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Knee Replacement Surgery--A Patient's Viewpoint.


Knee Replacement Surgery from the Patient's Viewpoint
(c)2001 by Tom Holzel
Rev: 14 April, 2002

This essay describes the decision-making process and results of a 61-year old man suffering increasing knee pain and immobility, who finally decided to have both knees replaced. It differs from the usual Doctor's Office descriptions of knee surgery in that the experience of a single person is used, avoiding the diluting effect of broad, all-encompassing generalities designed to cover all possibilities. It differs also in that none of this is medical advice. The writer has no medical training whatever. This essay describes a major medical procedure as experienced by a layman. Statements written as "facts" are merely my opinion, of which there are plenty. Judge or dismiss their value for yourself.

Symptoms

At age 55, my left knee was beginning to ache more and more frequently. At first it was from sitting still (at the movies), or from longer runs. But this aching was easily treatable with ibuprofen. However, by age 58, this steadily escalating "discomfort" was enough to have reduced my running from 3-5 times a week to once or twice. I have been a life-long runner, skier, hiker. In the last five years I have become overweight and (because of the knee problems) much more sedentary.

Eventually, moments of acute pain would occur while merely walking that required me to sit down and rub the knee to get it back in order. After consultation with knee specialists, I decided to undergo arthroscopic cleaning of the knee joint. This is usually an outpatient debridement of the knee joint of all the chewed-up cartilage floating inside the joint.

Cartilage is the softer lining of the bone that cushions the bearing surfaces of the knee joint. As one ages, this cartilage is slowly worn down or shredded by cuts, until the knuckle of the joints rub up against each other as bare bone, causing acute aching. This loss of cartilage can be easily seen (in x-rays) in the reduced spacing within the knee joint of the tibia and femur. And it can be felt by the doctor as he moves the knee and lets his hand feel the grinding.

Photographs of the interior of my knee showed the cartilage to look like so much crab meat salad. A clean interior looks smooth and shiny, much like the inside (mother of pearl) of a claim shell.

However the knee doctor1 at Stanford Medical Center was very straightforward about my prospects: "Sure they'll be some improvement, but you've got 60,000 miles on 30,000-mile knees, and no amount of cleaning is going to put tread back on that worn-down tire." The alternative was total knee replacement, a major surgery that no one wanted to suggest, especially at my young age. Total knee replacement was reputed to last about ten years, at which time the leg bones become weakened by the constant pounding of the knee-joint spikes that attach the artificial knee joint surfaces to the femur and tibia, and thus make a re-do even less strong.

Total knee replacement sounds like a horrendous operation with the leg essentially being severed at the knee-and then re-attached. So I never seriously considered it.

The arthroscopic cleaning did work as advertised-but nothing more: it did eliminated the sudden onset of sharp pain when walking, and I no longer had to stop and reposition the knee by massaging it to stop acute walking pain. But it did nothing for the background ache. I still could not sit with my leg in any one position for too long, and running was becoming more and more unpleasant, inflicting a dull ache that was beginning to verge on downright pain. At the end of a hard day, the knee would swell and feel deeply bruised.

One side effect of the operation was my inability to straighten my knee completely and lock it in place (so as to be able to stand on it without using the quad muscle to hold me up). I was told this was due to my failure to exercise-stretch-out-the hamstring muscle adequately after surgery. And it is true I could have done that with rehab help. But I am certain I went into surgery able to lock my knee joint, so the subsequent crook was definitely a consequence of the procedure itself.

Two years later my other knee started acting up. I had it arthroscoped with the same results: less pain, no significant improvement in functioning, and now neither knee could be locked straight. I could stand briefly in a slightly crooked position, but standing for any length of time (e.g., at a cocktail party or trade show) was impossible. The knee still ached. Two operations later, was I any better off?

Although it is disgusting to see doctors try to push procedures on people where they are of questionable value, I probably would have been better off having had knee replacement surgery 3 years earlier than I did-and wish I had been pushed harder to have had it done. The medical professions seems reluctant to do so because the life of a knee replacement has traditionally been only 10 years, and a re-do is more difficult because of the wear and tear of the bone caused by the first replacement. However, today's versions are reputed to last 20 years (if running is given up). One wonders if insurance company recalcitrance to fund earlier knee replacements has anything to do with this professional reluctance.

