassembly.
Pieces of the heads of both the tibia and fibula were, to quote the surgeon, “lying in the meat”. A piece of the femur head, too (see green arrow).
The medical term for this is “tibial plateau fracture”.
It was a mess.
This is my leg before surgery:
Something looks amiss, right?
They put me in a room and later that evening, the on-call orthopedic surgeon came by — L. Anthony Agtarap, MD. I told him that I already had an orthopedic surgeon with whom I was happy and that I would have the hospital call him. He asked me the surgeon’s name, and when I told him, he replied,
Oh, he and I are in the same practice, Olympia Orthopedics.
He went on to say that if I waited for Dr. Helpenstell, the earliest he’d probably be able to schedule surgery would be mid-week — three to five days from now, whereas he could do the surgery tomorrow (Sunday) because he was on-call.
With the heavy pain meds on-board, I was a pushover. I agreed.
Eight and a half years later, I’m still paying for that lapse in judgement.
He performed the surgery the following morning. Note all the white stuff above and to the left of the hardware that makes it look like both the tibia and the fibula were repaired.
Now look at the x-rays from my follow-up appointment 10 days later:
The “white stuff” is gone and there is still a BIG chunk of bone missing. You can also see my left knee (on the right) and get a good idea of what’s wrong in the right knee.
What I am STILL TODAY REALLY PISSED OFF about is that prior to the original surgery, I asked Agtarap if he could do a knee replacement and he told me that there wasn’t enough bone left to attach the hardware. He said it would have to rebuild before they could “do a knee”. This was bullshit because when they did the knee replacement six months later (see photo below), they cut away a lot of the tibia, way below this damage. The femur cap would’ve covered and made up for the femur damage.
Agtarap showed me the above x-ray (without the arrow) and didn’t mention the gash. I’m neither a surgeon nor an osteologist, so didn’t notice it until a couple months later. I was back in Việt Nam, and a Saigon orthopedist, Dr. Phat, pointed it out to me when I went to him to ask why the level of pain had not yet decreased.
He took one look at the above x-ray and said that until that was repaired with a knee replacement, the constant pain I was experiencing would never abate.
A “Partial” Mistake
Dr. Phat also told me that because of my size (184 cm/6’1”), he couldn’t perform the surgery because in Việt Nam, they can’t get hardware big enough to properly fit my big American bones. He suggested I go either back to the U.S. or to Bangkok.
I called Olympia Orthopedics and made an appointment to see a surgeon who’d done a good job on a rotator cuff repair for me back in 1999… Jerome Zechmann, MD, ‘cause there was no fucking way I was going back to Agtarap!1
Then I flew back to the U.S., where Zechmann surprised me with two revelations.
He told me
Every other surgeon will tell you that you need a full knee. I’m the only one who is good enough to do a partial knee to fix this.
I should’ve headed for the door, but I trusted him based on my previous
experience with him.
He pointed out that my knee was crooked (knock-kneed) and that he would fix that, too. WTaF??? I hadn’t even noticed! I went back to my AirBnb and took this photo.
That fucking incompetent hack (redundant?) Agtarap “fixed” my knee cock-eyed!
In late April 2017, six-plus months after the accident and the first surgery, Zechmann did the partial knee AND straightened it. Straightness was the first thing I checked when I woke up in Recovery and the first thing Dr. Z asked me about when I saw him.
While I was still in Recovery, Zechmann visited and told me that he’d had to cut more of the bone away than he’d anticipated, necessitating use of the largest partial knee available. If he’d cut away any more bone, he’d’ve had to wake me up to get me to sign off on a full knee. I felt fortunate.
I wasn’t.
After my two week follow-up appointment, I flew home to Dalat and got on with my life for almost a year.
My most consequential shower, probably ever
Then one April 2018 morning, I was in the shower washing the bottom of my right foot
when I heard and felt something POP in my knee. Feeling around, I saw and felt a lump that hadn’t been there 10 seconds ago.
A couple days later, I was back in Saigon to see Dr. Phat. He confirmed that the anchors “securing” the tibia component (see x-ray above) had come out of the bone. He added that I needed to fly back to the U.S. for a full knee replacement and marveled that an experienced orthopedic surgeon had thought a partial knee replacement was sufficient for my situation.
