My great total knee replacement

Two years, three months --- and no longer counting

2007-01-05T16:36:00.000-05:00

Today, I had my two year post-op check-up. Yes, it's actually been 2 years, 3 months, and let's see --- 7 days.

The news? I don't need to go back to the surgeon until 2010. Well, the 5 year anniversary is actually 29-Sep-2009, but 3 years from today is ... January, 2010.

OK, enough word play. At the two-year-mark, my TKR is absolutely perfect, as good as it can possibly get. On the X-ray (which I could NOT get digitized to post, btw), there is no sign of osteolysis. Everything is in perfect alignment. No unusual wearing of any of the joint surfaces.

When the doc asked how I was feeling ... I told him that I was working with a trainer every other day; walking 3.5 miles on alternate days; and ... I can kneel and sit on my heels. And so then, I showed him.

I started going to the trainer in May, 2006, simply because I was not being able to restore any kind of bilateral symmetry on my own. After 30+ years of a bad knee, I continued to favor the formerly-bad-leg even after the TKR. I still shifted my weight away from the "bad side", and this was creating some serious posture-related lower back pain. My TKR leg continued to be much smaller and atrophied when compared to my non-TKR leg. I was not making progress on my own --- so I gulped hard, and started going to a trainer on a regular basis.

Eight months later, I am walking 3.5 mi easily --- outdoors, and with significant hills to climb. The calf on my TKR-leg is almost the same size as the other. The quadriceps on the TKR leg are much stronger and very well-defined, however, there are still obvious upper leg diameter and mass differences. This is no longer as striking as it was pre-op, but still exists.

I've lost NO overall body weight. There have been significant muscular shifts though --- my waist is at least 2 or 3 inches smaller, for instance.

And ... there is no need for another check-up until the five year mark.

As always, I will try to respond to your emailed questions within a few days.

TKR-plus-22-months --- almost two years after unilateral total knee replacement, and loving it !!!

2006-07-14T10:55:00.000-04:00

For those of you who had been hoping that I would be posting more frequently, my humble apologies. As it does with many of us, life post-TKR has really changed my normal patterns.

For those of you who have emailed me, I hope that I have gotten back to you in time to have been of service. The gmail address bounces twice before it gets to a box that I monitor on a routine basis, and sometimes that path is less than reliable. I do, however, try and check the gmail account directly every month or so.

Now, the update.

It's been just about 22 months since my unilateral (right) TKR. If you've been here before, you know that my experience has been incredibly positive. If not, I encourage you to read your way through the archives --- the whole story is in there. My experience continues to be absolutely positive.

About ten weeks ago, I decided that my post-TKR body was still not balanced or symmetric. 30-plus years of favoring my right knee had created many bad posture and balance habits which I still unconsciously retain. My solution was and is) to go to a personal trainer 3X a week for an hour. 6 AM, MWF. Yes, ouch. And on the "off days", I walk or bike for an hour.

As comfortable as I had been pre-trainer with my TKR, things after 10 weeks of effort are much MUCH better. Flexibility, balance, strength --- all are improved. This enables me to do more, and protect both my knees and my back much better than before.

For example, I've mentioned kneeling in here more than once. "Can you kneel with a TKR?" is a frequent Delphi forum question. Although my experience may be unique, and yes, my TKR is uni, not bi, let me tell you: I CAN KNEEL. We do yoga-type stretching from kneeling positions all the time, and I am able to comfortably go into a yoga "prayer" position. The trainer does not call it that, but it resembles the arms-forward variation of the balasana, or yoga child's pose. I can almost sit on my heels, and can almost put my chest onto my thighs. Interestingly enough, it is no longer my KNEE that limits my flexibility, but my lower back and hips.

What has this done to my daily life? I now garden on my knees, wearing gel-filled knee pads, rather than always sitting (because I was unable to kneel).

I have NO pain, even after extended exercise. I routinely walk 3 to 5 miles at a time, at a fairly fast pace. No pain.

My two-year anniversary is at the end of September, 2006. I expect to be posting a full update at that time.

I would encourage those of you who read this to simply know that with persistence, hard work, a good surgeon, and a good PTist, you will get through the TKR experience. There may be days or weeks when it doesn't seem like it. There will be weeks where the incremental improvement just doesn't seem real. But it will be.

Or at least, that has been my experience.

One-year TKR anniversary! 12 months of life after a total knee replacement and loving it.

2005-09-29T07:30:00.000-04:00

Welcome! If you are reading this, you've found your way here from either a browser search (looking for TKR information), or from the Delphi "On Our Feet" forum.

This post marks the one-year anniversary of my TKR. Unilateral, right knee only (the left is fine, thank God). My experience has been exceptionally positive, and I certainly recognize how lucky and blessed I am to have an experience this positive. I posted a summary of my TKR experience here: http://greattkr.blogspot.com/2005/05/knee-plus-eight-months-anniversary.html.

Actually, I've been told that my experience is not all that unusual, and that many TKR patients have positive TKR experiences. I am certain that this is true. However, it is human nature to focus on the negatives, and this is also true on the Web. A year ago, it was difficult to find positive TKR information on the Web. Furthermore, it was really easy to find TKR horror stories, and I found enough information to really scare me pre-surgery. I decided that if my TKR went well, I would try to blog about it on a regular basis, just so that there was some detail on-line of a real experience, from beginning through surgery and PT, to the one-year anniversary. That's what this blog is.

My TKR occurred on the morning of 29-September-2004. Please roam through the archives. All of the detail is there. My story actually starts in 1969, with my initial knee injury and old-style ligament and meniscus surgery. I kept a detailed journal of my actual TKR last year, and then posted the journal to this blog. You can read all of my fears (both realized and unfounded). Recognize that I am a scientist --- I included lots of details that may not be for the squeamish.

There are no pictures here except for the ones below from our recent hiking-and-biking vacation post-TKR. You can google pictures of TKR surgeries pretty easily, if you're looking for gore.

I've been asked about continuous-passive-motion machines. The surgeons in the practice I used do not use them unless the patient needs them. I suspect that ultimately, it's an insurance coverage issue. There are recent studies in the literature that indicate that PT without CPM is as effective as PT with CPM. At least, after 6 weeks post-op. What the studies do not tell you is that those 6 weeks of PT without CPM require a tremendous amount of effort on the part of the patient. If you don't (or can't) do the PT, you may not recover as quickly or as fully as someone who did (or can). If you are physically weak, if you tend to develop scar tissue, if you cannot take pain-killers --- talk to your OS about prescribing a CPM for you. It is not a perfect solution: you will still need to work hard at PT. But in some cases, it can help.

I've also been asked --- a lot --- about kneeling. This is a discussion you need to have with your surgeon. Not all TKR devices allow kneeling. Not all TKR recoveries will get to the kneeling stage. Mine did.

What are my current limitations, one year after my TKR? I'm not sure that I have any, except a fear of falling down and whacking my TKR knee. I walk. I hike. I bike. I mow the lawn. I garden, including tilling and kneeling.

I spent last Friday going up and down scaffolding on a Habitat house. I actually was on top of two stories of scaffolding, with my TKR knee bent over the toprail of the scaffolding so that I could lean out, and use both hands to install the framing for a soffit return. A year ago, pre-TKR, I could not have thought about climbing a ladder, let alone hanging from a scaffold.

If you have specific questions, you can email me at the address listed in the sidebar. I can't promise an immediate answer, but I do try to check that mailbox at least once a week.

I will also continue to post to this blog. Each month, the anniversary of my TKR still makes me realize what a tremendous change in my life the TKR has been. Thanks for allowing me to share that with you.

Another successful total knee replacement (TKR) climbs Mt Quandary !!!

2005-09-26T09:47:00.000-04:00

It appears that I've inspired someone! I recently got a note from another TKRer who climbed Mt. Quandary:
Hello Great TKR - I believe we have much in common. I am 58 years old, and had a right TKR in August 2004. ... As with you, my TKR has been highly successful and the operation gave me my life back. My positive and negative experiences were pretty much the same as yours. I have not done the biking to the extent that you have, but have been swimming regularly, and working out at a fitness center since I finished PT. I also avoided the pain meds, worked hard to get in shape before surgery, scared myself when I saw"the bruise," and have had an overall very positive experience.

Here is the ironic part. I climbed to the summit of Mt. Quandary last Sunday (9/18). (My wife and I) went up to Breckenridge where we have friends who had been after us for several years to come out and stay with them. Their house is a few miles north of Breck, quite near the Mt. Quandary trailhead. I was thinking about attempting this mountain when I found your inspiring website and that settled the matter, I had to give it a try. Our friends are in their 70's and my wife is a cancer survivor, so none of them were capable of attempting a fourteener. I did a solo climb. Near the summit pyramid, I met a group of very buff young men and women from a Colorado Springs climbing club. They let the"old guy" tag along with them and helped me over the tough spots near the summit. I kept wondering where all the oxygen went! They gave me a round of applause when I reached the top. Very rewarding. On the way down I took some great pictures of mountain goats (below the saddle).

Your blog site is great. I hope lots of people considering TKR will read it.

There can be no limits to what you can do after a successful TKR. That's been my experience. That's also the experience of the gentlemen who followed me up to the summit of Mt. Quandary: "... the operation gave me my life back." All that I can say is "I agree!"

Month 11 TKR anniversary: my total knee replacement goes mountain climbing

2005-08-29T16:56:00.000-04:00

This is Mt. Quandary, in the Rockies west of Denver. The peak height is 14,265 feet above sea level.

In early August, about 10 months and a week after my TKR, our extended family took a group of ten people from 10,400 feet (the trailhead) up Mt Quandary to the summit.

I "only" made it to about 13,700 ft. There's a "saddle" on the ridge. I made it across the saddle and about a third of the way up the last push to the summit.

Here's the view from the other direction, looking down into the valley (at the top of the picture).

This picture was shot by my brother-in-law, looking back down onto the saddle. You can see the saddle in the shot from below. Those "ants" are people, folks. Please note the patch of light colored rocks and the patch of green.

This is me, at about 13,500 ft. You can see the light colored rocks and the green patch behind me. I made it this far, and met the rest of the crew returning from the summit.

The hike took 3.5 hrs to the top (or for me, being last in the group, to get to this height). The trip down took 2.5 hrs. All of us live our normal lives at about 1,200 ft. We flew to Denver on a Saturday, and did Quandary on the following Thursday. Breathing was a challenge, and for all of us.

My TKR knee was fine, both up and down. However, all of our calves ached from the return trip.

We also did a 23+ mi bike ride (on Sunday), and a 3 hr hike up a mountain at a lower elevation (on Tuesday). I went into this vacation expecting to have limitations re outdoor activities. I was pleasantly surprised to discover that there were none. My knee did not hold me back --- at all.

This is me at the top of Vail Pass, at about 12,000 ft, just about to ride the bike DOWN from the pass to a town called Frisco, about 15 miles away. After we got to Frisco, my daughter and I pedaled from a additional 8 or 9 mi --- uphill --- from Frisco to the outskirts of Breckenridge. Breck is about 500 ft higher than Frisco, so it was only slightly uphill. But I can assure you, we KNEW that the road was uphill.

I really just wanted you to see the scar on my knee.

Knee-plus-ten-months: my TKR is still going strong

2005-08-03T17:09:00.000-04:00

It's been more than ten months since my TKR.

I work about 3 miles from home. I can walk it (but I do limit this to good weather).

I can ride a bicycle comfortably. Longest bike rides have been in the 5 mile range. Uphill is not a problem. Standing is not a problem.

I can and do kneel regularly.

I am once again actively gardening. I mow the lawn weekly. I use a big ol' rototiller. I rake and hoe. I kneel. I squat. Yes, I still tend to sit cross-legged to weed or plant. I can straddle my 3 to 4 ft wide garden beds to weed, seed, plant, harvest.

And we're planning a vacation in which we plan to hike up a 14,000 ft mountain in Colorado. With luck, I'll have pictures by the eleventh month anniversary.

I know how lucky and blessed I am to have had such a positive TKR experience. But I absolutely love it!

Knee-plus-eight-months anniversary: progress continues after my total knee replacement

2005-05-24T17:14:00.000-04:00

Sunday 29-May-05 will be the 8th month anniversary of my total knee replacement. Tomorrow 25-May-05 is the 34th anniversary week. I feel like a teenager again, counting the weeks and months that my new knee and I have been "going together".

So far, I continue to be be extremely pleased with the TKR process. I've been lurking regularly over at the Delphi On-Our-Feet forum, and have been interested to see the wide variety of individual reactions that TKR recipients have had. There are many common experiences, but it is clear that each TKR is different, because each of us is different. The Delphis provide a great service to the TKR community as an online support group. Keep up the good work, folks.

That said, it is pretty clear to me that I've been extremely lucky with my TKR. I feel that this anniversary is an appropriate time to lay out the positives and negatives of my personal TKR experience. And yes, there have been some negatives.

The remainder of this post is simply a summary of the positives and negatives of my TKR experiences, as I remember them. These are simply my memories and my personal opinions. I am neither a surgeon or a therapist, and am providing these simply as a reference for those of you who may be looking ahead to a TKR in the near future.

Positives:

Good pain control post-op:

Compared to the pain I had following my pre-arthroscopy cartilage and ligament surgery in 1969 (general anesthesia plus a nerve block to the leg), the pain I experienced following my TKR was nothing . I had a spinal / epidural with a button-controlled fentanyl drip that was simply awesome. Removal of the epidural catheter on Day 2 was painless. I was on oxycontin and percocet for a month or so following surgery, and I needed both of them to get through PT.