Note: Many web sites advise that new knees will NOT restore your legs to their pre-injury state. You will not be able to do full squats. (Maximum knee angulation will be about 120-degrees.) But consider how much better shape you'll be in than you are right now. No more pain when walking, for example. No limp. No ache from sitting in one position for an hour or so. However, my doctor says there is no mechanical reason why nearly complete flexibility can't be obtained--if one works at it long and hard enough. (See more on this below under "Day 79.")

One factor with which these two surgeries reacquainted me was the inevitable nausea I experience due to the narcotic pain killers of general anesthesia, and the oral pain killers given after surgery. I am told that a significant minority of patients experience excessive nausea, being especially sensitive to morphine and its derivatives. "Percocet" a powerful and ubiquitously-prescribed pain killer for many, causes me acute 'want-to-die" nausea.

Still afraid of total knee replacement, I found on the web the mention of a less invasive procedure called "uni-chondular" repair. Many worn-out knee joints are only worn out on one side of the joint or the other. In that case, if the rest of the knee is still in good condition, instead of replacing the entire knee bearing surfaces, left and right, top and bottom, an inlay of metal is incised into the top afflicted bearing surface, and a shock-absorbing plastic strip is cemented into place on the bottom joint surface. One doctor has perfected this operation into a one-hour, outpatient procedure.2

This, I decided would be the operation for me-a compromise between the palliative of arthroscopic cleansing and the gruesomeness of total knee replacement. But, as clever as my self-diagnosis seemed, this compromise measure was not to be.

I had especially chosen a doctor 3 at Mass General Hospital who did the uni-chondular procedure. One of the questions he asked me was whether I experienced any knee cap pain. I told him I didn't, but that I would occasionally experience sharp joint pain. He sent me for x-rays and we made a date for surgery. We would meet for a final consultation two days before the operation.

No sooner had I left his office than I experienced a return of the sharp joint pain-and what do you know: it wasn't in "the joint," it was directly behind the knee cap. I had just never isolated the pain more specifically than "the joint" before. But his question, and my sharp pain was a clear indication of what was to come.

At the pre-op meeting, I told the doctor about the knee cap situation, an event that was becoming ever more frequent. "Well, uni-chondular won't do anything for the kneecap pain," he informed me. In addition, I had stopped taking ibuprofen4 for the first time in many years (because of the impending operation) and had begun to feel the first harbingers of knee cap pain in my "good" knee. "Not only that, Tom," he added, "but to me the knee cap on the good side doesn't feel as if it's very far behind the bad one." He manipulated both knee caps at the same time and I could feel the worn-in grooves of each one sliding over my knee joint. The backs of the knee caps are supposed to be smooth.

"OK," I agreed, "let's bite the bullet and replace them both. But I sure as hell don't want to go through this procedure more than once. Can we do them both at the same time?"

The doctor explained the pros and cons of doing them at one time, and spacing them out (see more on this subject, below). The single disadvantage of doing them both at once (assuming the patient is hardy and can endure the much longer procedure-many older people cannot) is that it makes recovery a little more difficult because the patient doesn't have a good leg to help support his walking rehabilitation. Thus, it is less attractive for totally unathletic types. Having made the two-at-once decision, I was met with wonder by many hospital personnel who spotted the twin incisions. "Brave," was their average comment, and it was obvious from this repeated commentary that only a small group of patients choose that route.

Anethesia
My anesthesiologist explained my three options:
1. General anesthesia via an IV. This was what most people chose because you are out the whole time but can be brought conscious at any moment. However, this method releases the most narcotic into your bloodstream and brain. Given my propensity toward anesthesia nausea, he recommended against this option (but the choice was truly mine to make).
2. An epidural, in which the anesthetic is placed by needle alongside the spinal sleeve. The advantage is that the spinal sleeve is not punctured, eliminating that mild risk factor; the disadvantage is that it takes more anesthetic to perfuse through to the spinal cord, and thus more is floating around the body.
3. A spinal. Here the anesthesia is administered directly through the sleeve housing the spinal cord with maximum concentrated benefit and a minimum of anesthesia used. In fact, you would remain completely conscious with only a spinal. The disadvantages are the slightly riskier nature of piercing the spinal sack (infection, etc.) and (as with the epidural) the fact that it is a one-shot procedure. If the operation drags on, additional anesthesia must be administered, but this can only be done as general anesthesia via an IV.