WTF, Zechmann!!!
What really sucked financially was that, six months earlier, while in the U.S. to facilitate Customer Communications classes, I’d had a rotator cuff repair2 done by another surgeon, Dr. David Coons, NOT of OlyOrtho. If only this POS partial had broken loose sooner…
I called and made an appointment to see Zechmann, then got on a plane.
When he saw the lump and manipulated my knee, Zechmann said,
No problem, we’ll just put in a bigger device.
I reminded him that, in Recovery after the surgery, he’d told me that he’d used the largest one available. He looked at my chart and said,
Oh, yeah, we did.
“Who’s this ‘we’, kimosabe?” — Tonto
He gave me a large, hinged knee brace and said I should wear it until he could fix me.
On my way out, I asked the receptionist who in the practice did the most knee revisions (re-doing a knee replacement). Without hesitation, she said,
“Great, when can I get in to see him?”
Isn’t Dr. Zechmann your surgeon? He has to sign off on you seeing Dr. Wood.
“Seriously? Dr. Zechmann was my surgeon, but I just fired him.”
You did?
“No, but I will if you can get him out here.”
She said they’d work it out internally and put me in touch with Dr. Wood’s scheduler.
Good answer.
In retrospect, I should’ve run like hell to another orthopedic practice, but that involved more time than I was willing to take. It was costing me over $120 per day to be in the U.S., and I wanted to get home as soon as I could.
What’s that saying about penny-wise and pound-foolish?
FINALLY — What Zechman should’ve done
I got in to see Dr. Wood within a couple days. He said he’d do a full knee and take good care of me.
Yeah, and I have a bridge for sale in Brooklyn.3
Wood found an opening for me in his schedule and did the full knee a week later (early May 2018). I flew home a couple weeks after that.
The extra-long spike into the tibia was necessary because the bone was soft and spongy, so they needed to go deep to anchor the hardware very securely. This softness was also there when Zechmann did the partial, but, “cowboy” that he is, he tried to get away with it. That’s why the partial came off the bone.
After three surgeries in 19 months, all was well in the world.
Until it wasn’t.
Six months later, 01 November 2018, was my first day of Medicare coverage. Since I was back in the US for more facilitation the following week, Dr. Wood recommended that he do an MUA — Manipulation Under Anesthesia — to break up scar tissue that had developed in my knee and was impinging on my ability to bend it.4 For this one, they put you out, do their best to touch your heel to your butt, then wake you up. I’m told the popping scar tissue can sound like automatic weapons firing.
Total time from walking into the OR to waking up in Recovery was only 20 minutes.
Back home again, I was doing okay until, almost a year after the MUA and 16 months after the full knee, the knee pains started up again, along with a bit of instability.
This time, Dr. Phat (Saigon) smiled sadly as he told me I would be returning to the U.S. for another surgery.
Aw, come on! Really???
As the years and the procedures roll on, I’d burned through hundreds of thousands of frequent flyer miles accumulated when I lived and worked in the U.S., flying on between 60 and 180 planes every year. I kept wishing that orthopedic surgeons had a frequent surgery program. If they did, by now I’d’ve had enough points for a freebie. Instead, between flights to/from Saigon; Saigon hotels; rental cars, AirBnB, and food in the U.S.; and deductibles, co-pays, and prescriptions in the U.S., I’d spent well over US$60,000 out-of-pocket even though I used miles for all my flights from Việt Nam to the US.
And the end was nowhere in sight.
In November 2019, I was back in the US for more facilitation. Prior to heading to Southern California and work, I went to Olympia to see Dr. Wood again ‘cause I still trusted him. No, I don’t know why. His PA told me he’d most likely stabilize my knee with a rod, but when Wood came in and saw the knee, he said replacing the 16mm tibia plate (the thing in-between the femur and the tibia that you can’t see on the x-rays) with a 22mm one was the solution5. I asked about the rod without mentioning the PA, and Wood said it wasn’t needed; I’d be fine.
WRONG!
Once I finished facilitating in SoCal, I flew back up to Olympia and had Thanksgiving dinner with Cathy and Doug and 100 of their closest friends, many of whom I also knew. A couple days later, I had my fourth knee surgery. No rod.