Recovery time:

I was on my feet at knee-plus-one-day, using a walker. And had graduated to a cane a week or so later. And was cane-free within about a month. My point of comparison was my earlier (1969) knee surgeries: 14 days in the hospital, and still being on crutches for weeks after I got home.

No pain:

After 30 years of being bone-on-bone in my right knee, and the last 10 of those being in chronic deep arthritic pain, I woke up in the recovery room realizing that there was no pain in my knee. Yes, I certainly was drugged, and had acute post-op pain. But the deep gnawing joint ache that I had lived with for so long was gone. This is one of the most astounding parts of my TKR recovery. I am basically pain-free.

Good flexion, good extension:

By the time I decided to go through with the TKR, I could no longer completely straighten my right leg (limited extension) nor could I bend my right knee much more than 90 degrees, if that (limited flexion). I woke up in recovery with full extension (although I had to work during recovery to retain that degree of mobility) and flexion >90 degrees. PT during recovery took my flexion >125 degrees, and at 8 months, I am well beyond that point. Although I have not been measured since my final in-office PT session.

Kneeling and squatting:

It had been years, perhaps a decade or more, since I had last been able to kneel or squat. I'm a serious gardener, and this limitation was a significant consideration for me. I can now kneel adequately although it still feels odd, and if I kneel for more than a few minutes, my new knee feels really loose afterwards. But I can kneel.

I can also squat down, and am coming close to being able to sit on my heels. I'm not there yet, but I seem to be getting closer each week.

Walking:

In the last 2 years pre-op, I had almost completely lost my ability to walk for more than 15 or 20 min at a time. This had some obvious impacts on my general health. I can now walk comfortably for an indefinite length of time. I still get tired, and I can really feel my legs stretch when I walk hard and uphill. But I can do it, with little residual pain, and with an increasing amount of comfort.

Biking:

My wife and I took a long-overdue vacation a year before my TKR, and spent a couple of days on a motor-vehicle-free island in the Chesapeake. To get around, you either walked or biked. I could not bend my right knee enough to pedal a bicycle.

We have a stationary bike that I used effectively during my recovery and PT. In fact, the bike helped me get through one of those recovery plateaus in extension. I recently graduated to an outdoor bike, and am now biking through our Appalachian hills for 45 min to an hour at a time.

Improved sleep:

Sound sleep during the three to five years pre-op had gotten increasingly difficult, due to the nagging chronic joint pain. I took prescription grade ibuprofen until my ears rang, and it initially helped. But eventually, not even high doses helped.

Post-op --- and post-recovery --- I am experiencing good sound deep sleep for the first time in many years. How sound? I no longer turn on the alarm clock: I wake up at my normal time (early), every day, ready to go.

Negatives:

It would be naive to try and convince anyone that a surgical procedure as invasive as a TKR has no potential negatives. Yes, I am generally a positive thinker, and an optimist. But I also think of myself as a realist about the hard things in life.

Recovery is HARD work:

I had a great TKR. I am thrilled that I did it. But recovery was (and is) very hard work. You need to push yourself pre-op to be prepared. You need to push yourself during recovery to maintain the extension that your surgeon gave you in your new knee. You need to push yourself in recovery to retain the flexion that comes with your new knee. I was told that there are no physical limitations re extension or flexion following a TKR --- when you are "under" ( i.e., fully anesthetized during surgery), your surgeon can bend and flex your knee far more completely than you will be able to once you are awake. Why? Because when you are awake, you can feel both the pain and the pressure. Your job during recovery is to gain and retain the mobility that comes with the new joint. This will be very hard work.

Agonizing PT during early recovery:

Therapy will hurt. Period. If you do not hurt during PT, you are not pushing yourself (or allowing your therapist to push you) hard enough. To quote my surgeon: "You cannot damage your new knee during PT. You can only cause yourself pain. And that's what pain medication is for". The good news is that for most of us, pain meds work, and that the intensely painful PT period only lasts two or three weeks. This is the period when you are recovering from the surgery, and the incision is healing most rapidly.

It is also the period when your body tries to heal the surgical invasion with scar tissue. Scar tissue forming in the joint can be a problem, and can severely limit your joint mobility. This is why it is extremely important to work through the pain. If you allow the scar tissue to form and become stiff, you may limit your joint mobility forever. In extreme cases, your surgeon will need to "release" the joint by means of another surgical event, one in which the scar tissue is cut and removed.

Pain meds make you fuzzy:

I hated being on pain medication because I could not focus. At all. I could not read. I could not concentrate. I could not follow the progress of even a simple sit-com on TV.

And work? When I attempted to work from home via laptop, it was a joke. There was no way I could take pain meds and work from home.

Constipation from pain meds:

Opiate-based pain killers inhibit intestinal peristalsis. Pain meds give you constipation. I had never in my life had a problem with constipation, but even with daily doses of a stool softener, Metamucil cookies, oatmeal spiked with FiberOne, and quarts and quarts of fluids --- I was constipated as long as I was on pain meds.

Reaction to stopping meds once pain subsided:

Pain meds are addictive, both physically and psychologically. For me, stopping became possible once I healed enough to get through a hard PT session without them. And then, I went through two days and nights of mild withdrawal symptoms. I itched and scratched and itched and scratched for two solid days. And then it was over.

Poor sleep for first few months:

TKR is a very invasive surgery. There is a lot of minor residual pain during recovery. For me, even during the pain medication phase, I had trouble sleeping for more than a few hours at a time. Insomnia is a common complaint on the Delphi joint replacement forum.

Fatigue during initial healing phase:

TKR is a very invasive surgery. Healing and PT will be exhausting, no matter how well you are prepared. I thought that I could get back to work within days of surgery, at least from home with my laptop. Ha. It was three months before I could handle full days at my office, and even then, I would be exhausted by the end of the day.

Depression and frustration during recovery:

Recovery takes time. PT is hard work. You will get frustrated that you are not making faster progress. You will run into recovery plateaus where you will feel that improvement just isn't going to happen. This is completely normal and to be expected. We all went through it --- this, too, is one of the more common threads on the Delphi forum.

And if you keep at it, you will get through the plateaus.

Pre-op fears that ended up being unfounded --- at least for ME:

Epidural/spinal anesthesia:

I had a real problem with the thought of having a needle and catheter stuck into my spine. In hindsight, I barely remember it going in, and could not feel it being removed. And as I mentioned above, the button-controlled pain relief that an epidural catheter enabled was one of the most wonderful post-op advances that has been made in the past 30 years.

Catheterization:

If my fear of a spinal was irrational, my apprehension about having a urinary catheter in place was worse. Urinary catheterization was really nothing at all: insertion occurred after anesthesia, so I have no recollection of insertion. Removal occurred on day 2, and was not a problem at all. My surgery took >2 hrs --- being catheterized was a good decision. Some of the Delphis did not have a urinary catheter installed, with their surgeon believing that a urinary catheter had the potential to develop an infection post-op.

Deep vein thrombosis / blood clots:

Post-op blood clots / DVT can be a problem following joint surgery. I wore constantly inflating/deflating leg balloons while I was in the hospital, took preventative doses of an anticoagulant (in my case, warfarin, although there are many alternatives) and wore compression stockings (TED) during the first few weeks post-op.

I had no problems with DVT. However, one of the women in my PT class did develop a blood clot on her way home from the hospital. She described her symptoms as unusual pain and swelling. The event set back her PT schedule significantly. I asked my surgeon how I would know if I had a clot --- he said, simply "You'll know", and said that the pain, swelling and leg discoloration would make it obvious.

Post-op infection:

TKR is an invasive surgery. My entire TKR surgical team wore "space suit helmets" during surgery --- the air they breathed in and out (for their protection, and mine) was delivered via a tube. The surgical site was constantly irrigated with an antibiotic solution during surgery. I was dosed with two strong doses of an antibiotic by IV following surgery. And that was it.

I had expected a more vigorous antibiotic therapy post-op, and quizzed my surgeon about it. He said that his practice follows the most current recommendations available, and that since they switched to the practice described above, they have had NO post-op infections.

That said, he warned me that for the remainder of my life, ANY invasive surgery (even a dental cleaning) would require pre-treatment of a strong antibiotic dose. He then told me a story of a patient who developed an infection in a TKR 18 years after installation, and as the result of dental work (with no preventative antibiotic treatment).

Things no one really tells you ahead of time:

Healing and recovery take up to a year --- or longer:

Recovery will teach you patience. One of the most shocking statements from the surgeon post-op was when he told me that I should expect recovery to take more than a year. If he had told me that pre-op, I sure didn't remember it.

Recovery is full of plateaus. For me, when I got to about 85%, I began to slack off. This was a mistake --- I lost some mobility both in flexion and in extension. I've had to work hard to get those back. Apparently, this, too, is a common post-op occurrence. For most of us, the limitation to full recovery is NOT the new joint, but our ability and willingness to develop and retain muscle strength supporting that new joint.

Avoid the pillow:

Most of us with chronic knee pain figure out that putting a pillow under the knee to keep it slightly flexed at night supports the joint and minimizes the pain. However ...

... you probably should not do this after your TKR. My surgeon and his staff were very adamant about "Nothing under the knee". The rationale is that if you put a pillow under your knee during recovery, the newly developing scar tissue "sets" the knee in that slightly flexed position. This could limit your ability to fully extend your leg/knee.

I was probably more than a little obsessive about this during the first few weeks post-op. I would build a ramp of pillows and towels at night under my leg, so that the leg was both elevated (to reduce swelling) yet with the leg/knee in full extension (to avoid keeping it bent).

Did it help? I think so, at least for me. I do miss that little pillow sometimes, however.

The recovering joint gets HOT:

Recovery --- healing --- is an energy-intensive process. There's lots of activity in there as you heal. Biological activity produces heat, and your new knee will get quite warm to the touch. The first time I noticed this, it scared the heck out of me, and caused me to call the surgeon's office in a panic (I thought: "Blood clot!"). This is completely normal, and even 8 months after surgery, a hard day of work in the yard may cause me to have a hot knee that night.

The new knee is noisy (clunks and thunks):

Your new knew will be noisy. Expect to hear clunks and thunks. As the muscles, tendons, and ligaments tighten around the new joint, apparently the new joint will become more quiet. My surgeon tells me that this may take more than a year to occur. During the past two months, the knee has been generally quiet, unless I have been stretching it through exercise of some kind. THEN, the clunks and thunks are likely to occur again.

PT is YOUR responsibility, not your therapist's:

Pre-op, I thought that recovery would be a vacation. I'd go to PT 3X a week, and have the rest of the time to read; work from home; basically kick back and enjoy some time off.

Post-op, I realized that my recovery was UP TO ME. I relaxed the first weekend we had company, and didn't do my daily sets of PT. Monday at PT, I learned that I lost the progress that I had made the week before. This taught me to do PT at home at least 2X a day, if not 3X a day. When I would run into a plateau, I'd ask the therapist for more exercises to do at home to push through the barrier.

Every TKR patient recovers at a different rate. I was 51 years old when I had my TKR. Some of my peers in my PT class were 20 to 30 years older than I was. The age difference alone would be expected to cause a difference in recovery rates.

I was(am) lucky --- I am blessed with a supportive family; a supportive employer; and suffered few if any post-op complications. Not everyone is so lucky. However, it was fairly obvious to me that the people who were recovering quickly were those who were able to do PT at home, regardless of age, gender, or general health. The people who were having the most trouble regaining extension and flexion were those who were not able to do daily PT at home.

PT will be painful, especially to break-through the plateaus:

If you want to recover fully from your TKR, you will need to work hard at PT. And working hard at PT will cause you pain.

PT and exercise of the new knee is probably a forever consideration:

At almost 8 months, if I do not walk or bike or otherwise exercise my leg on a daily basis, I can tell the difference when I restart physical activity.

Ice will be your friend during recovery (CryoCuff, ice-and-isopropyl alcohol slush):

PT causes pain, and during early recovery, PT causes swelling. I found that ice was a great solution to both pain and swelling. My favorite cold treatment was a device called a CryoCuff made by a company called AirCast. This is what they used at my PT office, and it is a simple device: an inflatable cuff that you can fill with cold water via a hose connected to a one-gallon ice-and-water-filled drink cooler. Wonderful device. The cuff inflates to the shape of your knee (which an ice pack doesn't). When it gets warm, you drain the water back into the cooler, shake it up, and refill again with ice-cold water. For me, I got about 20 min of good cold before having to refill the cuff; and a 50-50 ice water filling of the cooler would last about two hours.

Many of the Delphis fill gallon-sized ZipLock Baggies with a 1:2 or 1:3 mixture of water and drugstore rubbing alcohol, and freeze them. The alcohol keeps the water from freezing solid so what you get is a frozen slush. The alcohol also lowers the freezing point of the solution so the slush is actually colder than simple water ice. I have not tried it, but as a scientist, it makes a lot of sense to me. You can link to the Delphi site and search on "slush" to follow the thread.

Pre-op strengthening and stretching exercises are important (my hero, Ginger):

Four months before my TKR, I met the wife of a business colleague who had had a bilateral TKR less than three months before we met. We met in Holland. Not only did she fly to the Netherlands, she and her husband were walking 2 or 3 miles each day from our hotel into a nearby town. Ginger, you are my hero. You inspired me to go through with my TKR.