I certainly did not want to remain conscious! To me, one of the great wonders of modern medicine is to have someone slip an IV into your arm, and two minutes later, wake up in bandages, an entire 3-hour operation having occurred in the interim. I chose the spinal. In what seemed like less than a minute, the anesthesiologists numbed the injection entry point, gave me a catheter and injected the spinal. I didn't feel a thing.

One knee or two?

About 20% of knee replacements are for both knees.5 Of these "bilateral" replacements about half are undertaken at the same time, that is, both knees are operated on under the same anesthetic event. Otherwise one knee is replaced and than the other in a second procedure. Since the aggravation of the knee replacement is roughly the same for having one or two knees done, why doesn't everyone have them both done at the same time?

The reasons given for not replacing both knees at the same time are:

1. Older, weaker patients may not tolerate the twice-as-long operation safely enough. That makes sense, and my 78-year old mom had hers done a few weeks apart for that reason.

2. The recovery process requires a mildly more athletic patient when he does not have one "good" leg to help the other. Some older patients are very feeble.

3. The lesson plan for physical therapy does not even mention how to do various exercises if both legs are incapacitated, giving examples of how to walk by saying "Start with the good leg..." However, that is not a big deal. One manages, and is soon over the hump.

4. One maneuver surprisingly not addressed by the physical therapy, is how to get down on the floor-and up again. (A lot of the exercises have you lying down. Presumably this is on the floor. A bed is a lousy place do to exercises.) It turns out to be quite tricky to get up off the floor with two bad knees, and certainly not something a person with limited upper body strength could accomplish at all. Missing from the arsenal of physical therapy gadgets is a 3-step staircase that you place at the foot of the chair you want to hoist yourself into. Using your arms, you would lift your butt 2-inches onto the lower stoop, reposition your hands and hoist yourself up 2-inches to the next step, etc. It takes some strength to accomplish even the 2-inch lift, but nothing like the 6-inches necessary to get up to foot stool height. Maybe a crude lever-actuated butt elevator could get you up from the first, most difficult 12-inches, so you could then hoist yourself the rest of the way onto a chair.

My advice is to try everything you can to have both knees done at once. The difference between having one knee done or having two knees done is that two will take a little longer to recover from, but then its over. You're cured. To have the unpleasantness to look forward to of having the first knee, done all over again, understandably turns a lot of people off-and they hobble through life with only one good knee when-with a little more fortitude--they could be fully restored to an active life.

"Pain Management."

Since the middle of the century the U.S. medical profession has been cursed with the Puritan stricture of "no pain, no gain." Which is to say, some pain is inevitable and even good for you. Eliminating pain boarders on having fun. Although found no place in the bible, Puritanism (and most Christian religions) has suffering and anti-pleasure woven into its very warp and woof. This attitude is mirrored in the fundamentalist philosophy guiding the U.S anti-drug effort, which can be summed up as the acute fear that someone, somewhere, is having a good time.

This has changed, and the patients in my wing of Mass General Hospital were on self-administered morphine drips. You can push the button as frequently as every 10 minutes (or any interval set by the nurse) to get a shot of pain-killer. Essentially the idea is that once you feel a lot of pain, it takes more narcotic to eliminate that pain, than would be used in smaller doses to keep it from occurring in the first place. So by allowing the patient to give himself a small squirt as soon as he feels the first onset of discomfort, he can nip the pain in the bud and use less narcotic than the previously rigidly scheduled intervals (4 hours). Plus, correctly self-administered, he never feels any pain at all--a very civilized procedure, instituted only 50 years behind European hospital practice. People in pain almost never get addicted to morphine (except in novels and the movies).

The operation of the morphine squirter was all explained to me, but it took three days before I learned to negotiate the rocky road of too little morphine and too much discomfort, or no joint discomfort but a constant sense of nausea. Pain vs nausea. To me, the nausea is worse. The majority of patients not allergic to morphine will find the system very effective. But, of course, not 100%. Some patients will still be subject to some pain some of the time-usually in the first post-operative week.

It took me a while to make my nausea complaint clear to the nurses, but they finally took me off morphine and gave me the pill "Ultram." Ultram is a cox-2 inhibitor that binds in the body to certain opiod pain receptors. By doing this, it modifies the pain message--specifically by blocking the re-uptake of the neuro chemicals norepinephrine and serotonin. The net result is effective pain relief.

