Day 25

 Merry Christmas!

Day 25 of my Total Knee Replacement recovery. Progress is not particularly quick and there is a fair amount of tedious work that I process through each day, but progress is happening.

On day 13, I had my staples removed which led to being able to add baths and swimming back to the menu. I did my first post surgery swim….just 1,000 yards but it was my first aerobic activity in 2+ weeks.

On Day 22 and yesterday, Day 24, I was able to do very easy spins on my Wahoo Kickr bike. The first ride was just 1-mile and that took 6:35 to complete with a whopping avg power of 41 watts. Yesterday, I spun for 10 minutes and managed to cover 2.6 miles (15.6 mph) with an average power of 84 watts.

The key thing each day is to keep upping the stress on my knee and pushing my range of motion, without causing excessive swelling. In addition to the above, I’m going on 5-8 walks a day and while I haven’t gone as far as a mile yet, most walks now are 10+ minutes and near or over a half-mile. I also have 3 sets of range of motion exercises that I’ve been able to do 3-5 X/day. Lots of elevation and icing as well….

The biggest struggle is sleep. I can generally get 3-4 hours in but then my knee has enough discomfort in it that it wakes me up. This is usually around 2-3am. I usually struggle to get back to sleep and most days (like today), I just get up and start the day (it’s 7:45am as I write this and I’ve already been out for 3 walks in the single digit outside). I take a nap or two later, but the sleep challenge is probably the hardest part of the recovery so far.

Onward and upward!

New Knee Day 20: In the grind now!

 It's been 10 days since the last update on life with my new knee.  

Brian came over to watch Argentina take down Croatia and during halftime on Day 13 he removed my 27 staples.  This turned out to be mostly a non-event (with the exception of one spot where there was a matt of clotted blood and superglue).  Since then, the incision has continued to look better and better--I'll update with a new pic at some point.

With the staples out I was cleared to submerge my knee beginning on Day 14, which meant that baths and swimming were back on the menu.  I've been taking a warm bath each night, which helps with sleeping and I even went swimming on Day 16--just a 1,000 yds, which took almost 19 minutes, but it was good to actually do something quasi-aerobic again!  I'll probably swim a few more times before the end of the year but plan to get into a regular swim routine in January.

I've also been cleared to begin riding my bike trainers at no or very low resistance.  I tried yesterday, Day 19 for the first time on my recumbent and it's still a no go--too much swelling and resistance as my knee gets close too my body on each rotation.  I plan to check my Wahoo Kickr tomorrow but expect that I would be regularly on the bike before the New Year.

I still elevate for lengthy periods of time each day and spend about 2 hours on my Game Ready ice machine each day.  I've found it difficult to do 6-8 cycles of all 3 PT exercises and 5-10 minute walks each day without my knee swelling and suffering a set-back the next day.  I have to take it easier than is my nature but I'm really trying to listen to what my knee has to say about what I put it through each day and right now it's telling me to slow down a bit.

I still wake up from the pain around 2 or so in the morning (after a 10pm bed time) but have recently been able to get back to sleep for another 2-3 hours before dawn--still not enough sleep but a definite improvement.  

As my swelling has subsided my knee has started to "click" a lot which is annoying and a bit disconcerting.  But it appears to be fairly common and the hope would be as I continue to improve my range of motion the clicking will diminish and hopefully go away.

The other issue I have is first thing in the morning (especially at 2am) after a fuller day of PT the day before, when I get up, my knee is very tender and not super functional so I have to baby it a bit until it wakes up.  This also tells me I have to go slow on the day's activities.

I'd say my knee is at about 20-25% of the functionality of my good knee so still a long ways to go.  for reference, I'd say my left was at about 50% before the surgery so I'm hopeful I start moving ahead of where I was over the next month or so....

Trying to be a patient Patient!  Onward and Upward!

Day 10: Life with the new knee...

 The last three days since my Day 6 post have been all about settling into a routine of sorts.  My knee continues to progress, albeit at a slower rate and with steps backwards mixed in with the advances.

Dr. Galinat came by late on Day 6 (Wednesday 12/6) and changed out my dressing for me.  The wound looks good--healing well with no signs of infection:

As you can see, my knee still has quite a bit of swelling (although well down from its cartoonish-peak!)  My range of motion is within the target range but hasn't materially changed over the last 5-6 days.  I can bend to 90 degrees (as you can see above) but its not easy and a bit uncomfortable.  I can't quite get all the way to 180 when I straighten it unless I push it down.  90/180 are my targets for these two exercises until the staples come out.