Even more importantly, Ginger told me that the smartest thing she had done was to practice all of the PT exercises she would have to do AFTER her TKR BEFORE her TKR. She said that the strengthening and stretching that she did pre-op made her post-op recovery go much faster and easier. When we all got back to the States, she sent me the exercise sheet she had received from her surgeon. I took her advice, spent three months doing the exercises a few times a week, and for me, it also worked. One of my first post-op memories in the recovery room is that I could do a quad set and raise my leg up off of the surface of the gurney. I was very woozy --- and I certainly didn't lift it very far --- but I could do it.

Pain medications are good for you (you'll need them to work hard in PT):

My wife calls me a stoic. My pre-op life was full of chronic knee pain, and I thought that I had a pretty high pain threshold.

Wrong. PT will be painful. Take your pain meds. Otherwise, the pain from the healing process will interfere with your determination to exercise the joint. And PT/exercise is the key to a full recovery from your TKR.

Healing incision will itch as it stretches:

As the incision heals, the scar tissue shrinks and tightens. As you exercise the joint, you will stretch the scar tissue. This stretching will cause the incision to itch. For me (another common point with many of us), the itching drove me crazy. But eventually, the incision heals, the stretching stops, and the itching subsides.

Post-op bruising may be significant (especially with a tourniquet):

There are many ways to conduct a TKR. One of the more common practices is to put a tourniquet above the knee pre-surgery so that there is only a limited amount of blood loss during surgery. For me, the tourniquet was placed at about mid-thigh. Unfortunately, blood pools above the tourniquet (towards your torso), and this pool will form a huge bruise.

Of course, since I was on my back most of the time during the first few days post-op, the blood pooled in the back of my thigh. And, since I was wearing those wonderful white TED compression stockings to prevent DVTs, I never saw the bruise. Until, I got fully undressed one morning to do a sponge-bath and happened to catch a glimpse of the back of my leg in the mirror. AAAHHHHH!!!! What's that bruise?

I was on the phone with the surgeon's office in a heartbeat, thinking BLOOD CLOT!!! Nope. The surgeon's assistant very calmly asked me where the bruise was, and if it was painful and hot. When I told her it was at the back of my thigh, and that there was neither pain nor apparent inflammation, she said --- calmly and gently --- that this was completely normal and was the result of the tourniquet being applied during surgery.

Whew. What a relief THAT was!

My TKR was done on 29-Sep-2004. If you want to read my daily journal before and after the surgery, please go into the archives for that period.

Riding a bicycle with my TKR

2005-05-23T09:13:00.000-04:00

We've re-discovered a love for bicycling! And have been riding daily after work, at least when the weather cooperates. Our typical after-work ride takes about 45 min, and is usually about 3 mi or so in length. We live at the top of a hill which is part of a series of ridges, so we're riding uphill and down.

Early Saturday AM, before anyone else in the house was awake, I decided to explore a new bike path just to see what it was like. Turns out the short route is about 6 mi, with the first mile being almost entirely uphill. I certainly learned to use the gears on the bike for this one, although I still have a problem understanding why a bike has to have 21 (or more) gears. I probably use a total of 8 gears at most, and then only when there is a long steep grade. Otherwise, I'm using maybe 3 of them?

My legs were like jelly when I got home, and I did have to walk the bike up one short-but-steep grade. But for the remainder of the ride, I was on the bike, and sitting down, using the gears on the bike. There was no pain, either in the knee(s) or in the supporting muscles. However, by the end of the day, my legs did feel very tired, so much so that I came in from the gardening much earlier than usual.

Could I stand up and "pump" going upgrade? Yes, although my sense of balance is not good enough to ride that way for very long. I'd certainly NOT want to ride that way uphill and in traffic. But I can do it.

I'm working on a long post in celebration of my upcoming 8th month TKR anniversary. It's very clear to me that I have been extremely lucky with my TKR. I will take this opportunity to post the positives, the negatives, and the things "I wish I knew BEFORE my TKR".

Riding a real bicycle, outdoors and with a TKR

2005-05-09T08:15:00.000-04:00

Today was a new experience for my new knee: I rode a real bicycle. I had not been able to do this comfortably for at least a decade pre-surgery. And as they say, it IS just like riding a bike.

The biggest question of the day: would I be able to stand up and pump up the hills? Well, the answer was "YES!" Balance was a little awkward at first --- it's been a real long time since I had been on anything but a stationary bike --- but once I got comfortable with the idea, there was no problem.

This is a big day. If I can bicycle outdoors comfortably, my wife and I intend to begin cycling regularly. For our aging 50 year-old bodies, another aerobic physical activity can only be a good and healthy thing.

I need to tell you about the past weekend. It's spring and we are in serious gardening mode. Saturday, we laid about 600 SF of concrete pavers. Lifting, carrying, bending, kneeling. All with only the physical discomfort of unaccustomed activity. There was no pain.

Then, I tilled the garden beds (about 90 min of tilling) for the last time pre-planting, to incorporate lime and fertilizer. I then raked and formed the beds. All in all, I was on my feet, working outdoors for more than 10 hrs.

Sunday, we puttered. I mowed the lawn, did some planting and transplanting, and then ...

We saw our grown children's bicycles in the storage barn, and decided that it was time to try them out. What a great feeling to be able to be physically active again. Gardening. Outdoor chores. Biking.

I did not realize how much I was missing. The limitations caused by my arthritic knee occurred so gradually and over such an extended period of time that I never thought about what I was missing. I knew what I could and couldn't do, but I didn't think about what MORE I could be doing if only my knee worked. But now ...

The Happy Tiller strikes again!

2005-04-28T08:12:00.000-04:00

Yesterday was the 7th month anniversary of knee-day. Knee-plus-seven-months.

Well, spring has REALLY arrived at my house --- I began to till the garden last night. Now this may not seem like a challenging task to you, but you need to understand a couple of things.

One, I garden in 3 to 4 ft wide raised beds, with grassed paths in between. These are ground beds (no board or stone edges), raked into raised beds. I typically till them at the beginning and end of the season. However, last year, I had to hire someone to till them for me. Why? Because my knee would not tolerate the strain.

Two, when I till, I straddle the bed. The width of the bed is just about at the maximum stretch that I can do comfortably, and still operate the tiller. One of my primary reasons for going through with the RTKR last fall was that I could no longer garden in the manner to which I was accustomed. This includes tilling the beds twice a year.

Please think about the stress that my straddle-the-bed tilling style produces on the knee. I am leaning and pushing on the joint with my legs splayed out at significant angle. The tiller (Troy-Bilt, rear-tines, 8 HP) is pulling itself forward. I use my body to guide the tiller and keep it on track.

Last night, I was the Happy Tiller once again.

I also weed and plant using that same straddle the bed position. Again, there is a fair amount of lateral strain on the joint. And, happily, I can once again work the garden from that position.

Ah, Spring.

Spring cleaning

2005-04-13T09:00:00.000-04:00

Well, spring is finally here. The daffodils are beginning to pop, and the forsythia should be opening later this week. And we had a dry weekend for a change, so ...

It's time to work outside! We spent the weekend cleaning the gardens from their winter and fall debris. Raking and pruning. Mowed the lawn for the first time. No pain!

We've got a modest lawn remaining (I've been converting lawn to garden for most of the past decade), but it still takes a good 45 min to an hour behind a walking mower to complete the yard. Pre-surgery, I simply could not do this, and my wife had to do the mowing. Not only was there more pain than I could tolerate, I could not not push with my right leg. Now, I feel as though I could keep right on going. There was no pain --- none!

We also washed all of the windows in the house, inside and out. This is a total of about 40 windows --- some large, some small, some two stories up in the cathedral ceiling-ed areas. Pre-surgery, I could not handle being on either a stepladder or an extension ladder. To do the upper windows, we had to call in ServiceMaster. This year, before we made the phone call, I convinced my wife that I thought that we could do it ourselves.

And we did. I was up and down both kinds of ladders all during Sunday afternoon. No problems. No pain. The windows look great, and I am continue to be thrilled with my TKR.

Now, I'm wondering if I can climb those big trees and get some of that pruning done by myself.

And just to take even more advantage of my new-found freedom, we began to paint the board fence that forms the backdrop to most of our shrub borders. Simple treated southern yellow pine wood, but it had aged to a less-than-attractive yellow-grey color. We decided to stain it a grey-green, so that it would disappear into the background trees. Once again, I can now stand, bend, stretch and pivot as I paint --- without pain, without strain, without discomfort --- for 2 or 3 hours at a time.

Today is knee-day-plus-six-months

2005-03-30T07:07:00.000-05:00

Today makes six full months. SIX MONTHS. I've had a new knee for six months. And my overall experience remains positive.

Last weekend, my wife and I rode in four little airplanes (Dash 8's) from home through Philadelphia to Virginia Beach (and back) for the weekend. First of all, it was a joy to be able to stride through the airports. No need to stop and rest. No need to eat Motrin like candy.

Second, it is getting to be SOP with the TSA guys at check-in. "I've got a fake knee". "George, he's got a knee". And they wand you all over, and pat you down whereever the wand squeaks. Less than 3 minutes, max.

Third, I spent the long weekend working on a wood-turning lathe. On my feet. Standing upright in front of the lathe. For hours and hours on end. No knee pain. NONE. My legs were not even tired.

And yes, I do recognize that I am still healing. It's come a long way, and there's still more to do. But where I am today is really good, and so much better than I was before my TKR.

Changes to this blog

2005-03-20T13:17:00.000-05:00

Knee-plus- ... well, it'll be six months next Wednesday:
Ch-ch-changes:
If you have been watching this blog evolve, you'll notice many changes in the older posts. Each day from the day before surgery until knee-plus-36 days are now posted individually, and in the archives. Knee-day for me was 29-Sep-04.

re blog frequency:
I attempt to blog on this site at least once a week. Sometimes more, sometimes less. Topics are those which I am experiencing re my TKR, although e-mail questions will trigger blogged responses at times.

re forum participation:
I drop into the Delphi joint replacement site at least once a week. I also occasionally drop by the Yahoo KneeSurgery forum and the Knee1 sites.

re best way to contact me:
E-mail should now go to greatTKR@gmail.com. I've been very happy with the Google e-mail service.

If you have questions re ANY of my postings on this blog, please e-mail me. I'll do my best to get back to you within a week.

Kneeling and crawling

2005-03-15T07:30:00.000-05:00

There's been a continuing discussion over on Delphi about whether or not you can kneel on a TKR. I can't speak for anyone's experience but my own. And I can kneel.

It certainly feels a little strange. There are obviously no pressure sensors in the artificial joint, as there are in the natural joint, so the knees don't "match" in that sense. But I can kneel on the new one, and with increasing comfort.

The first time I tried it, I was on a bed. I turned onto my hands and knees, and sat up and back, keeping the TKR at about 90 degrees.

Now, as I approach knee-plus-six months, I can comfortably kneel on carpeted floors, and have begun to sit farther and farther back onto my heels. I'm not yet in a complete sit-on-heels position, and may never get there. But I can go a lot farther back than I ever expected to be able to do. When I hold a kneeling position for a few minutes, and then stand up, my knee feels very stretched out. A little loose. And I think that it rattles and clunks more after kneeling, but that may simply be my heightened sensitivity, looking for problems after doing something new.

That said, I knelt in bed the other day, and on that soft cushion-ey surface, was indeed able to sit back onto my heels. I could not hold this position for very long --- the muscles at the back of my thighs started to cramp up and twitch in response to the "new" experience, but I could indeed put my butt onto my heels. I am not at all sure that I could do this (yet) on a less cushioned surface. But it's a lot more flexibility than I am accustomed to having.

It's been more than a decade since I could comfortably kneel in my garden and work. I'm now looking at kneeling stools, and kneeling pads, and kneeling mats. I'm thinking about changing the garden mulch to something a little softer and thicker, just so I can kneel on it. I'm so excited about this being-able-to-kneel thing. It's such a small part of life, but it's not something I expected to regain post-TKR.

Airport security?

2005-03-08T09:00:00.000-05:00

Yesterday, I took my first trip through an airport since knee-day. And yes, the replacement sets off the alarms.

I live in a small college town, with a relatively small airport. It was an early flight --- 0530 AM --- and I was not yet caffeinated, and only marginally awake. Nonetheless, I walked through the magnetic gate THREE TIMES, taking off more and more things each time, before I remembered that I HAD A KNEE REPLACEMENT LAST FALL. This recognition --- that I am so comfortable with the new knee that I did not even remember that it was there --- made me chuckle all day long.

Did I carry my knee-replacement card? No. But I did ask the question "Would I have to go through this if I had a card from my doctor?" The answer was "Yes". You set off the alarm, you get patted-down and wanded. It adds all of about 3 minutes to the process, and is not at all invasive. At both the small and large airports, the process is the same. Sit down. Wand each leg. Stand up, feet spread, arms raised, palms up. Wanded again all around. Repeat over the areas which "beep". Pat down those areas which "beep". The TSA employees I encountered were gentle and polite.

Be aware that your "stuff" sits in the bins on the conveyor belt, waiting for you. If you are traveling alone, you might want to keep an eye on your things. If you are traveling with a companion (and a companion who does not need to get patted down at each security checkpoint), I'd recommend that your companion watch your coat / shoes / bags / bins for you.

The other revelation of my first major travel day post-knee-day was that for the first time in years, I could walk comfortably from one end of the airport to the other, as fast as I wanted to walk, and without pain. In comparison, during one of my last business trips pre-knee-day, I had to walk 5 minutes, and then rest for 5 minutes, because my knee would no longer support me. I stubbornly refused the courtesy carts, but was to the point where I was seriously considering them.