Ultram is a steroidal anti inflammatory drug and--most important--not a narcotic. Ultram is something like ibuprofen ("Motrin"), but more effective and without the stomach upset side effect. (Although it gave me a bile-tasting dragon breath.) Constipation is a side effect of Ultram6, and I got it, but not severely so. Patients coming off the IV and not nauseated by narcotics might be given Percocet or Darvon.

The biggest mistake I made was not taking enough pain reliever-again, influenced either by a macho "I don't need any pain relievers", or an "ethical" (i.e., political) posture against taking too many pills of any kind-all of which goes back to the cold dead hand of the Puritan Ethic.

Taking a minimum of pain pills (and feeling smug about it) resulted in "discomfort" setting in. By "discomfort," I mean exactly what the word suggests (before it became a medical euphemism for sharp pain), that is, a pressure or aching stiffness. But not sharp "dentist pain." This gnawing pressure was significantly relieved by exercise-stretching and activating the muscles. I would be sitting in bed, squirming to get comfortable by shifting my position from one to another, never able to get comfortable. I did not think of this pressure as "pain." As a result, the first few days I exercised too much and my legs became stiff and tired. I actually back-slid on my daily PT test. I called the next day off and did nothing, just to let my muscles relax for once. And I snuck in a few Ultrams--not only to kill the discomfort, but for the minor side effect of drowsiness which let me nap. Sleep is a wonderful balm.

Even "Ambien," a marvelous, hang-over-free sleeping pill, would not let sleep occur in the presence of the discomfort. Once I figured it out--that Ultram did work on the discomfort (eliminating it completely), I didn't need the Ambien--sleep could come naturally.

So the drill for me was to not let discomfort occur at all, because as it arose, I would unconsciously exercise to subdue it, on top of my regular twice-a-day hour-long PT exercises. This pain-reliever exercise would amount to an additional 3-5 hours more of fidgety half-hearted exercise-and always resulted the next day in sore, stiff muscles with less strength than before.

I was extraordinarily lucky not to experience any "pain" (as opposed to discomfort) at all. My stitches never hurt, my muscles never hurt. Only the gnawing ache of the joint itself bothered me, and it was largely controllable with pain pills. However, my lack-of-pain experience was not the norm. Others in my rehab wing did experience some pain, most of which (but not all ) they were able to control with pain pills. My single complaint about the whole business: I went in bow-legged, like all good athletes-and came out slightly knock-kneed (and probably 1/2-inch taller!).7

My Recovery

* Day 0. Operation
* Day 4. Left Mass General Hospital for the Spaulding Rehabilitation Hosptial
* Day 14. Left Spaulding Rehab Hospital for home. They required me to show I could maneuver my way up and down stairs using a crutch and the handrail before they would let me go. But my insurance (Blue Cross HMO) covered me only for 10 days. The whole Blue Cross paperwork issue was extremely well-handled and patient-friendly.
* Day 16. I went outside and hobbled around for 100 yards on the sidewalk using my crutches.
* Day 19. First tenuous walks indoors without crutches.
* Day 22. Walked one-half mile without crutches, including going up and down stairs using the handrails. Muscles ached the next day, but not severely. But the joint didn't! (However, still pretty creaky, and by no means able to walk at normal speed.) In spite of lots of stretching exercises, still can't completely straightened out my hamstring muscles, so I still can't lock my leg when standing up. But I will prevail.
*Day 74. Walk completely normally. Going down stairs still tweaks a bit. Can lock one standing-up knee, but not yet the other. (Still working it--45 minutes a day.) When I sit on one position for an hour or more (e.g., at the computer) getting up is done with very stiff muscles! They adjust in 15-30 seconds, but the doc says not to worry, this will clear up in 1-2 YEARS!
*Day 79. I seemed to have hit a solid barrier in bending my knees: 120-degrees for the left one and 115-degrees for the right one. Pushing harder seems to be stopped solidly. The doctor says no--I should be able to flex as completely as before the operation(!), i.e., there is no mechanical reason normal flexibility can't be achieved. By accident (sore back) I took two ibuprofen, and when I then exercised--lo & behold, the "solid" resistance softened, and I was able to push a bit past the barrier. So now I am softening the barrier with ibuprofen--taken with breakfast--and pushing to achieve greater flexibility.