With the swelling comes a modest bit of pain that unfortunately manifests itself at night and is leading to low quality sleep.  I seem to sleep pretty solid for 2-3 hours and then as the Tylenol begins to wear off, the pain is enough to make me uncomfortable enough to only get little bits of sleep here and there.  My docs both warned me that this second week would probably be the hardest with respect to sleep.  I'll try to muddle through.

I took a PATIENT PATIENT day yesterday as I felt like my knee swelled a bit form a full day of rehab (with my longest walks) on day 8.  Today, I'm going to be a bit cautious again and will walk 4-6 times vs. 7-9, which is a full day.  I've also gone back to limiting the duration to 5 minutes.

My staples will come out early next week and a day or two after that I'll be cleared to swim/take baths again.  I may wait until January before starting a regular swim program but I'll be all over the baths in hopes of helping sleep better.

I've started driving again which is good for my spirits and takes some of the burden off of Judy.  I'm not certain when I'll get cleared for low-resistance cycling but maybe not too long after I get the staples out if I can keep the selling down.

All good!  Onward and upward!

TKR Recovery Day 6

 A couple of quick updates.  I received these Cat Scans of my new knee:

In the first picture, a frontal view, my new knee is obviously on my left (right side above as it is a frontal view).  My left leg is a bit lower in this pic as I must not be lying on the table perfectly straight in the picture.  A couple of things to note: 1. you can see how much smaller my lower left leg is than my right by looking at the outlines of the skin.  It's especially evident the higher up the calf you go.  This is due to many years of my right leg doing more of the work as my knee deteriorated.  This is the longer term rehab I need to undertake--probably a couple year project and realistically, I'll probably never get back to a 50/50 balance.  But I'm sure I can do better than the 62/38 power balance I had on my bike this summer. Second, you can see the extra wide channel (above my knee cap) for the new more athletic implant.

The second picture is a side view.  Notice the nice big space between the two implants--yea!  You can also see the 27 staples on the frontal surface of my skin. (yikes)

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I had a really active day yesterday PT-wise.  I had 5 cycles in by noon but found that I was getting some selling and I started to feel a bit fatigued so I backed off in the afternoon.  I also decided to forgo my 2nd dose of Tylenol last night (and had some red wine with dinner--yea).  This might have been too soon as I didn't feel a lot of pain last night but it was enough to lead to more sporadic sleep.  I've decided to go back on it today and for the next couple of days.  My meds now are 2 Aleve/4 Tylenol/2 aspirin a day.

Lastly, I'm now walking outside as part of my PT and up and down stairs with no assistance!  It's slow but its feels quite easy.  I hope to start driving tomorrow.

Onward and Upward!

TKR surgery recovery: Day 5

 Right of the flight path with my recovery.  On Friday, poor Judy had to drive use at dusk in a fair amount of rain from Lodi to SFO all the while enduring my directions.  We made it.  We got to the airport 5 hours early (am I becoming my parents?) to manage all the transitional stuff with my knee but it was a real breeze and it turns out the Harvey Milk terminal there is fantastic.  Was able to spread out and find a place to elevate my knee and read and chill prior to the flight.

We left an hour late because the inbound from the East coast was an hour late due to exceptionally strong headwinds.  This in fact turned out to be great news as the same wind actually got us to PHL early despite the late start.  In total our flight time was just over 4 hours, which must be close to a record of some kind.  I wasn't able to elevate my leg, even though we were up in First Class but it didn't matter as the leg felt fine.  I got up to go to the restroom at one point and just used my $11 Walmart cane.

We arrived in Philly and had an easy transit home to our house in DE where I set up shop for the day on my couch watching yet more soccer and the EAGLES!  I did 7 cycles of PT (walking/exercises) and did the last walk without the walker, which has now been retired.  I have a Game Ready Ice Machine and I spent 100 minutes on that--its amazing!

I ended up only taking 1 Percocet during the day (I'm prescribed 6) and after talking to my surgeon decided to take one last night and that chapter is not thankfully closed.  I ended up taking 14 of them out of the 42 they had given me for use over 7 days.  So day 5 is Oxy free! 