If this blog is new to you ...

2005-03-05T12:05:00.000-05:00

... let me tell you why I am doing this.

Last summer (2004) as I was getting ready for my total knee replacement (TKR), it was obvious to me that there was not a lot of experiential information out there. What was it like? How long did it take? What were the details of the actual process? How long did it REALLY take to get off pain killers and back to work?

Yes, there is an abundance of information from the surgical community. You can readily find pictures and video of the actual surgery, and for a geek like me (yes, I'm a scientist), that's great information. But what was it REALLY like? There's just not much of this kind of information out there.

Yes, there's a joint replacement forum on Delphi (hi, Robin!). And Delphi is great place to ask questions. If you are looking for a place to ask questions about your knee or joint replacement, and get good answers in a back-and-forth format, the Delphi joint forum is the place. There are also Q&A forums on Yahoo (KneeSurgery) and on Knee1. Both are good.

But mostly, what I found on the web last summer tended to be negative experiences. Or worse, CYA behavior by the surgical and medical community. Both are completely understandable --- negative experiences tend to get more widely shared than positive experiences (that's human nature). And CYA behavior falls into the "I have to tell you all of the worst possibilities, just in case".

But positive experiences? I heard them from friends, but found very few on the web.

Detailed experiences by someone who went through a TKR? Nope. So I decided to keep a daily diary of what happened, what I felt, how I felt, and what the actual process was on a day-by-day basis. Reverse chronological order, going all the way back to the first knee injury in 1969, which is when this whole thing started.

After five months, I consider my TKR to have been an absolutely wonderful and positive experience. I've got way more range-of-motion now than I've had in years. I've got NO PAIN at all, and it's been >20 years since I could say that. I'm taking NO pain meds --- none --- not even ibuprofen, and there were years on end when I was taking prescription-grade Motrin at doses high enough to make my ears ring almost constantly. That regime finally got to my stomach, and I cut it out cold-turkey. But then I had to learn to live with the constant chronic deep arthritis pain. And eventually, this got to me. Sleep was constantly interrupted by pain. I couldn't stand on my feet for more than 15 or 20 minutes at a time. I couldn't walk for more than a few hundred feet.

Now, I can walk for miles. I can pedal a bike for the first time in more than a decade. I take NO analgesics at all. I literally can run up and down stairs. And I am sleeping soundly.

It's truly been a wonderful experience, and one I felt that I had to find a way to share.

Unfortunately, I will probably not be able to blog on a daily basis. Please comment --- and be patient. I'll do my best to respond through this site (or the gmail address) within a week.

Swollen gland is NOT an infection

2005-03-04T07:00:00.000-05:00

Knee-day plus 5 months: Friday, 4-Mar-2005:
Twenty-two weeks and two days.

The swollen lymph node turned out to be completely unrelated to my earlier root canal, and no risk at all to the knee [no infection]. Appears that I have a stone (yes, a stone) in the sublingual salivary gland, causing it to get irritated and swollen. Whew.

Why did it go away following my knee surgery? No idea, but there is apparently no relationship.

So how's the knee doing now? Great. My work schedule is keeping me from maintaining the exercise regimen at earlier levels, but I do what I can.

I can kneel comfortably on the new knee. It feels a little weird, since there is not the same kind of feeling in the implant (duh!). But I can kneel comfortably with the joint at 90 degrees, and can even begin to sit back on my heels, maybe to about 45 degrees (although I don't ever expect to be able to completely sit on my heels).

It's been years, and yes, I am kneeling on a carpeted surface. But it's been years ... I am looking forward to getting back into the garden.

Four-month post-op check-up

2005-01-28T10:12:00.000-05:00

Knee-plus-17 weeks, 2 days, Friday, 28-Jan-2005:
Today was my 4 month check-up. Interesting conversation with the surgeon. First of all, he is extremely pleased with my progress. I got to the office a little early, and was sitting in the exam room with my right leg crossed over my left, knee bent. He looked down at my knee and grinned.

I rolled my pants legs up over each knee, and he again grinned. Little swelling in the right knee, nice scar formation. And we began to chat about how I was feeling.

He felt my right knee and was pleased to note that it was not hot, and indeed, was barely warmer than the left one. I told him that I had noticed that the right knee did occasionally get warm. This is apparently both normal and expected, that the inflammatory process of healing will continue for months. If the knee were to swell and get really hot, that would be a sign of post-op infection. But warm, especially after exercise, this is normal and healthy.

He asked me if I could kneel without pain. I indicated that I could, but that it was not yet really comfortable. Again, he was pleased that I could do this at 4 months, but that it might take a year to get comfortable, if at all.

The incision scar has begun to stretch, mostly above the patella. This is normal, as is the itching that accompanies the stretching.

The device continues to make noises sometimes as I walk. Rattles and pops. This, too, is normal but should diminish with time. I asked why it would diminish. Apparently, a combination of scar tissue regressing, and tendons tightening will allow the replacement knee to better integrate into normal motion and activities, and the rattling from things being a little loose will begin to go away.

I continue to be restless in my sleep, at least according to my wife. When I sleep on my left side, right leg bent over left, there is stretching of the joint as I relax. This will wake me up if I am not deeply asleep, and make me twitch and be restless if I am more deeply asleep. The surgeon indicated that this should diminish with time, too.

Overall, the surgeon is happy with my progress, and indeed, indicated that if he did not know the date of my surgery, would guess from looking at the scar and swelling that surgery had occurred 8 or more months ago, rather than 4. We talked about the “why” of this observation. I told him that I was convinced that pre-op exercise helped a lot, and that multiple at-home rehab exercises a day got me through the initial recovery phase as quickly as I did. He nodded politely and said “Yes, but ...”.

His perspective is that yes, it might be exercise, yes it might be determination, but he has patients my age who do all of those things and still have a slower recovery than I did. He told me a story of a 56 year-old woman who --- 10 months after surgery --- is still taking pain meds, still has serious knee swelling, and still has a very hot/inflamed knee. Muscle tone pre-op was good; rehab exercise regimen was good.

He thinks that it is a combination of genetics and attitude.

The surgeon indicated that if my experience were the norm, his job would be easy. He drew a bell curve, and said that my recovery was way up in the tail of the curve.

We discussed antibiotic prophylaxis. I was surprised to only see two post-op doses by IV. He indicated that this is the current recommendation from “the Academy”, that his practice switched to this more than a year ago, and has had zero incidence of post-op infections. Irrigation of the surgical site during the surgery is with a Waterpik-type device that flushes the wound with an antibiotic solution. Then, two systemic doses post-op, and that’s it. Apparently, longer term prophylaxis carries with it its own series of side effects, and to no benefit.

We discussed antibiotic therapy pre-dental work, pre-colonoscopy and ANY time outpatient surgery or dental work could allow bacteria to enter the blood system. I have a scrip from my dentist for amoxicillin, taken an hour before dental work. The surgeon indicated that this would be fine, but that it would be something I would have to do for the rest of my life. He told me of a patient who developed a joint/device infection 18 years after implant, and following a root canal.

I asked about symptoms of infection. He said “You’ll know”. It would be a systemic infection: fever, swollen knee, hot and inflamed knee, an inability for the joint to support weight, severe pain.

My swollen sublingual lymph node did indeed return. It’s on my list to discuss with the dentist next week. I’m probably being paranoid, but ...

Knee? What knee?

2004-12-22T10:08:00.000-05:00

Knee-plus-12 weeks, 22-Dec-04, Wednesday:
I am now to where I do not think about my knee. Somedays, not at all. There is no pain. I am not even taking ibuprofen unless I’ve been on my feet for a long time and my legs feel tired. Range of motion is good: I can routinely walk up and down three flights of stairs. Right-leg ROM is almost as good as the left. Right-leg extension IS as good, maybe better, than the left. Certainly, my hamstrings are more flexible with my right than my left.

We visited relatives last weekend --- a 3+ hour drive. My wife and I shared driving duties going out, but because of the weather, I drove the entire trip home. No problems at all, although my thigh muscles felt a little tired.

It’s the holiday season. Two weekends ago, I stood and schmoozed at our Christmas party for more than three hours without pain. I’ve been up and down ladders hanging ornaments on the tree. I sat cross-legged on the floor for an hour putting together a stereo system.

My brother and I took a long walk yesterday. I realized that he was half a step behind me and was watching my stride. I said “What are you doing?” His response was “You really are walking normally”. Duh. We were only out for half an hour, but I walked hard, uphill and down. Yes, I was showing off, but I could do it comfortably.

12 weeks post-surgery, I am thrilled with the results of my TKR. I have much better ROM than I’ve had in 20 years. I can do things that I’ve been unable to do for more than a decade. I can ride a bike again --- we are actually planning bike trips for next summer. I felt so good this AM that I actually skipped across the parking lot at work!

There is still a long way to go in terms of rebuilding strength. I recognize that, too.

But there is NO pain. Yes, the quads and hams get tired, and can ache when they do. But there is no joint pain at all. I could not have asked for a more positive experience re my TKR.

Would I do it again? In a heartbeat! I feel 20 years younger.

Did I wait too long? I actually don’t think so. I took three months to prepare mentally and physically for my TKR. These were important. I am convinced that the physical prep made rehab go faster and easier. Equally important, the mental preparation --- both in terms of what to expect as well as what my limitations had been pre-surgery --- makes me all the more appreciative of how successful my TKR has been.

Contemplating a TKR? Here's my advice ...

2004-12-15T10:06:00.000-05:00

Do I have any advice for someone contemplating a TKR? Of course I do.
One, take the pain medications that are available. Don’t be a tough guy. Recovery and rehab are going to be painful. Use the tools that are available to you to control the pain.

Two, prepare yourself mentally and physically for surgery and rehab. If you can delay surgery for a month or two, put the time into strengthening your arms, torso, and legs. You will need this strength during recovery and rehab. Your recovery is likely to go faster if you do.

Three, work hard at rehab. Physical therapy needs to be done at least once a day, whether facilitated by a therapist or at home, on your own. Every day that you work at rehab, there will be incremental progress. Conversely, every day that you don’t work at rehab, there will be incremental decline.

Four, don’t quit. There will be performance plateaus during rehab. Look for them, and work with your therapist to break through those plateaus. Full rehabilitation may take up to 18 months or longer. Be patient. Be persistent.

Five, ask questions. Your doctors and nurses have knowledge and experience you lack. If you don’t ask, they won’t know to tell you. Think about how many patients they see in a week. Asking questions of your healthcare team is YOUR responsibility.

Six, look for problems. Unexpected pain? Unexpected swelling? Unexpected brusing? Call the surgeon immediately. There is no reason to wait, or to worry. Make the call. Your surgeon’s staff is trained to answer your questions, and to know when to put you through to the surgeon.

Finally, you should realize that the first 2 weeks are going to be the most painful, and that the first 6 weeks will require the hardest work in rehab/PT. However, by 12 weeks, you should expect to be walking comfortably, sleeping comfortably, and asking yourself “Why didn’t I do this sooner?”

"Workin' in a coal mine, goin' downtown ..."

2004-12-04T10:04:00.000-05:00

Knee-plus-10 weeks, 8-Dec-04, Wednesday:
The hardest part of working full time is making sure that the AHPT continues. “The plan” was to go home at 1130A, exercise, eat a quick lunch, and return to work by 1P. This week, this occurred exactly ONCE. Client lunches, interviews, holiday errands.

Swelling continues to come and go. I spent Wednesday pretty much at my desk (and then at a after-work meeting). Leg down, knee-high socks --- significantly swelling above the sock line. My wife worries about potential infections, blood clots, etc. I am watching very closely for any symptoms --- there are none. No hot spots, no localized pain, no joint pain at all.

However, I am very restless at night after falling asleep. It’s easy to think that it’s related to the knee, and it may be. But I feel no significant pain, maybe a little muscle soreness. Maybe. And I continue to take ibuprofen before bed, just in case.

Extension and flexion both continue to be good. Stairs up and down are getting increasingly easier.

Clicking and clunking away on my noisy knee

2004-11-24T10:03:00.000-05:00

Knee-plus-8 weeks, 24-Nov-04, Wednesday:
Exercise equipment now upstairs, except for the stationery bike. I am spending more of my evening in the upstairs living room, at least after my Mom goes to bed at 8 PM. Different “feel” in my torso, working on the carpeted floor versus exercising on a firm bed. No real difference noticeable in my legs.

We are discussing a return to full days at work next week. The trick will be to “make” time in the AM or PM to both walk and to continue AHPT. Going home for a long lunch, and spending 90 min walking/exercising may actually make the most sense. It’s nice to be the boss ...

The surgeon had warned me to expect the TKR device to make noises during this phase. I am having very little clicking or popping. It’s possible that the PT/AHPT has tightened up the tendons and ligaments to where there is very little “play” possible.

Swelling is also virtually gone, except after being on my feet for an extended period. Muscle definition in the thigh and calf of the TKR (right) leg continues to develop. I had not realized how much tone and strength I had lost in that leg during the past few years, but the PT people said that the muscles of right leg were about half the size of the left. Right leg is still “flabby” when compared to the left, but it is improving.

The end of hard-core PT

2004-11-17T10:01:00.000-05:00

Knee-plus-49 days, 17-Nov-04, Wednesday:
Seven weeks. I began half-days at work yesterday.