Month 5.5: Walking 5-6 miles regularly, after which my muscles are tired, but the knees don't bother. Take Ultram maybe once every two weeks when restless leg occurs, but not nearly as before. When warmed-up, the right leg can be bent nearly all the way; the left leg still has a ways to go. When properly warmed- up, I can squat, sort of (i.e. not fully, but I can get into the squat position). Knees still sort of bother if I sleep without a pillow between them. I feel that they need to be kept straight during sleep or they'll ache the next day. The only "discomfort" is an occasional tweak if the knee is twisted mildly, which would not occur if the knees were normal. Most of the mild discomfort is muscle related, not the knee joint itself. I think the torque of the knees causes some mild pain on the bone where the metal parts are attached--who knows. In no way are my knees back to normal as if they had never been injured. But they are far, far better than when I went in--and I bless the day I decided to have them done. Today, my wife and I had a two-hour walk in the glorious English countryside, followed by a lovely dinner at an English pub--the Boar's Head in Ardington south of Oxford. My legs ached from the effort, but relaxed deliciously as the red wine hit my brain. No question that alcohol gives as much relief as Ultram--and goes down a lot easier.

Note that this recovery time is not typical.8 I have a history of rapid recuperation, am a lifelong athlete, and relatively young for this operation, which is usually conducted on patients in their 70's and 80's. But even average patients do recovery in perhaps 50% more time. The biggest problem patients have is not keeping up their physical therapy. If even young, athletic patients MUST exercise, so all the more must older, less agile patients. A nine-month exercise program is necessary for the agile; A year or more for the older and less athletic. There is no way around formal exercise, and those who don't see it through will be doomed to hobble around in the "Frankenstein walk" characteristic of inadequate muscle control due to lack of strength and lack of flexibility.

Tips: If you Decide to have Knee Replacement Surgery

1. Let's not kid ourselves. In spite of possible rapid recover, this is still major surgery. And if you are older and weaker, recovery will be longer and more stressful. My most important tip is to pick a big hospital and a surgeon who specializes in this procedure. Two of my hospital roommates were men who were having bungled hip replacements repaired--originally installed in small hospitals (one can visualize the surgeon, flipping to page 12 during the procedure). The minimum size of the incision, the sure-scalpel slickness of minimizing tissue and muscle damage during the procedure, the speed and accuracy achieved in correctly aligning the lower leg with the upper--all these elements are hallmarks of a skilled and practiced surgeon--and done right will shorten recovery, minimize "discomfort," and result in quicker return to a correct stance and gait--exactly as it did with me.

2. Visualize Small Victories. The first couple of days after the Big Dig, you will be feeling woozy and uncomfortable. And you will be lying the entire time on your back. Imagine the thrill to finally be able (about the 3rd or 4th day) to maneuver yourself onto your side for a good nights sleep. Wow-the sense of accomplishment when you finally make that happen. Complete recovery can not be far behind... And think ahead. In one or two months you will be practically your old self again--much better than your old self--and you will look back and see only a brief blur of the recovery period. Certainly a terrific investment in yourself and your improved quality of life. Hobbling all by myself to the bathroom and finally being able to pee like a man (i.e. standing up) was for me another small thrill.

3. Coping. There will be a few moments--hours perhaps--in the first few days where you are lying there as miserable as you can get. Throbbing pain, cold sweats-with me it was the acute, wish-I-were-dead nausea of too much of the wrong (for me) pain killer. I find that in those rare instances, one thing to do is visualize that you are a prisoner of war. Many suffered and yet made it back in one piece. Except that in their situation, things only got worse. In your case you will only get better-a lot better-and rapidly. Think ahead to that time, which will be in a few hours, or at most, tomorrow. Takes some of the misery out of it for me.

4. The Pee Bottle. Right after the operation, getting out of bed is so complicated and is not permitted unaided, that most men will prefer to empty their bladders by means of the handy one-liter plastic urinal (pee bottle). However, there is an unexpected catch. All your life, your parents, and then you yourself admonished you not to pee in bed. Now, after 60 years of this unrelenting discipline, do you really think you are going to be able to let loose as soon as all the parts are aligned? Think again! For many, the first time we succeed in releasing that recalcitrant urinary sphincter is after coaxing it for 10 frustrating minutes. "It's OK. You can go now. Nothing will spill. Just let loose. Piece of cake." Etc., etc. All our entreaties will fall on deaf ears as we try to unlock a lifetime of Pavlovian training. This can get so embarrassing (the nurse is waiting for you to "do it") that you seize up entirely. My advice-practice a few times at home. (No joke!)