I'm settling in for a routine recovery week where I expect to basically do the same stuff every day. 7-8 cycles of PT with gradually lengthening walks--line maybe up to 10 minutes a few times a day by the end of the week--most will stay at 5.  I want to be on the Game Ready for at least 2 hours a day.My range of motion is slowly getting better and when I'm sitting around it occurs to me that I have the least amount of pain I've had in 5-10 years!

Onward and Upward!

Post Knee Replacement Day 3 and details on what they actually do when they replace your knee

Pretty good night last night.  I’ve learned a few tricks on how to sleep on my back with my leg elevated.  That plus, my body reaching a bit more of a equilibrium on fluid retention/swelling means I actually first slept for 5 straight hours! This is an important aspect of my recovery process as I’m sure my body is busy trying to adjust to the radical changes that I’ve inflicted on it and needs the sleep to do its thing.  I also was able to get an additional couple of hours after that so really positive on that front.

My pain level has greatly diminished at this point.  I went 8 hours between meds last night and without doubt the pain is still there (and increasing as morning rolled in) and I need to stay on the pain killers for a bit longer, although at a lower level.  Even with the 8 hour gap I’d say the pain only got to about a 4 or so, which frankly has been a pretty common level of pain for me over quite a few years and is not that big of a deal.

I’m settling into my PT routine which is quite basic at this point, just entailing 2 exercises designed to get my range of motion to 90-180 degrees at this point.  90 is easy, 180 a bit more difficult…I probably top out at about 170 degrees so far…still too much swelling.  These exercises combined with the walking takes about 20 minutes and since I repeat hourly, it’s a bit of a time sink.  It’s surprisingly challenging but since I can’t work out I’m fine with it.

We're getting ready to head back home and I'm looking forward to getting into a routine there and really rebuilding my leg!

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A final quick note on what they actually do when they replace your knee--here are the general steps:

1. They cut open your knee from above your knee cap to below it down on the upper shin--about 8 inches or so.

2.  They move your kneecap to the side taking care to not strain the tendons attached to the knee cap.

3.  They remove your ACL so they can get at the back of the femur and tibia.  The basic design of the artificial knee mitigates the need for the stabilization normally provided by the ACL.  They leave the PCL in place.

4.  They remove about an inch or so from the bottom of your femur.  I'm not sure how they do it because frankly when it happened I wasn't paining attention!

5.  They drill a couple of holes in the bottom of the femur and then cement the cobalt (basically steel) implant in place.

6.  They cut a similar amount of bone off the top of your tibia and put a couple of holes in it and cement that implant in place.

7.  They insert a plastic type part on top of the tibia implant and this basically serves as my meniscus.  The femur implant glides back and forth across this plastic.

8.  They cut part of the back of the knee cap off and cement a plastic insert there, which also glides against the femur implant.

9. They move the knee cap back into place and make sure it all moves well.

10. They then staple your skin together with about 20-25 staples and wheel you out to recovery.

Pretty amazing really!

My new knee!

Here’s the update on my total knee replacement.

First off, I had what’s called a Kinematically Aligned Total Knee Replacement (KA) by Dr. Stephen Howell out in Lodi, California.  This procedure was invented by Dr. Howell back in 2005.  This differs from the more common surgical technique which is called Mechanical Alignment (MA).  I think about 85% of procedures are Mechanical and most of the remainder being Kinematic.  There are a number of differences between the two philosophies and both have strong proponents with very good efficacy track records.

I could ramble about how they are different (Kinematic takes into account 3 dimensional alignment vs. 2 for Mechanical for example) but the basic difference is that the more common MA design intent is to give the patient a straight leg from the hip, through the knee to the foot, while the approach I went with is designed to replicate the geometry that the patient was born with.  

Lots of people are born with quite straight legs but some are either bow-legged or knock kneed.  I’m not talking about disease caused crookedness but rather normal and relatively slight variation.  I was born a bit bow legged.  For people like me, if I were to have a MA procedure I’d essentially end up with one leg straight (my new knee) and one leg bowed (my natural shape).  This tends to lead to unnatural feelings and results in less patient satisfaction, especially among more active people, which given the age of most knee replacement people, I’m at the far end of the activeness bell curve.

In general, straighter legged, generally older, generally heavier people are better suited for MA, while bow-legged/knock-kneed people who are more athletic tend to be better candidates for KA.