Today was the last day of facilitated PT, although daily AHPT will need to continue at least through the EOY, if not indefinitely. I asked “How much longer?”. The answer: “You can be done today, if you like.”

125 degrees active flexion via standard on-back heel slide. PTist was very happy.

Another good night of sleep. Into bed at 11P, awake at 530A. A couple of ibuprofen before going to bed. This is working.

There is virtually no pain. I get a little achey if I sit in the same position for too long (easy to do in the office), but it dissipates if I take a little walk down the hall.

No pain, no cane!

2004-11-15T10:00:00.000-05:00

Knee-plus-47 days, 15-Nov-04, Monday:
We have been sleeping upstairs since the middle of last week, and more or less successfully. I am still waking up at 3 AM-ish, and generally again at 5 AM. May or may not need to get up to urinate, depending on how much liquid I consume after 5 PM. Stopped percocets entirely last week (Dulcolax as well), and then stopped ibuprofen during the day over last weekend. There is no longer much in the way of pain, except from exercise. I am still using ibuprofen to get me through the night, though. Not sure if that is even necessary.

I stopped using the cane in the past few days, too.

I have also stopped icing down after AHPT. I think that I’m about as far along as I am going to get, at least short-term. The remainder is continuing to rebuild strength while retaining ROM.

Re range-of-motion (ROM): I can readily do wall slides at ca. 120 degrees, and can sit with my toes at the edge of the template (even with the front of the chair legs). However, I am still having problems coming down stairs, whether this is an ROM problem or a strength problem, who knows.

I also upped the weight regime to 5# on each leg.

Sleep improves, and walking is getting comfortable

2004-11-10T09:45:00.000-05:00

Knee-plus-42 days, 10-Nov-04, Wednesday:
PT today went well. 120 degrees active (and easily from wall slides), 127 degrees at the point of pain. The chair trick seems to be working well.

Another full night of sleep. It may be time to move back upstairs.

Knee-plus-41 days, 9-Nov-04, Tuesday:
Progress continues with AHPT. At work 2 hrs/da.

Last night was the first night since surgery that saw no getting out of bed from 1030P til 530A.
Percocet use is down to 2 @ 730A, and 2 @ 330P. Ibuprofen every 4 hrs from 930A to 930P. I may just stop the percocet entirely after PT Wednesday.

Walking is very comfortable, and can be done at a good fast pace. I carry the cane, just in case, but I am walking mostly without it. 1+ mi: time: 25 to 30 min.

The joys of a CryoCuff

2004-11-05T09:43:00.000-05:00

Knee-plus-37 days, 5-Nov-04, Friday:
AHPT. One full set in the AM, no walk at noon (weather); PM full set, with walk after short day at work. “Full set” including 16 min bike, takes a good 90 min.

The CryoCuff came last PM and is great. I can now “ice” pretty much for hours on end. Knee feels really good and tight after icing for an hour.

I also made a template to monitor foot-under-chair process from a piece of cardboard. I put the cardboard in front of a dining room chair, and made orientation marks on the cardboard where the chair legs touch. Each day, I simply trace how far back my toes can go. I should be able to calibrate “toe mark” on the template with degrees flexion after the PTist measures it each Wednesday.

I am making good progress on the stairs, too. Once loose, 10X up and down from the landing. “Up” continues to go smoothly. “Down” has that “pop” in it, whether from muscle weakness or just approaching current limits re ROM, who knows?

[daily entries will no longer occur after this date]

Getting through the flexion barrier

2004-11-04T09:06:00.001-05:00

Knee-plus-36 days, 4-Nov-04, Thursday:
Full AM set, including bike. It’s raining, so the likelihood of a walk is pretty low. Once I regain more confidence in stability, walking in all weather will not be an issue, but right now it is.

Doing steps at home works IF I am fully loose before hand. Stretch, bike for 15 min, and then I can do steps. Going up is rarely a problem, but even fully loose, going down is still marginal. I need a few more degrees of flexion, and all the time. But it is going to work.

Sitting on a chair by the fire, putting my heel under the chair, and slowly sitting down on the right leg seems to be an effective mechanism to get that last few degrees of flexion. I hope that by doing this routinely, I can break through the plateau, and retain the ROM.

Stairs! I can do stairs!!

2004-11-03T09:05:00.000-05:00

Knee-plus-35 days, 3-Nov-04, Wednesday:
I’m now on a once-a-week PT schedule. Today, I am still much more swollen than I like. Hoping that the CryoCuff helps, once it gets here.

I can now get 110 degrees on a wall slide without much problem. Working with the PTist pushing, I can get to 122 degrees with some pain, again on a wall slide. I think that the “heel-under-the-chair” plan to push beyond the 125 degree barrier is going to be the solution.

I tried to do the hamstring-dips today from a higher platform. Not good. I’m still at the lowest level --- maybe 4”.

I also had modest problems doing the one-leg calf-raises during PT today. Day 1 seemed so easy. AHPT began to be a little more difficult. PT was actually tough --- I had to break the 30 count down into 10, 10, 5 & 5. Maybe, I am just pushing too many of the same exercises into the warm-up?

I climbed steps for the first time today, 10X up and down, 4 steps. Not a problem so long as I am really loose. However, ROM re flexion is limiting not on the up-step, but certainly on the down. I’m almost there, but each down-step requires some adjustment to my foot or leg. I’m just not there yet, although it’s close. Meaning that I need to do steps as often as possible, but only after thoroughly loosening up each time.

Walking. Biking. Steps. Stretching. And building strength in every muscle group possible. The next ten weeks are going to be both hard and busy.

Time to buy a CryoCuff for home

2004-11-02T09:03:00.000-05:00

Knee-plus-34 days, 2-Nov-04, Tuesday:
Election day, and physically, today is an achey day, for whatever reason. It could be that I am just reacting to pushing the AHPT pretty hard. It could be that the hour I stood in line to vote today was a little more than I should have done, especially since we followed it up with a post-voting Waffle Shop breakfast, meaning that the knee was bent and down for another hour after voting.

Regardless, I went ahead and ordered a CryoCuff for home. The swelling is keeping me in more pain than I want, and limiting my ROM exercising. Although this ice-water device is really simple, it costs $125. I ordered mine from Medco in Tonawanda NY. $113 plus tax and shipping took the total up to $132.87. I probably could have gotten a scrip for it had I been more patient, but ...

No walk today at noon, but went to work anyway. I’ll ice down as best I can when I go home, take some Percocet, and then do the PM full set of exercises. Maybe take the bike ride out to 30 min [I’ve been only doing 15, since the set is starting to get longer ...]

Daily exercise schedule, month 2

2004-11-02T07:00:00.000-05:00

ON BED / MAT / FLOOR:
Quad sets (push downs): 30 @ 10 count, relax 10 count in-between [right leg only]
Straight leg raises (2.5# weight), 30 each leg [lift, hold 2, 3, down on 4]
Short arcs (2.5#), 30 each leg [lift, hold 2, 3, down on 4]
Side raises (abduction) (one side), (2.5#), top leg, 30
Side raises (abduction) (one side), (2.5#), bottom leg, 30
Side raises (abduction) (other side), (2.5#), top leg, 30
Side raises (abduction) (other side), (2.5#), bottom leg, 30
Rear raises (2.5#), both legs, 30
Elevated flexion (2.5#), both legs, 30 (as much flex as possible)
Quad lifts (bedside) (2.5#), both legs, 30 [do not exceed 45 degrees]

STANDING UP:
Calf lifts (2.5#), lift to rear, use walker or cane to keep thigh vertical, 30
Abduction, both legs, 2.5#, 30
To rear, both legs, 2.5#, 30
[remove weight]
Calf raises, single-leg, both legs, 30
Mini-squats, free-standing, 30
Dips, 3” [dictionary], both legs, 30
Mini-lunges, both legs, 30 [do on pads when available]
Balance, 30 count, 5X, each leg

STRETCH:
Calf, slant block, 5X, 20 count
Hamstring, stairs, 5X, 20 count

STATIONARY BIKE:
16 min, alternating forward/backward

ON BED:
Wall slides, 20, hold for 10 count. Take it “to the pain”. Wall slides all the way to the bed/mat are getting to be easier to do. I can readily get my heel to the mat (110 degrees), but getting the extra few degrees to get my foot flat against the bed is not always possible (120 degrees).

In addition to trying to do two full sets per day:
ONCE A DAY:
Walk 1 mi, ca. 30 min

Even more exercises

2004-11-01T08:58:00.000-05:00

Knee-plus-33 days, 1-Nov-04, Monday:
PT to be reduced to 1X a week, but with increased rigor during AHPT. New exercises focusing on calf and quad strength, plus balance work. 115 degrees active, 120+ passive (sitting on bench and “sitting” down to get beyond 120. Swelling above knee continues to limit ROM, and we agreed to “work” on how to get past this barrier. The plywood top of the padded mat at PT is the height of the first hole in the cane, and the pad is to the second hole. When I put my right foot under the bench, I can then sit on it to get more flexion. The trick will be to figure out WHICH chair at home lets me get away with this one most effectively.

New exercises added at PT. One leg calf raises (30). One leg step-downs (new toy). Mini-squats on balance pads. Quad lifts (only to 45 degrees, do NOT lock). Lunges without bars. One leg balance (30 sec, 5X).

Slant board design and construction

2004-10-31T08:51:00.000-05:00

Knee-plus-32 days, 31-Oct-04, Sunday:
I made a slant board for stretching today. Very cool. I had reached my positive limit re calf stretches with the towel, and fell in love with the stretch board at the PT suite. Simple simple concept, but very effective.

I'll take a photo and try to insert it here. The slant board is just a simple box. A 1x8 board forms the high end (the back). A piece of 3/4" plywood forms the surface for your feet, and slants from the top of the back to flat on the floor. A second 1x8 is ripped on the diagonal to form two triangles which become the sides. The plywood top is screwed to the sides and the high-end (back). I cut a belt sander belt in half to form two traction strips for my feet.

Why did I do this? I was not able to get a good stretch and extension any other way. I can now stand on the slant board, lean forward from my ankles (towards a wall to keep me from falling over) and REALLY stretch out the back of my knees. This is wonderful.

2X full sets AHPT, including the bike. 1X mi walk.

Driving solo, at last

2004-10-30T08:50:00.000-04:00

Knee-plus-31 days, 30-Oct-04, Saturday:
I drove into town to get a haircut. By myself. 2 sets AHPT, including 15 min bike, 1 mi walk.

Freedom!!!

2004-10-29T08:48:00.000-04:00

Knee-plus-30 days, 29-Oct-04, Friday:
Freedom! Very happy day after the meeting with the surgeon. He was extremely pleased with my progress. No more TED stockings. No more warfarin. I am now permitted to drive. Had X-rays done --- implant looks very very good. The quote of the day: “If you had taken four months to get to this point, I would have been happy. To have done it in a month, especially considering how bad your knee was when we operated, is pretty amazing.”

The next two months / 10 weeks are apparently more of the same battle. Keep the knee as mobile as possible by working constantly. Begin to build strength. Walk more, bike more, but continue ALL of the ROM exercises. Surgeon does not need to see me for 3 months, but expects me to work out a reasonable schedule of AHPT exercise with PTist. He doesn’t care if I go to PT 1X or 3X per week, so long as the daily AHPT continues as it has been.

When will I ever get a good night's sleep?

2004-10-28T08:46:00.000-04:00

Knee-plus-29 days, 28-Oct-04, Thursday:
The night was much improved, although I still was awake repeatedly. Normal AHPT sequence, including a 1 mile walk over lunch.

I went to work for 90 min, then came home, iced down. We’ll see.

Oxycontin withdrawal

2004-10-27T08:45:00.000-04:00

Knee-plus-28 days, 27-Oct-04, Wednesday:
Very rough night for sleep. Up every 90 min to 2 hrs. My wife thinks that it’s oxy-withdrawal. She could be right. I definitely felt itchy creepy-crawley all night long.

I called the surgeon (and received) a fresh percocet scrip. There is still too much rehab pain to not continue percocet while I remain on warfarin.

My leg is very swollen above the knee. There are no reasons to think “blood clots”, just swelling from exercise. That and sitting upright at work for 2 hrs with the knee bent and below my waist. My wife convinced me to not go to work today --- she’s probably right.

PT was pretty standard. I do not have the ROM that I want, thanks to the swelling. But progress continues.

Slacking off = loss of progress

2004-10-26T08:43:00.000-04:00

Knee-plus-27 days, 26-Oct-04, Tuesday:
Returned to work for 2 hours. Today was the last oxycontin. Had been thinking about backing off the percocets, but not if I need to keep pushing on the AHPT.

My PT conclusion is that the knee “seizes up” very quickly if you slack off at all on the AHPT. The pillow under the knee may feel good, but even one day can cause loss of extension-ROM. Kind of stunning at how quickly things can change.

The new regimen is PT in the AM; work in the afternoon; PT after work. Don’t know what I will do once I am working full-time. Maybe the body won’t be trying so hard to limit ROM by then.

Tell me again how you measure with that thing?

2004-10-25T08:41:00.000-04:00

Knee-plus-26 days, 25-Oct-04, Monday:
PT. Variation in goniometer use by PT-ist? Today’s PTist measured me at 105 active, 115 passive. She did the bending on the pad, rather than letting me use the wall.

Returned to work for 2 hrs. Did not do AHPT after work. Came home, and crashed.