5. A Fan. Since all hospitals are heated so as not to chill any 98-year old women sleeping on top of her bed, the temperature in the recovery wards is always suffocatingly high. Many patients had brought with them small (Not too small--12-inch diameter) box fans that they kept running on their night table. I quickly got one too. What a blessing!

6. Hospital Couture. Most men seemed to wear polo shirts and either drawers and khaki short pants (instead of the immodest "Johnny"). Another idea is to wear bathing trunks which serve as underpants and shorts in the same garment. Also, bathing trunks are easy to wash out.

7. Crutches vs Walker. When my mother-in-law went home with her replaced hip, they would not give her a walker, insisting she learn to use crutches. In her case they did that to prevent her from becoming permanently attached to the walker, and never taking the risks associated with learning to walk again. If you are highly motivated, and actually use the crutches (say by walking outdoors with them every day) then using a walker at home has the advantage-for a few days--that you can get around more quickly, and without the constant concentration of walking, that the crutches require. I chose the hand-held "Loftstrand" crutches (which are known under many other names) over the conventional armpit-support crutches. The Loftstrand crutches allow more accurate pointing of the crutch leg, but require some arm strength. Conventional armpit crutches are less comfortable, but allow the user to employ shoulder strength-which is always higher than arm strength. However, once you do switch to crutches, the walker will seem like an anachronism.

8. Hateful Exercises. After the operation your main leg muscles and ligaments will have lost all their responsiveness, strength and flexibility. You wake up looking at a useless stump attached to your body called "your leg." At first it will do little that you tell it to. Physical therapy consists of bringing these body parts back up to operating speed. Stretching muscles beyond where they want to go (which is nowhere) is painful. But prevail--there is a silver lining. At first each stretch is equally painful. In fact subsequent stretches may become more painful as you go on, say stretch numbers 4, 5 & 6; however, after this initial warm-up, the muscles do relax slightly-you can feel them soften-and the angle of flex increases by a few degrees. Success! Even my accursed hamstring stretching began to work better after the first half-dozen or so tries and the remainder became a tiny bit easier.

9. The order of your exercises. It is well known that all physical therapists must first demonstrate an innate passion for sadism--otherwise they are counseled to take up less demanding pursuits. Mine gleefully started me off with the most difficult (for me) one--the hamstring stretch. The more I complained, the harder he pressed. When the Department Head walked by as I was being tortured, I greeted him with "Ow, ow, ow, ow, ow." Without missing a beat he replied: "Only outright crying and tears work around here."

When I got home and figured out which end was up, I promptly re-ordered all the exercises so that each one containing a difficult element would be preceded by an exercise that contained less of the same difficult movement. This meant each exercise was a warm-up for the next one. For example, I did the heel slide before doing the quad set.9 By the time I got to the hamstring stretch, it was...fun!

10. Warming-up. I once watched Wendel Motley dash fully dressed in street clothes into the Madison Square Garden locker room, late for our indoor 440-yard run. He just barely made it to the starting line in time--and promptly set a new world's record for the indoor 440. Like me, Wendel has muscles that don't really need warming up. I have almost never had a muscle cramp. NEVERTHELESS, I discovered that warming-up for my post operative knee exercises had a strong and beneficial effect, and made the exercise both easier, more productive and less painful. This will be all the more beneficial to those with less flexible muscles. Warming-up is essential to good results. (And this can include massage or a hot bath.)

11. Massage. Not mentioned once in my rehab sessions was the excellent discomfort relief obtained by simply massaging the afflicted muscles! It would probably be wise to hold off on this until the staples are out and the incision completely healed-some tw0-plus weeks in my case--but massaging my quads and all the muscles above the knee cap reduced ache significantly. I also rubbed the numb area around the outside half of the knee cap and felt those dead portions begin to tingle a bit. Although this second technique is for later, when your incision is completely healed, get into the bathtub (If you are a bilateral, this can be quite a trick), and sitting up with the hot water covering your outstretched legs, flex/stretch those muscles. WOW--will you be pleased to witness an additional inch or so of movement beyond anything done in the dry. It was in the tub that I first got my accursedly stubborn hamstrings to flatten out.