When I asked Dr. Wood if he could fit me with a zipper instead of staples, so it would be easier to open it up again for the next surgery, he didn’t smile. I wasn’t wrong.
I flew home in mid-December 2019.
But there’s MORE!
By early January 2020, I was back to see Dr. Phat with nerve pain on the inside of the knee. I’d had the same pain only days after the surgery, but Dr. Wood told me it would go away “soon”. I was unable to get him to tell me what “soon” meant to him.
It took Dr. Phat all of 10 seconds of examining the area of the pain to declare that during the surgery they had pinched my saphenous nerve.
To verify it, he injected the nerve with a solution of lidocaine and cortisone. Within 20 minutes, the pain was gone. I immediately mentally fired Dr. Wood and Olympia Orthopedic Associates. I’d rather die in an ambulance driving past them on my way to a good surgeon than have any of them ever operate on me again.
I went home to Dalat and continued living my life.
Then Covid hit.
In March 2020, with little-to-no warning, Việt Nam locked down tight. People could leave, but without a diplomatic passport or special dispensation from the government as an “expert”, no one was getting in, not even citizens. After a while, only citizens were eligible to pay an exorbitant fee for a special “repatriation flight”, but there were very few flights. Expats who’d gone to Cambodia or Thailand for the (wrong) weekend were unable to get back for well over a year. Many of them had a spouse and kids here. Việt Nam was extremely serious about protecting its people and this was before vaccines became available.
Sometime that summer, the knee pain kicked in again, so I started researching where in the U.S. I wanted to have my next surgery. I chose the #3 best orthopedic hospital in the country, Cedars-Sinai in Beverly Hills (Los Angeles), California. I chose them because #1 is in New York City and #2 is the Mayo Clinic in Minnesota and both NYC and MN are cold af in the winter, which is when I schedule most of my surgeries because I teach in SoCal every November so I’m already in-country. I also greatly prefer the west coast over the east, even if it weren’t a day’s flight closer to Việt Nam.
Cedars has a great referral system in which an actual human (at least for now) asks a bunch of pertinent questions, actually listens to the answers, and then recommends the doctor or specialist who they think would be best for you.
My referral person said that the ONLY surgeon she would recommend for my pathetic (my word, not hers) situation was Dr. Guy Paiement. She was right.
By this time, my knee was pretty bad. It was so unstable that I could move my shin without moving either my knee or my foot. I made this video just before the surgery.6 I got the date wrong, probably because I was tired and had heavy pharmaceuticals on-board. It was 19 November, the morning of my surgery, not 19 December.
When Dr. Paiement’s office heard my story and that I live in Vietnam, they suggested a phone consultation. During the phone consultation, I mentioned to Dr. Paiement that I’d seen two orthopedic surgeons in Saigon and that they had both said that even if they could get the larger hardware I need because I’m “not small like Vietnamese people” and they were not experienced enough with such complicated cases as mine. They both said I should go to the U.S. for surgery.
Have you EVER heard a doctor say something was beyond their skill level? Until then, I sure hadn’t, and I was very impressed. Hell, I had three U.S. doctors fuck me up because they wouldn’t admit they were in over their heads.
Hearing this, Dr. Paiement asked if I could arrange for him to talk with the Chief Surgeon at Cho Ray Hospital in Saigon, where I had gone for a second opinion. I said, I’d do everything I could to arrange the consultation.
Cho Ray’s Chief Surgeon was flattered that Dr. Paiement wanted to consult with him and arranged to be available early one morning, which was the previous evening in California. Another doctor who is fluent in English translated for both of them, and I got to listen in and be available for questions one or the other might have.
Remember that at this time, Việt Nam was locked down tightly for entries. Because no one knew when the lock down would be lifted, I didn’t want to leave before I figured out a way to come back “legally” after the surgery.
That took some time.
FINALLY — What Wood should’ve done
Eventually, I secured a “position” as a Sales Manager for a company in Saigon owned by a U.S. citizen. His employment letter got me the expert exemption I needed to return. So I flew to LA and had the surgery on 19 November 2020.