As it turns out, Dr. Howell is a colleague of my ortho, Dr. Galinat in Wilmington and as we reviewed my case we all quickly agreed I would be a great candidate for a KA knee from Dr. Howell, hence my journey to Lodi for my knee replacement.

Wednesday 11/30

Judy and I drove to the hospital and checked in at 5:45am as I was first on the docket, scheduled for 8am.  I went through all the pre surgery prep (and btw, I had been cleaning my nose, mouth, and skin for 5 days prior and attended a 2.5-hr class on Tuesday).  I won’t bore you with all the details but at one point my blood pressure came in at 155/120, which is very high relative to my typical 120/90…I guess my calm exterior belied an underlying nervousness about what the day would bring.

Anyways, about 7:45 I said goodbye to Judy and was wheeled into the OR.  I looked around and marveled at the high tech lights, the various beeping, clicking machines and the 7-8 people there including a couple in full hazmat like surgical gear.  I didn’t see Dr. Howell and then….

The nurse was waking me up and asking me how I felt.  Apparently, I didn’t even know I was going under or maybe it was erased from my short-term memory but the procedure was done and I had a new knee.  Judy soon walked in and there were 4-6 people buzzing about talking in cheery tones and doing various things like adding fluids to my IV drip.  I wasn’t that engaged because frankly I was a little loopy at that point.

Here is a pic in my surgery attire pre-game:

This is the somewhat anxious moment when I said goodbye to my bride and was wheeled into the OR:

Back in recovery feeling pretty good but definitely a bit loopy:

My femur implant was of a relatively new type that has a wider channel for my patella which in theory will giver me greater athletic performance potential down the road.  Due to this I am taking part in a study that will track its effectiveness and as a result when I got my wits about me I was wheeled off to get a Cat Scan of my knee:

Hopefully this new device will lead to a better outcome for me and others down the road!

After a while, they came in and had me walk for about 100 feet or so on my new knee with the assistance of a walker.  Apparently, the implants are cemented in and one can walk on them in as little as 10 minutes after implantation.  The PT also demonstrated some exercises for me and showed me how to climb up and down stairs properly during the early stages with the new knee:

Dr. Howell came in and chatted for a while and told me 25 times to take it easy in the early days and after I was able to demonstrate that I could still pee I was allowed to exit via wheel chair and Judy drove me back to the hotel.  I went for 6-7 5-minute walks and frankly felt like I didn't even need the walker.  Later, I elevated and iced my knee and watched Argentina crush Poland on my iPad:

Late Wednesday/Thursday

I knew the pain would come at some point over the first 36-48 hours but mine arrived early.  About 9 or 10 pm my knee and quad (from the tourniquet) began to swell to an amazing size and with it some pretty, disheartening pain.  It was a rough night that led to zero sleep.  Not fun.  In retrospect, we were too slow to dip into our pain killer arsenal and I paid the price the night.

By morning, we flipped the switch and began throwing Aleve, Extra Strength Tylenol and Percocet at it.  I also walked much more timidly and tried the various PT moves to try to get the swelling and pain under control.  The meds kicked in and I begin to get my pain level down to about 5 on the 10 point scale.

By nightfall things improved greatly and I was able to actually sleep for 30 minute stretches.  These were interrupted by trips to the bathroom for amazing amounts of pee as my body began to dump the accumulated fluid.  By morning my knee had deflated considerably (really crazy to experience) and with it the pain subsided to quite manageable levels.  We removed my ace bandage to reveal the incision and it looked very good indeed (or at least as good as they things can).

Friday

48 hours after surgery my knee was down to a much more manageable size and the scar, while quite big looks pretty good:

As we roll into Friday night things are progressing nicely.  I had a consult with Dr. Howell and he is pleased.  My pain is manageable and I'm able to walk a bit further, which I do with my walker every hour or so.  I've also stepped up my modest PT exercises but am taking things very easy at this point.

My GI track is back on line and I have no blood clot symptoms so we are good to go for a return to DE tomorrow night.  My prognosis appears excellent and I am motivated and optimistic!

As a result of the surgery my left foot has shifted inward by about an inch and half and now my feet are nearly together when I stand (like normal people).  Look back at my pics from Kona and you can see that was certainly not the case before surgery.  I'm excited to see what its like when I get to put the new knee through its paces but first I have a bit of road to travel before I can ditch the walker and see what it's like to walk like a normal man and to hopefully be relatively pain-free after 20+ years of chronic pain.

Onward and Upward!