12. The most important exercise duty: Remember why you are in rehab at all--it is to exercise your leg muscles. Be sure you are fully loaded up with your pain-killer of choice! Forget the Puritan idea of working your muscles "naturally." The exercise you do is mostly the mechanical stretching of some shriveled muscle tissue. The more doped-up you are, the farther you can stretch the muscles before pain is reached. And the longer (i.e., one full minute for each stretch) you can hold the stretched position. And being on full painkiller medication will not let you damage the muscle, or the knee implant. It is as strong as it will ever be. So get the maximum benefit our of your work-out and be fully-loaded with painkiller. With me, Ultram took 30-45 minutes to kick-in. Learn how long your painkiller takes. Add 15 minutes-and then go for it.

13. Poor little you. It is a riot to hear the variety of excuses given to the physical therapist about why only you can't do some particular required exercise. From one old geezer who used the tired "Weak heart" spiel, to "I know my body," to the one I found myself using (to no avail) of "previous injury."

14. Too much exercise. Stakanovites such as me tend to overdo everything. If 500 mg of Vitamin C good, 1000 mg must be better. If two hours of exercise is good, four hours is better. This is wrong. As a college quarter-miler, I found that more exercise than optimum didn't make me faster, it made me slower. It didn't result in more strength, it resulted in soreness, less ability to exercise and a net reduction in reaching peak performance. Likewise, if you are a Type A, you must have the hands-off patience to find the optimum exercise routine that gives your body a good, solid workout without causing stiffness to accumulate into the next routine. Listen to your body. It is the boss, not your iron will. My practice has always been to exercise hard and then nap. Yes nap, as in a short sleep. Even during track meets I would sleep for 10-15 minutes after the first (trials) quarter-mile. Then be much refreshed for the finals, and still have energy left for the last leg of the ensuing 4 X 440yd run.

15. Muscle Memory. Walking correctly after surgery requires that the lower brain (the unconscious motor activator) learns what is now required of it. This is done by physical repetition. No amount of cogitation or book learning can teach your autonomous nervous system how to do something. Walking can only be "learned" by doing it, and letting the brain figure out what is required to achieve maximum efficiency and elegance. So if you want to relearn to walk quickly, walk a lot. You don't need to think about; you just need to do it.

16. Balance. After making up my own exercise of stepping up and down off a foot stool to simulate stair-climbing, I let go of my hand rail. Whoa-nelly--did my legs go jittery to find equilibrium. And so I learned to do as many standing exercises without holding on to anything. And quickly gained an extra measure of stability and confidence.

Side Effects

Quite amazing was the lack of any description of side effects for knee replacement surgery. It is clear from the many descriptions of the procedure that they are all honest--and they are all sales documents; that is, everything they say is true. It's what they leave out that is discussed here.

1. Biliousness. At first I blamed the Ultram for a sense of biliousness that always hovered in the background. But when I stopped taking that pain-killer, this sub-clinical nausea persisted. This was a sense of not feeling good--almost like a minor hangover. Initially it would make itself known at 11 AM and result in my taking a 45-minute nap. ( I slept at least ten hours a day.) Spirits restored, it generally was held at bay until the evening. Even 8 weeks after the operation, it was still an annoying part of my life, but diminishing.

2. Lack of appetite. This was not a disadvantage, but one thing the biliousness did was greatly restrict the amount of food I ate. Going out for evening dinner was always as flop, as I could not get up an appetite for food or drink. (So we switched and went out for lunches instead.) I lost 25-lbs (down from 225 to 200) and 2-3 inches around my waist. Almost all of that weight loss came from a recently acquired beer belly, and the effect was quite positive. It will undoubtedly pass. [Day 74--starting to get my appetite back--and the weight!] [Day 165: beer belly almost all back, weight back to 210. Food tastes great.]

3. Dead zone. No one mentioned that the skin around the outer side of the incision around the knee cap about the size of a pack of cigarettes would become anesthetized. The doc said this unavoidable but would reduce in size as time went on, but not entirely. [Day 165-it seems the area has reduced, and underneath the dead area seems to have come back to life. But kneeling is still almost impossible.]