Dr. Paiement added the “rod” that Brodie Wood had, 11 months earlier, said I didn’t need. He also cut a section out of the saphenous nerve to stop the pinched signal from getting to my brain. All good to go home.
Once I cleared Immigration in Saigon, they put me in an almost full—body condom (it would’ve been so for a local) and sent me off to a 15-day quarantine.
I was the only passenger in a big bus adapted for quarantine.
Thank the gods I’d thought ahead and reserved a higher-priced room with a balcony so I got plenty of fresh air every day. People who know me personally won’t be surprised that I very much enjoyed the 15 days in which the only time I left my room or saw other people face-to-face was for Covid testing. Right, Mr. Kaczynski?
Some poor mutts trying to save pennies got rooms with a non-opening window; I think I’d’ve gone postal.
May I please get off this damn merry-go-round?
All was well for almost four years. Then, last September (2024), the knee started hurting 24/7 and felt unstable. Fortunately, I was headed back to SoCal to facilitate the Customer Communications classes in November. The only time I could schedule an appointment with Dr. Paiement was a few hours before I flew home. He confirmed the instability — the shin again moves independently — and said I need another surgery.
I said that if he could fit me into his schedule before the New Year, I would postpone my flight and hang out ‘til then. He apologized and told me both that his schedule was full ‘til the end of the year AND that he would be teaching in South America for the first quarter of 2025, so the earliest possible surgery date would be in April.
I’m batting 1.000, aren’t I?
He also said he needed to do some research and determine the best way forward. This was the second time I told him: “Maybe it’s time to take the leg.”
There’s this relatively new procedure called osseointegration that I think is the only way I will ever be able to live actively and without knee pain.
By inserting an advanced implant into the bone, it provides a secure and stable connection for a range of external prosthetic limbs. Eliminating the need for a traditional socket prosthetic, osseointegration can improve mobility, comfort and quality of life. — https://osseointegration.org/
If you click on this link or the one immediately above, there’s a very cool graphic.
When Dr. Paiement got back to me, he said he wants to replace the plate on the head of the femur. I’m guessing it’ll be similar to this hinged joint:
I again lobbied for osseointegration.
And “Frequent Surgery” points7.
He said it’s too early for osseointegration and chuckled at my request for points.
I’ve also asked that he adjust the length so that both legs are again the same. Since the 2019 surgery, the larger spacer made my right leg 1+ cm longer than my left and it’s playing hell with my spinal alignment, giving me nerve pain in my left hip that I really want to stop. It’s also degraded my gait so that I sometimes feel like I’m Amos McCoy on a small ship in rough seas.
What’s next?
I don’t know.
I’m desperately hoping it takes and I can get on with my post-surgery life.
If there’s EVER another knee surgery in my future, I want to go with osseointegration, ‘cause five attempts to fix what fucking Agatrap fucked up is my limit.
October 2016 — Tibial plateau fracture “repair”
April 2017 — Partial knee replacement & straightening
May 2018 — Full knee replacement
November 2018 — Manipulation Under Anesthesia (MUA)
November 2019 — Replace tibial plate (16mm - 22mm)
January 2020 — Injection to saphenous nerve
March 2020 — Manipulation Under Anesthesia (MUA)
November 2020 — Knee revision PS Rotating Platform / Cut saphenous nerve
April 2025 — Hinged knee revision (TBD)
See you on the other side…
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Reviews on the web page I linked to above (they didn’t let me give one) say that Agtarap’s now retired. I wonder if other horribly-botched surgeries had anything to do with that?
I debated the point and decided to leave the foreshadowing in.
Most likely because I didn’t do my stretching exercises EVERY day.
The largest tibia plate available in Việt Nam is 15mm.
When this publishes, I will be staying in that same LA AirBnB room waiting for surgery day.
Like the airlines’ Frequent Flier points, but for surgeries
Oh John. That's awful. I feel for you. I know the pain of having knee replacements. I've had both done. Thankfully fabulous surgeon. Makes me even more happy that I live in Australia!
Take good care of yourself x
That whole thing just sounds all kinds of painful. I had a friend in the military and he messed up his back and then a ton of VA surgeries messed it up more. Too many doctors think they are gods and get away with murder.
Best of luck, fingers crossed, the whole bit.