Slacking off for another weekend of football and houseguests

2004-10-24T08:40:00.000-04:00

Knee-plus-25 days, 24-Oct-04, Sunday:
Normal Sunday --- up early, read the papers over coffee. Did AHPT 1X (one full set, including 30 min on bike), and did not walk.

Knee-plus-24 days, 23-Oct-04, Saturday:
Another weekend of guests. Did AHPT while the football gang was tailgating, but did not walk.

Making progress

2004-10-22T08:38:00.000-04:00

Knee-plus-23 days, 22-Oct-04, Friday:
Good PT. 115 degrees flexion active; 123 degrees passive. The end goal is 125. Walked 1 mile.

Knee-plus-22 days, 21-Oct-04, Thursday:
Good night sleep. Awake only once.

Quiet day. At-home PT. Walked one mile. Walking uses a different set of muscles than biking --- I had to stretch out after walking by riding the bike for 10 min!

The end of the pain?

2004-10-20T08:37:00.000-04:00

Knee-plus-21 days, 20-Oct-04, Wednesday:
Good PT. Made 123 degrees (passive, with pain). 116 active, pretty much without pain. At-home PT yesterday included 3 full sets, and 3x3x5 (30 min) on the bike, each time. This was really tiring, but appears to be effective.

Sleep last night was good. Up twice, but fell back to sleep readily.

New scrips at the pharmacy. These should be the last ones, I hope. The plan is to stop oxycontin when current lot runs out (Sunday, I think), and then run this lot of percocet out til it’s gone. By then, I should be off of the warfarin, and able to resume ibuprofen. If I need anything at all. Right now, except for the exercise pain, there’s very little pain left to handle.

I need more drugs

2004-10-19T08:29:00.000-04:00

Knee-plus-20 days, 19-Oct-2004, Tuesday:
Today is the first day where I attempt to run 3 full sets.

Sleep last night was decent. Two awake periods, one at 1-ish, a second at 3-ish. I doubled the oxycontin, trying to break through the pattern, but could sense no real difference. I reduced evening fluid intake which may have helped (increase in AM, decrease in PM).

I need a new percocet scrip, since I am about to run out. 2X regime may be helping get me through PT, but it burns through the pills.

When can I go back to work?

2004-10-18T08:23:00.000-04:00

Knee-plus-19 days, 18-Oct-2004, Monday:
Sleep last night was much improved. I reduced fluid intake last evening, and backed off on the percocet (1 tab at 730 AM, and then none until 1 AM, and then nothing until 730 AM Monday).

PT went smoothly. Did a reduced set pre-PT (at home), and loosened up by slowly working on the bike. The PTers did a "re-assessment" (OKing additional authorization from insurer) --- I was making good progress. Target for this week is 120 degrees flexion. Today, active flexion (my control) was at 110. Added mini-lunges to routine.

I would like to do a full set 3X a day this week. 9 AM, 1 PM, 5 PM. Maybe one of those should be replaced with a walk down the block.

When will I go back to work? My wife is thinking the first week of November. I hope to get in some hour-at-a-time time next week.

Next week’s surgeon visit should let me stop wearing TED hose, and should let me stop taking warfarin. Once I am off the warfarin, I can taper down on the percocet and oxycontin, eventually going back to good ol’ ibuprofen.

Pain meds and constipation

2004-10-17T08:21:00.000-04:00

Knee-plus-18 days, 17-Oct-2004, Sunday:
Another home football game, another weekend of company, and another weekend of minimal exercise. I did do a full set in the AM, but only biked in the PM.

Knee-plus-17 days, 16-Oct-2004, Saturday:
2X percocet regime may be working for pain control and PT, but it is wreaking havoc with my digestive system. It took an incredible amount of exertion and >50 min on the toilet to move my bowels today. Finally did it, but it was exhausting.

Residual gut pain from the effort continued all day, and into Sunday.

Finally making progress with PT

2004-10-15T08:20:00.000-04:00

Knee-plus-16 days, 15-Oct-2004, Friday:
PT went well. I could do 116 degrees “active” (unassisted), and 120 “passive” (with the PTist pushing the relaxed leg until I couldn’t handle any more pain). I also got the PT recumbent bike to go around for the first time. The therapist was both surprised and impressed with the progress that I made in the past 2 days. I am convinced that a) it was the bike, and b) that by doing a reduced set of exercises before going to PT, including loosening up on the stationary bike, I could get loose enough to meet his expectations. Next week’s goal is 120 active.

I did a second full set in the PM. Bike is 2 min forward, 2 back, repeated 3X.

[Looking back, this second week post-op was a "breakthrough" week all around]

I hate PT, I love PT

2004-10-14T08:18:00.000-04:00

Knee-plus-15 days, 14-Oct-2004, Thursday:
Wednesday PM PT was also agony. The residual pain post-PT was intense. I doubled the percocet regime (2 tabs every 4 hrs) --- still within the instructions on the bottle.

Wall slides are simply not very easy to do in this house. I can slide my foot down the wall until I have to scream, but I am still not convinced that I am getting enough flexion. Therefore, I brought out the stationary bike, and began to work with it. I raised the seat until I could make the wheel go around, and then just kept working at it until I could make circles repeatedly. Afterwards, my knee feels looser than ever before, and with good ROM.

Blood flow from the right leg also seems to be better, and the swelling has gone down. That could be from using ice non-stop when not exercising, though.

What's that HUGE bruise on the back of your leg?

2004-10-13T08:17:00.000-04:00

Knee-plus-14 days, 13-Oct-2004, Wednesday:
Knee-plus-2 weeks!

I scheduled my AM oxycontin and percocet to “peak” during PT.

PT today was absolutely brutal. My PTist could force my knee to 105 degrees, but I screamed in pain when he got it there. I left PT determined to get it there myself, and by Friday. It is ever so much easier for me to hurt myself than to let someone else do it to me.

The PTist also taught me to do wall slides to improve ROM. Butt about 3 ft from the wall; feet up high on the wall. Bend knee by sliding foot downwards to bed. Use other leg to push/pull it down the wall. This is agony, but it also seems to be effective.

Again, the only thing stopping me from better ROM is pain. And continued swelling.

After my shower today, I noticed that there was a huge bruise on the back of my right thigh!! No pain though, and neither pain nor “heat”. Nonetheless, I panicked. I immediately called the surgeon’s office and got his PA. Duh. The bruise is from the tourniquet which was on my leg during surgery. Of course, there’s a bruise, since I bled profusely after the tourniquet was released. It was a deep bruise and on the back of my thigh. I have only been taking showers for a day. I simply didn’t see it during the sponge baths.

First shower

2004-10-12T08:14:00.000-04:00

Knee-plus-13 days, 12-Oct-2004, Tuesday:
Today was first shower day. With the staples out, I felt very comfortable taking a shower. Ahhh. We had installed a heavy-duty support bar in the first floor shower before my surgery --- this was a good idea.

I added side-steps and backwards-steps across the house to the AHPT routine. These are not yet called for by formal PT, but there are people ahead of me in the process doing these, and it makes sense. The ligaments and tendons that were loosened during surgery need to be strengthened and tightened.

Ice is your friend

2004-10-11T17:28:00.000-04:00

Knee-plus-12 days, 11-Oct-2004, Monday:
Happy birthday! Today, I am 51 years old.

PT in the AM. I can almost get the bike wheel to go around. I think that if the seat is just a little farther back, I can do this. Regular PT routine --- flexion (ROM) is still really tough, though.

I met with the surgeon in the PM. It was a quick visit. Staples were removed. Simple, painless. Incision was covered partially with little SteriStrips, but these seem to have no real function.

The surgeon was pleased with my progress, but wanted more PT. He was unhappy that I was only going to PT 2X a week; and changed that immediately back to 3X/wk. He told me that if the PTers were not hurting me, they weren’t doing their job. He said that I could not damage the new joint, that all I could do was to cause myself hurt (i.e., exercise-caused muscle pain) and that this was both expected and necessary. The only thing limiting my flexion ROM was pain and swelling. Pain should be controlled by meds; swelling by ice.

“Ice is your friend”.

The surgeon was also surprised that no one had told me to go to the hospital for coag time monitoring, and set that up immediately. I went to the hospital immediately after the appointment to bleed.

It must be the meds

2004-10-10T17:27:00.000-04:00

Knee-plus-11 days, 10-Oct-2004, Sunday:
It is very curious at how little reading I am actually getting done. It must be the meds reducing my ability to focus.

Weekend house guests do NOT mean you can relax

2004-10-09T17:26:00.000-04:00

Knee-plus-10 days, 9-Oct-2004, Saturday:
I got a haircut today. My wife called the barber and set it up so that the barber would meet us before the shop opened (7 AM), and get me done without waiting. Ahh. This felt good. I am still sponge-bathing, though. I am content to wait until the staples are out before I try doing the shower routine.

We have a full house of company this weekend and since I had such a rough PT day on Friday, I did very little today except for a walk my two blocks and back. This was probably an error in judgment. PT needs to have first priority, social responsibilities can come second.

As a point of reference, we live in a small town connected to a large college, with a large college football program. Our house is full of family, friends --- all alums or connected to alums. This is a wonderful experience. Every home football game becomes a family reunion, and an extended family reunion at that. However ... I was not terribly social this weekend.

Walking two blocks

2004-10-08T17:24:00.000-04:00

Knee-plus-9 days, 8-Oct-2004, Friday:
PT was really brutal today. I am having trouble increasing the flexion angle. My knee is still very swollen. The PT team put me on the bike today, but only to work the knee --- there is no way that I could go completely around on the cycle. And the PT-ist really caused a lot of pain as he pushed my new knee further into flexion.

I walked two blocks back and forth. Walking is a lot more comfortable than PT.

Look, Ma --- I'm using a cane!

2004-10-07T17:23:00.000-04:00

Knee-plus-8 days, 7-Oct-2004, Thursday:
PT taught me to use the cane, instead of the walker. I walked in our neighborhood for 1 block and back. Cane goes to the ground with the right TKR knee, to assist in the support. This is the reverse of what I was doing pre-surgery. It may take me a little while to re-learn this one.

The folding walker was still a good acquisition. I use it for the p-bar exercises during AHPT, and very effectively.

BM continue to be difficult, with an “every other day” pattern appearing to develop. I am drinking fluids almost non-stop; eating Metamucil cookies 1X a day; taking Dulcolax 2X a day.

Really, it's the drugs talking

2004-10-06T17:22:00.000-04:00

Knee-plus-7 days, 6-Oct-2004, Wednesday:
More of the same. Wake, sponge bath, breakfast, exercise, walk. Doze. Repeat. Sleep at night is pretty much on a 2 hr cycle. Pee, sleep, wake up, pee, take a pill, sleep. Repeat.

Checked in at work with my VP Operations. We talked for about 20 minutes. When I got off the phone, he immediately went to my wife and asked her what kind of drugs I was taking ... Obviously, I am not nearly as much in control as I think!

First official day of PT

2004-10-05T17:21:00.000-04:00

Knee-plus-6 days, 5-Oct-2004, Tuesday:
First PT session. Standard exercises, plus some new things on the parallel bars. Abduction (foot to the side, both sides). Foot to the rear (both sides). Mini-squats [I noticed that I lean too much on the left (good) side, so I actually did a couple of one-legged squats on the right (TKR) leg, frightening the therapist]. Calf raises. Hamstring stretches.

Mat exercises included an interesting crossed-rope heel slide, and a calf stretch (quad set, but with a towel/rope under the ball of the foot, pulling back on the towel to stretch the calf).

I was told to bring the cane with me to the next PT session (Thursday). Told to focus on extension, that my flexion (ca. 95 degrees) was coming along fine.

There is a $30 per-visit co-pay with our Blue Cross plan. I squawked about the rate (figuring that it should be $30 per week, not per visit). The lead PT guy decided that I was far enough along (essentially working at the knee-plus-3 week rate on day 1) that I could reduce to 2X per week without harm.

I continued to walk around the driveway loop, 3X. And I duplicated the PT routine at home, once more today, and planning to do 2X per day, with or without formal PT.

Walking the walker around the driveway

2004-10-04T17:19:00.000-04:00

Knee-plus-five-days, 4-Oct-2004, Monday:
More of the same routine. I added more loops of walking around the driveway. I did AHPT 2X a day, plus quad sets whenever it occurred to me.

I called the surgeon’s office when they opened and scheduled the first follow-up appointment for 11-Oct. My first formal PT session is tomorrow. Apparently, PT is written as a scrip, and I could use any PTist from any practice that I choose. This is probably a billing issue --- PT is after all a separate service --- but it really made no sense to me to do the PT anywhere but at the practice where the surgeon is.

I felt so good that I checked into e-mail at work. No problems, but there was a lot of surprise that I was back at it.

Up, down. Up, down. Up, down. All night long.

2004-10-03T17:18:00.000-04:00

Knee-plus-four days, 3-Oct-2004, Sunday:
It was amazing how quiet it is at home, in comparison to the hospital.

Saturday night was full of naps and urinations. I slept for an hour or two or three, got up, urinated, took a percocet (if the schedule allowed), and went back to sleep.

At-Home Physical Therapy (AHPT) was a little frustrating. I had trouble figuring out how to flex the knee adequately (duplicating the wheel chair roll). Knee slides on the bed just were not giving me the flexion I could do in the hospital. The swelling I experienced after removal of the Ace bandage was still more than I was comfortable with. I began rolling an 8 or 9” plastic ball under my foot as I sat on the edge of the bed, and this seemed to work very well.
I walked around the driveway repeatedly (ca. 300 ft), using the walker. It felt good to be outdoors.