4. Reduced flex. This is mentioned in the literature, but not stressed. Normal knees flex about 140-degrees. This lets you squat and get up off the floor quickly and easily. The maximum flex for an artificial knee is said to be about 120-degrees, and could be less for the lazy. (That's still more than I had going in to the operation, so I'm not complaining.) It means you always have to sort of roll on to your feet when getting up off the floor. However, the doc says there is no mechanical reason while one can't get back full motion. It's just the stiff, shortened (from lack of stretching) muscles, ligaments, etc., that hold you back. We'll see...

[Day 105: Can walk 3 miles easily. 4 miles make my leg muscles ache. It surprises me that I haven't been able to walk farther more quickly. I'm improving--by pushing it, but slowly.]

5. Restless leg. Long after I no longer needed routinely to take a pain killer during the day, or even ibuprofen to facilitate physical therapy, I still needed to take something to reduce the "restless leg" syndrome that turned-up when I went to bed. This fidgeting might start with my crossing and uncrossing my legs while sitting, and then, in bed, not being able to find any suitable position for my legs when lying down. The legs didn't feel any different; they didn't itch or ache--but they would not lie still. Every change of position felt better than the last, although there was nothing noticeably wrong with the last position! I tried to wean myself from Ultram ((which works great against Restless Leg) by taking Tylanol, aspirin, ibuprofen, but although they helped, they didn't really do the job. So now, seventy-four days later, I still need to take Ultram at night about every other night to stop this infernal fidgeting in order to fall asleep.

[Day 105: Down to 2 Ultrams a week. Restless leg syndrome almost completely gone.]

6. The shocker. The cost. The bill (paid for by Blue Cross) for a bilateral knee replacement arthrosplasty (In other words, having both knees replaced) was thirty-seven thousand, five hundred dollars (,500) for the surgery and four days stay at Mass General Hospital. The anesthesia bill was twenty-two hundred dollars (). Not included was a 10-day stay at the Spaulding Rehabilitation Hospital. Let's say that cost $1,000/day. That means my new knees cost twenty-five thousand dollars (,000) dollars each! (Worth every penny!!)

Good luck.


(Footnotes:)
1 Dr. Robert Mohr.
2 Dr. John Repicce, Buffalo, NY
3 Dr. John Siliski at Mass General Hospital
4 Which promptly cured several years of heart-burn!! Coming home, out went the 2-3 bottles of ibuprofen, out went the Tums, out went the Zantec 75, out went the glucosamine.
5 Estimate by Dr. Ricardo Knight, Spaulding Rehab Hospital. But this number might be low-that is, more patients should have both done--due to patients not wanting to even consider having both knees done at once.
6 The constipation only occurred when taken 3 Ultrams a day, was partially neutralized by taking one CVS brand "Stool softener plus stimulant laxative" (which is 100 mg of docusate sodium and 30 mg of casathranol) with each tablet of Ultram. But I was never "regular" (until I cut back to one pill a day). Increasing the dose of stool softener resulted in diarrhea. Also, Ultram made me fart more than usual.
7 My doctor winced at my knock-knee complaint. "Tom, we line up the ankle-joint, the knee-joint and hip joint to be on a straight line in order to equalize the weight on both sides of the knee joint. Yours is within one-degree, so you're actually straight-legged for the first time."
8 I feel like the weight-loss ads on TV. "Miriam lost 60 lbs in 30 days," the ad bellows. In small type below is the barely legible note: "Results not typical."
9 With the legs flat on the floor, the heel slide consists of pulling the heel forward on the rug to bend the knee and stretch the quad muscles. But because the return stroke lays the leg flat on the floor, this passively stretches the hamstring. The quad set has you use your quads to press the knee joint into the floor. Although this is a qaud exercise, it also stretches (and warms up) the hamstring. Finally I do the hamstring stretch-Lying flat on the floor with the heels elevated by a book and letting the hamstring sag by gravity for 30 seconds at a time. You can feel the hamstring stretching out a bit.


December 3, 2001
Boston, MA

For another, more official view of this subject, see:
http://www.vh.org/Patients/IHB/Ortho/KneeReplace/KneeReplacement.html#1
Also:
http://www.scoi.com/tkr.htm





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