Home!

2004-10-02T17:16:00.000-04:00

Knee-plus-three days (2-Oct-2004, Saturday):
Saturday AM finally arrived. I bathed, packed and waited.

The surgeon’s PA and on-call partner came in; wrote me a handful of prescriptions (drugs, devices); and told me that a nurse would walk me through the remainder of the discharge process. However, I had to have one more PT session in the hospital before discharge. My leg had ballooned overnight, following removal of the Ace wrap. The doctor said that this was normal, and the swelling could take up to a month to go away. I needed to elevate my leg; keep it iced; and NOT put anything under my knee.

When I asked about follow-up appointments, PT, etc., I was given additional scrips and instructions to call the office on Monday.

Breakfast came. And then the PT person came by at 0900 to take me to PT. I was ready for release by 0930. The IV port was finally removed from my hand.

I was ready to go. So I called my college age daughter. And woke her up after she had just gone to bed.

My daughter and my mother (who now lives with us) came to pick me up at the hospital. A nurse took me in a wheelchair to the car, and we were off. We drove to a home health care supply store for a walker, a toilet riser, and TED stockings. Unfortunately, the TED stockings had to be ordered (I’ve got long legs), so I had to wear the same ones I used in the hospital until at least Monday. And the riser seat did not fit our toilet (my wife went to a building supplies store and replaced the entire seat). But the folding walker was great.

My daughter then went to the pharmacy to pick up the med prescriptions, only to discover that the warfarin scrip did not include dosage requirements. The pharmacist said “You’ll have to wait til Monday” and I panicked. Finally, after calling the pharmacy, the nurse’s station, and the physician’s answering service, the right connection was made, and all prescriptions were filled. Ta da.

Now, the problem was comfort at home. We live in a two-story house, but moved our bedroom to the first floor for the duration of my recovery. The “nest” we had made for me pre-surgery worked very well. However, the conflicting instructions that I was given by the surgeon (“elevate the leg”; “put nothing under the knee”) drove me crazy. We eventually hit upon building a ramp of pillows under the leg, from the thigh to the ankle, but with a gap under the knee. My knee and leg could then remain fully extended, yet be fully elevated. The “rule” stating “nothing under the knee” is intended to maximize the amount of time that the knee is in full extension. Yes, it will certainly feel better if you bend your knee and rest it on a pillow. However, this practice allows your knee to build up scar tissue (or muscle / ligament / tendon tightness) that keeps you from being able to attain full extension.

The remainder of the day was mostly spent with napping and trying to figure out how best to schedule pills and exercise. With both the percocet and the oxycontin, it took about 75 min from ingestion to noticeable reduction in pain. With both, I also tried to only take the minimum prescribed dose. I would later learn that this was an error in judgment.

Out, damned tubes ... out, I say!

2004-10-01T07:14:00.000-04:00

Knee-plus-two (Friday 1-Oct-2004):
I started today again with real coffee from home. Yummm.

Morning PT was pretty much like Thursday’s (k+1). However, tubes and drains began to be removed after lunch. The Foley came out (hurray!); the IV was shut down (although the port remained for IV administration purposes); and the epidural was removed. Pain killer was switched to ketorolac (that’s the generic name), syringed into the IV port; percocet and oxycontin for pain control began by mouth.

Once I was “free” --- except for the wound drain --- I put on a polo shirt, and began to feel normal. PT was great --- I was able to walk the halls as I chose, and could do so even when back on the floor. At the end of the day, I was walking the halls by myself when my wife and daughter came to see me.

Removal of the epidural was excruciatingly painful, not because of the catheter but because I have a hairy back, which was not shaved pre-op. The epidural catheter was secured to my back with a large adhesive pad (ca. 9 in x 13 in) covering most of my back. Removal of the epidural was as simple --- and as painful --- as freeing one edge of the large pad, and slowly ripping it off of my back, from top to bottom. I did not feel the actual catheter leave my body, only the adhesive being torn off.

My family physician tracked me down in PT, so I had him check the epidural site. I could not believe that the epi cath was removed by yanking the adhesive pad from my back. There was no bleeding --- the doc could hardly find the insert location). He also cut out the Fe supplement.

I was interested to learn that a Foley catheter is “held in place” by inflating a small balloon (with sterile water, not air) within the bladder. The catheter is actually a tube-in-tube with the urine flow occurring in the inner tube, and inflation/deflation of the balloon occurring through the outer tube. The nurse simply used a syringe at the collection bag end of the catheter to completely deflate the balloon, and then --- tug --- and out it came. A little pressure, uncomfortable but no pain, as it slid out of the ureter.

Removal of the Foley meant that I had to demonstrate that I could urinate without the catheter. I rapidly filled a bottle for the nurse [I was drinking a LOT of fluids]. However, there was a small friction sore at the opening to the ureter which had been caused by the catheter rubbing on my clothing. The nurse said that this was common and should go away overnight (which it did).

Preparing for a Saturday departure also meant that I had to have a bowel movement --- or else. The threat was “BM by 8 PM, natural, suppository, or enema.” Whew. I came through but it was painful. The opiate-derived pain killers suppress normal peristalsis, and “bind you up.” I had almost never in my life been constipated, but had become quite constipated following surgery, even with all of the fluids I was consuming and 2X daily doses of a stool softener.

At the end of their evening rounds, the surgeon’s PA (and the weekend on-call partner) visited. They confirmed that I could go home on Saturday (they’d come in for the discharge early in the AM), and removed both the Ace bandage and the blood drain. Blood volume in the drain during Friday was ca.125 mL --- the desired threshold was 100 mL or less. This put the “pull the drain” decision in the hands of the physicians, not the nurses. But they did pull it.

My wife and daughter went home, and took with them everything that I didn’t need for Saturday. I had horribly over-packed clothing. Until the catheters came out, I wore a hospital gown. I wore long boxer shorts with no additional underwear (catheters, remember, until Friday afternoon). And as much as I expected to be able to read, I could not. The pain killers kept me from being able to focus much at all. I would read and re-read the same sentence repeatedly.

And then ...
My entire hospital experience changed with the beginning of the weekend staffing schedule. Until Friday evening, I had only positive things to say about the service in the hospital. Friday night certainly changed those perceptions.

I was given my PM meds, and “put to bed” by 10 PM. By 11 PM, the hallways appeared to be empty. The night shift nurse (and apparently, only one, rather than the two or more who had been assigned to our wing the previous two nights), came in, got distracted by my roommate’s demands for sleeping pills, and neglected to take my temp and BP. Then he disappeared. A puls-ox alarm went off down the hall, and continued to shriek for more than an hour. No response from the nursing staff. This continued to occur during throughout t entire night, Friday. If I had been in the room with that patient, it would have completely freaked me out. I “listened” to CNN Headline News all night long to block out the alarms from the hallway.

Good coffee makes all the difference in the world

2004-09-30T07:12:00.000-04:00

Knee-plus-one: Thursday, 30-Sep-2004:
I woke up with the 7 AM change in shift. My wife stopped in on her way to work, bringing me a go-cup with REAL coffee. Ahhh. We’ve been drinking fresh ground coffee for years, thanks to our children who bought us a grinder for Christmas once upon a time.

Pain control during the first night was fine. It was much much better control than I had following the meniscectomies in 1969 and 1973. In the pre-arthoscopy days, pain control was by nerve block, and when the block wore off post-surgery, the only pain control was by narcotic injection (demerol, in my case). PCA (“the button”) is a much, much better way to go.

Breakfast arrived relatively late for my normal schedule --- I was ravenous --- and most of the shift change actions had already occurred by the time breakfast came.

After breakfast, I was allowed to walk into the bathroom using a walker, and to sponge-bathe in private. Of course, I was accompanied by my IV tree, to which was attached my Foley bag. Of course, the nurse stayed within ear shot of the room. We clipped the blood drain bag to my boxer short-pajamas. The puls-ox monitor was disconnected during bath time, and reconnected when I got back to the bed.

I have kept my hair in a crewcut for years, and having a crewcut made a sponge bath very effective. It felt especially good after a relatively warm night, wearing TED stockings and plastic inflatable legs. Bathe. Brush teeth. Put on fresh clothes. Ahhh.

PT began at 10 AM, but only after the nurses were sure that my BP was stable upon sitting and standing. No light-headedness this AM. I went to PT in a wheelchair, wearing a robe over the hospital gown and shorts. Mostly, in-hospital PT consisted of assisted walking (get out of the wheelchair into a walker, and then motoring around the halls on the new knee). Plus, I did assisted flexion exercises by sitting in a wheelchair and rolling “over” the new knee so that it was bent >90 degrees. Because of my height and the length of my legs, I found this relatively easy, and was >90 on knee-plus-one day. Similarly, I was able to walk in the walker with relative ease. PT occurred at 10 AM and at 2 PM. After breakfast and before lunch.

Occupational therapy occurred after PT on Thursday. The therapist taught me how to go from a walker to a dining room chair; from walker to toilet; from walker into shower. Very simple, very practical and very functional. OT was an impressive operation, preparing the post-surgical patient for all of the things that they would face, from “Where do you put the walker when you are in front of the frig?” to “How do I get from the walker to the shower or toilet?”.

Getting out of bed was still a chore, thanks to all of the tubes and bags. But I could readily swing my legs over the side of the bed. I could also lift my leg-and-new-knee (straight leg lift) almost immediately after surgery.

Nurses and the surgeon’s PA indicated that I should expect to go home on Saturday (knee-plus-three days). On Thursday (knee-plus-one), this seems like it will be a stretch. Maybe Sunday.

Knee-day: in the hospital room

2004-09-29T17:06:00.000-04:00

Knee-day: Wednesday, 29-Sep-2004:
In the hospital room:
I remember moving in the hallways on the cart; rolling (with assistance) from the gurney to the bed; getting everything hooked up, from the puls-ox monitor to the inflatable boots over my lower legs. A nurse gave me instructions on “the button” for pain control. My wife was there with me, and she had the bag of clothes from the gurney in her hand. She put it in the room’s closet.

I got to the hospital room about noon. Surgery was scheduled to take 45 minutes. It actually took two hours, thanks to the amount of gravel in the knee, and the need to remove the synovial membrane. There was ice water available --- I was certainly thirsty.

The blood draws seemed to start immediately. There were BP checks almost hourly (or so it seemed).

About 4 PM, a nurse came in to see if I could go to physical therapy (PT). I sat up OK, but when I attempted to stand, I got very light-headed, sat down (and backwards) very quickly and blacked out for a few seconds. My BP was not stable due to low blood volume, and I became hypotensive when I tried to stand. I was told to drink fluids, to build my blood volume back up. “You’ll go to PT tomorrow ...”

I was still dressed in a hospital gown that was open in the back, but was allowed to pull on short-ee pajama bottoms if I chose. I used knee length boxer shorts, made from soft jersey. Very baggy, which enabled me to thread the catheter bags under them for convenience.

Apparently, I was losing a lot of blood into the drain. Total blood loss during surgery was only ca. 100 mL (a tourniquet was used around the thigh above the knee), but I lost an additional 2 L or so of blood in the first 24 hrs post-surgery. [Yes, 2 L. This is a considerable loss of the body's blood volume]. There was a lot of hand-wringing by the nurses over the amount of blood going into the drain. I also ripped the end of the drain out of the bag a couple of times as I learned to move around with the catheters. This was better than ripping it out of my leg, I guess, but I made quite a mess.

A nurse came in and taught me to do breathing exercises using a plastic respirometer device. One size fits all. Inhale 2500 mL over 10 sec (move the little yellow ball up the tube), then exhale. Repeat 10X. This was a very effective device for deep breathing. For me, one deep breath raised the blood O2 concentration (measured via the fingertip puls-ox monitor) by about 1%.

The same nurse me some in-bed exercises that I was supposed to do once an hour or so. Simple and standard leg/knee stretching and flexing exercises. Quad sets. Ankle pumps (keep that venous blood moving). I was also allowed to do straight leg raises (when the compression stockings were off), but little else. This was a surprise. I was prepared for a lot more in-bed exercises.

There are two doctors in the family practice which we use. The partner who is not our family physician stopped to see me, which was a surprise. Apparently, the surgeon’s office routinely notifies the family physician when there is a surgery, so the partner stopped during his hospital rounds (my family doc was not at the hospital on Wednesday). He was not happy with the blood loss nor with my low BP. He cranked up the IV flow substantially to increase my fluid volume. He asked me to drink more by mouth. He was also not happy with my blood counts, so he added an iron (Fe) supplement to the routine.

Dinner came. No problems with eating/drinking, but I continued to push fluids.

My wife stayed until relatively late, simply holding my hand as I drifted in and out of alertness. Popsicles were available for me, too, whenever I wanted them.

The hospital shifts ran 7 to 3, 3 to 11, 11 to 7. At the change of each shift, someone would come in and check BP and temp; draw blood (clotting time, probably); check the urine and blood drains. IV bags were also checked routinely, but they also had their own volume alarms attached.

Post-op antibiotic therapy used some cephalosporin derivative; administered via the IV bag post-op, as two roughly 8-hr doses. Surprising to me, there was no additional antibiotic administered subsequently by mouth. And, interestingly enough, a swollen gland under my jaw (swollen since a root canal a few years ago) disappeared at the same time. I assume that the gland had a sub-clinical chronic infection, and that the high dose post-TKR surgery knocked that one out, too. [This later proved to be the WRONG assumption].

Antibiotic prophylaxis actually began during surgery. Irrigation of the site occurred throughout the surgery, using sterile water and a strong antibiotic. The surgeon described the process as a big Waterpik spraying away where they were working.

I began oral warfarin at 4 PM on knee-day. I assumed that an anti-coagulant therapy was also used during surgery, but have no verification of that.

The epidural catheter and Foley catheter remained in place, as did the wound drain. Fentanyl was available through the epidural, 3 doses per hour available through the button. I could feel the coolness of the ambient temperature fluid move through the epidural catheter as it crossed my shoulder and traveled under an adhesive pad (about 9 x 12”, apparently covering the entirety of my back from shoulder to lumbar region). By the time the cool fluid bolus got from my shoulder to the middle of my back, it had warmed to body temperature, and I could no longer feel it, nor could I feel it as it entered the epidural space. Time from pushing the button to being able to notice the effect (pain relief) was only a few minutes, and for the first few days post-surgery, this was much needed.

Hospitals at night are noisy. I brought along a cheap battery-powered radio with decent stereo headphones, and found this to be a sanity-saver during the nights. The room TV had a audio jack that also fit my headphones, so I could watch CNN all night long, if I wanted. Or, I could listen to the radio, and blank out the hallway noise very effectively.

Note re inflatable boots:
These are pneumatic compress-and-release cuffs that cover from ankle to knee, both legs. These provide good immobilization as well as prevent embolisms. However, they are plastic, and for me were annoyingly hot and sweaty, even with the TED stocking in between. Also, please be aware that if these are not properly placed on your leg, the compression will hurt a lot. There should be no additional pain when these are properly inflated. [I found this out when I removed them on my own to go to the bathroom, and put them on improperly by myself when I got back to the bed ...]

Note re puls-ox monitors:
These have controllable alarms. When I fell asleep, my blood O2 tended to fall just under the alarm trigger. So I would fall asleep; the alarm would go off and wake me up; I’d take a couple of deep breathes; the alarm would shut off, etc. This went on all night long. Finally, one of the night shift nurses said “Let’s just turn the volume down so you can sleep.” Bliss. You should realize that the alarm is connected to a monitoring station at the nurse’s desk, regardless of whether the volume on the local alarm is on.

Knee-day: operating and recovery rooms

2004-09-29T11:03:00.000-04:00

Knee-day: Wednesday, 29-Sep-2004:
Operating Room:
I had no recollection of going INTO the OR. However, I woke up in the OR as the team was cleaning up. There was a blue cloth drape in place at my waist that was about 18 inches high, just high enough that I could not see over it as I lay flat on my back. Someone from the surgical team noticed that I was awake, and the surgeon looked up and said “Hi -- everything went really well. You had one very ugly knee. We’re just finishing up. I’ll see you in recovery.” Then I was back out. My guess is that the anesthesiologist backed off on the sedation as the surgery was being completed, allowing me to wake up, and then took me back under.

Recovery room:
The surgeon talked with my wife, told her that the surgery went extremely well, and that mine was the 3rd or 4th worst knee he had ever seen. Apparently, there were many floaters and “spurs”, ranging from golf ball-sized on down to sand and gravel-sized pieces. It is standard practice to count the pieces as they are removed. When my count got to 20 pieces, they were down to gravel-sized pieces, and just flushed the remainder of them out, declaring them to be “TNC” ---“Too numerous to count”. The total count of things removed was >100.

In recovery, the surgeon later told me the same story, almost word-for-word, but also told me that he took out the entire synovial membrane. It was so irritated and inflamed that it resembled a piece of old leather, scarred and thickened. All of the “gravel” simply ground at the membrane, keeping it in constant irritation. He said that my body was already rebuilding the synovial membrane, giving me a brand-new one.

I said the word “osteophyte” out loud, and he went on about how some of the pieces were attached, and that some were floating, but that all were removed. He was able to remove so much of the spurring that he was able to use an implant that was 4 sizes smaller than originally planned (from the X-rays). This was one more good reason for the manufacturer’s rep to be in the OR. In all, my new knee was 4 inches thinner than my old knee.

And then he left the recovery room. I don’t remember much after that until I got to my hospital room.

Knee-day: anesthesia suite

2004-09-29T09:00:00.000-04:00

Knee-day, Wednesday, 29-Sep-04:
Anesthesia suite:
I met yet another nurse, and answered a series of questions. I met the anesthesiologist. We talked about anesthesia options. Since I have a clear history re anesthetics, he suggested the use of a spinal/epidural. I would be sedated to the edge of unconsciousness during surgery, with the spinal to initially block the pain, and the epidural to manage the pain after that. The epidural would then remain in place for a few days during recovery, allowing for button control for pain. This was referred to as PCA, which is (I think) patient-controlled analgesia. I simply thought of it as “the button”.

The surgeon came came into the anesthesia suite, and chatted about what would occur. I was asked to sign an authorization to allow the “manufacturer’s rep in the OR”. Having access to a full inventory of parts within the OR during surgery sounded like a good idea to me. My new knee will be a Stryker Howmedica Scorpio.

The insertion of the epidural was simple. I sat up on the gurney. The nurse in the anesthesia suite washed my back with an antiseptic. I was given a sedative through the IV port, and told to lean forward. There was a very slight prick, and then ... I was completely out until after surgery.

This is it --- knee day arrives: pre-op

2004-09-29T08:00:00.000-04:00

Knee-day: Wednesday, 29-Sep-2004:
I woke up, showered, and took my normal AM meds with a sip of water. Then it was on to hospital. I checked in, and was escorted to the surgical waiting room. We watched CNN for a few minutes, and then ...

Pre-op suite:
A nurse came and walked me into the pre-op suite. She looked at my chart and said “Just to verify the plan, you are scheduled to have both knees replaced, right?” Panic attack! I was supposed to only have my right knee replaced. Fortunately, the bilateral indication was only on the OR schedule, everyone else involved had it right --- unilateral, right knee only. I gave a urine sample. I was asked to move my bowels if possible.

And then I took off my street clothes, and put them into a bag (which apparently stayed with my gurney). Put on a hospital gown. A nurse shaved my right leg with a disposable electric razor (3M brand). It was not a terribly close shave, and the nurse and I talked about this change in surgery prep. The first of many BP checks occurred, and then an IV port was placed in my left hand.

And then ... I waited. I watched CNN, and my wife was eventually allowed to wait with me. I told the nurse that I had brought my normal prescriptions with me for that evening and for the remainder of stay. She said that the surgeon would prescribe matching meds from the hospital pharmacy for the duration of my stay. She gave no explanation --- my assumption is that patient-provided meds could be adulterated, or in error. This way, the hospital is fully responsible for the meds, since they are the ones doing the dispensing. This is an understandable legal/ethical position.

There was a phone call. “They’re about ready for you”. I get onto a gurney and am wheeled into the anesthesia suite. My wife kisses me on the cheek and goes back to the waiting room.

Are we nervous yet? Knee-minus-one-day

2004-09-28T16:55:00.000-04:00

Knee-minus-1 day, Tuesday 28-Sep-2004:
Finally. I called to find out my OR schedule. Surgery is scheduled for 910; I was to arrive at 710. Nothing to eat or drink after midnight --- typical pre-op instructions. Nonetheless, I had a very restless night --- anxious to get it over with.

Getting ready? Getting fret-ty.

2004-09-26T16:48:00.000-04:00

Knee-minus-3 days, Sunday 26-Sep-2004:
Three days to go, so I packed my bag for hospital. I made a run to the local libraries, and brought home 3 shopping bags of books to read during recovery (1/3 technical, 2/3 novels).

I fretted over general versus epidural anesthesia, and called the surgeon’s assistant. She said “We use epidurals almost exclusively”. Well. That cleared that up easily enough.

I also fretted over having a Foley catheter inserted --- until I learned that the insertion typically occurs after anesthesia. “You won’t feel a thing, or even remember having it inserted”. Well, OK, I guess.

I watched web videos of TKR surgery. I looked at web images of TKRs, both in photo and graphics forms. I compared brands. I read NIH reports. I dug into the research literature about TKRs, about antibiotic prophylaxis, about DVT therapies.

And then, I just stopped. The surgery was scheduled. I had very high confidence in my surgeon, the practice he is part of, and our local hospital. I stopped preparing for the worst, and started trying to think about how to prepare for the best.

Pre-admission screening

2004-09-15T16:46:00.000-04:00

Knee-minus-14 days, Wednesday 15-Sep-2004:
Pre-admin testing. These turned out to be typical clinical examinations of urine and blood. I had both an ECG and a chest X-ray. I met with a nurse who walked me through the details of a three to five-day stay in the hospital. What to wear, what to bring, what not to bring. I also had repeated opportunities to ask questions.

I then got a little neurotic, having been pummeled with information about the risks involved in surgery, in hospital stays, with anesthesia. I promptly went back to work and and developed contingency plans both for my business and for my home. We reviewed our wills, and power of attorney documents.

I also spent lots of time on-line digging into potential TKR complications, how to recognize them, and how to avoid them. Happily, I can now state that none of them happened with me.

It's getting closer ...

2004-08-30T16:43:00.000-04:00

Knee-minus-30 days, Monday 30-August-2004
Surgery is scheduled for 29-Sep, and pre-admission testing scheduled for 15-Sep.

Knee-minus-45 days: August, 2004
My family went to Bar Harbor for a week’s vacation. We do this every three or four years, and the entire extended family goes en masse. I had a cortisone shot before leaving, and the surgeon and I agreed to schedule surgery for mid-September. I was to call upon our return home. My wife drove for almost the entire trip.

Ginger, you are MY HERO!

2004-05-20T16:50:00.000-04:00

Knee-minus-4 months: May, 2004:
I was in Holland on business, and met the wife of a business colleague who had BOTH knees replaced in March 2004. Three months later, she was walking 3+ miles per day, and had flown to Holland without discomfort. I was shocked. How could she recover so quickly? She claimed that she did TKR rehab exercises for 3 months before surgery, and that this strengthened her leg muscles to the point where she flew through rehab. She sent me the exercises --- which turned out to be standard knee rehab exercises, readily available on the web, and very similar to the exercises I’ve been doing on and off for 34 years.

We came back to the States, and I began to do quad sets, straight leg raises, and short arcs 3 or 4 times a week.

The final straw, but let's try SynVisc anyway

2004-03-15T16:35:00.000-05:00

Knee-minus-18 months: March 2003:
I was on a sales call in wintry Minneapolis, and was rushing to get to the rental car following my last appointment of the trip, on the way to the airport. I slipped on a very icy street, fell down, and whacked my right knee on the curb. Regardless, I drove to airport, got on the plane, and then drove home from the airport (a 2-plus hour drive). This time, the pain and swelling continued for many weeks. Finally, I asked my family physician for a referral.

This began a series of visits to my orthopedic surgeon. “95% of people with knee like yours would not be walking.” We tried SynVisc (hyaluronic acid) injections, but these were completely ineffective for me. At that point (spring 2004), we decided to plan for a TKR in the fall of 2004. I had a fairly extensive work and vacation travel schedule planned or 2004 that could not easily be changed. The short-term solution was to get a shot of cortisone (DepoMedrol) the week before each extended trip. The long-term solution was to schedule the TKR.

"You know that you'll eventually need a TKR, don't you?"

2004-01-02T16:33:00.000-05:00

Knee-minus-20 years: 1984:
I fell on an icy parking lot and whacked my knee quite hard on the pavement. Subsequent pain, swelling, and “moving lumps in my knee” led to X-rays of right knee. The knee was full of “floating bodies”. The surgeon removed the biggest of the lumps via out-patient arthroscopy. He also provided me with a clear diagnosis of severe osteoarthritis, and evidence of a severe knee deformity as a result.

This was also the first surgeon to tell me that --- sooner or later --- I’d be getting a knee replacement, and probably sooner.

This story actually begins in ...

2004-01-01T06:00:00.000-05:00

Knee-minus-34-plus years: 1969
I was playing touch football in phys ed, and I was one of the big slow guys on the offensive line. I was head-to-head with another big guy on the defensive line and he beat me off the snap. I got pushed back, and as I was pushing off into loose gravel, I twisted my right knee and fell down. Upon getting back up, I discovered that couldn’t straighten out my right knee, nor could I put much weight on it. The gym teacher said “Go walk it off”. So I limped around the track, headed into the locker room, took a shower, and ran through the remainder of the school day as if nothing had happened. Except that my knee ached.

Two weeks later, we were playing basketball in gym class. I went up for a rebound, came down and pivoted on my right leg. There was a CRACK like a rifle shot as I fell to the floor. It was the ACL snapping that sounded like a rifle shot. I could not move. I was carried down to locker room. My mom took me to our family physician who diagnosed the injury as a probable torn cartilage. He set up an appointment with an orthopedic surgeon who decided to repair the MMC and the ACL.

This was in 1969. Pre-arthroscopy. MMC, ACL repair surgery and recovery meant a 14 day stay in the hospital. Those of you who have only dealt with arthroscopy, you just don't know how gruesome knee surgery used to be.

Four years later (winter, 1973), my right knee locked up as I was walking across campus, and could not walk. Apparently, I had also torn the lateral meniscus in the original injury, and calcification around the tear produced a lump that locked the knee in place. I took off a semester from college for the second surgery and recovery. This was quite serendipitous, since I made up that semester during the summer of 1974, and met the woman who would later become my wife.