The New Knee

On July 24, I went down to MCV (newcomers to town might call it “VCU Health”) and laid on a hard table while Dr. Gregory Golladay took a knife and saw to my left knee.

MCV has a helpful process that largely prepared me for the surgery. RN Janet Muntean, a consummate pro, ran the ortho boot camp with skill and kindness.

My experience since leaving the hospital has taught some further lessons. Here is my summary of those.

Four Factors

There are four factors, aside from luck, that determine the outcome of a joint replacement:

  • The skill and care of the medical team;
  • My condition going in;
  • My compliance with the post-op program; and
  • My attitude.

I am in charge of 75% of those.

The Medics

Based on my own experience with this and an earlier surgery and on Ms. Penelope’s several bouts with her own set of problems, the folks at MCV are remarkably skilled, careful, and cheerful. And, in important ways, they want what you want: They want you healthy and they want you out of the hospital.

My surgery started about 2 PM. I remember hearing the saw as they shaped the bone and hearing the pounding as they hammered in the implant. They had me sufficiently full of happy juice that I found those sounds merely curious.

About 4 PM they took me to Recovery. The kind nurse there went and got Ms. Penelope from the crowded waiting area.

The nurse told me they’d release me to the orthopedic floor as soon as I could wiggle my toes. I had not thought about toes until then and I found I could not even twitch them on the operated leg. Of course, with the nerve block I couldn’t feel any pain, either. The feeling slowly moved down that leg until, about 6 PM, my toes moved.

At about 2 AM the next morning (nobody gets much sleep the night after surgery), the night nurse had me up and standing beside the bed. Before breakfast she had the Foley catheter out. By midmorning, I had met the two requirements for discharge: I had produced some clear urine and I had demonstrated to the in-house Physical Terrorist (sometimes known as “Physical Therapist”) that I could manage the walker, the crutches, and the stairs. They threw me out about noon.

That was less than 24 hours after the first incision.

As always, you should avoid hospitals vigorously but, if you have to embrace the hospital risk, this one is really fine.

Condition Going In

One of the Physical Terrorists who worked on me after the operation told of his father’s knee operation. When the need for the operation arose, he hauled Dad to the gym and started him on a serious strength program that included, especially

  • Squats,
  • Deadlifts,
  • Bench Presses,
  • Rows,
  • Lat Pulldowns, and
  • Dips (think body weight crutch exercises).

ALL of those are crucial, with the squats, dips and bench press the first among equals.

The squats are first line leg strengtheners; they and the deadlifts are powerful balance exercises.

One of the first lessons from the bench press is hand position to put the weight straight thru the wrists. Grab the bar naturally and the wrists wind up bent, which is a prescription for hurt wrists. The lesson applies directly to the dips at the gym and to the walker and crutches at home.

I was pleased to hear that list of exercises: It mirrors most of what I’ve been doing at the gym for several years.

To that list I would add the ministrations of my former Yoga teacher, Sophia, the Princess of Pain. Among other things, she worked on abdominal strength and flexibility (not to mention balance). If you don’t think your tummy is important, get a glass of water and try to drink it in bed (without a straw, of course). Or lie back on the bed and try to use one leg to lift the other off the floor and onto the mattress. And with one gimpy leg and a post-op injunction from the Doctor, “DON’T FALL DOWN,” balance joins the crucial list.

Post-Op Compliance

If you’re dealing with Medicare, you can look forward to about five weeks of home visits by a Physical Terrorist. Mine were from Encompass Health; they did a fine job.

These folks know what is good for you and they are relentless. Indeed, as soon as you master one aspect, they’ll come up with something tougher to do. They can tell you horror stories of patients who wouldn’t stand the discomfort of PT and who wound up with knees that were as bad as or worse than before the operation.

I was pleased that the first basic exercise, marching all about the house on the walker, was not particularly uncomfortable; indeed, the knee usually felt better after the marching. They wanted me up and walking every hour. The marching soon enough progressed to other, less comfortable, torments.

I have learned from hard experience to not overdo the exercises. I can exercise a healthy joint to, or nearly to, failure and expect nothing worse than a sore joint in the morning. Working a hurt joint that hard is a painful mistake.

It is particularly dangerous (for me at least) to exercise a hurt knee, as some of the PT folks recommend, while in the gentle embrace of oxycodone. I prefer to work out without meds and I am careful to stop if anything gets to about 6 on my pain scale.

After the home PT, I had my choice of outpatient providers. I elected to stick with the MCV system and picked the Stony Point location for convenience. I am working there with David Naputi, yet another pro, and Cameron Gordon, a student doing her practicum under David’s supervision. I think Cameron will make a wonderful Terrorist.

The outpatient level of discomfort varied but the importance of doing the exercises, be they silly, uncomfortable, and/or boring, abided.

Attitude

The operation, the pain, and the boredom messed with my brain. The pervasive dependence on others tended to make me snappish.

This can be as dangerous as the drugs: Any less than cheerful behavior, especially any movement in the direction of depression, will poison the relationship with caregivers. Moreover, that stuff feeds upon itself; the first victim of my bad attitude is me.

I have learned to (try to) stay busy, do everything needed for the knee and then focus on something else. That can be tough when the knee banishes further sleep after the 02:00 bladder break but, hey, knee surgery is not for sissies.

Early on, the drugs are there as a last resort; even then, it’s time to work on being cheerful.

Misc. Lessons

I laid out a pair of moccasins for use after surgery. I thought I was being smart because the backs would keep them from slipping off while I was up. Silly me: I couldn’t get the left moc on because the foot, along with the rest of the leg, was swollen from the surgery. I was the Barefoot Boy for about ten days (Yoga was good practice for that).

Ice helped with the pain and swelling. I used it after exercise, before bed, and whenever I hadn’t cooled the knee for a while. I like a little ice bag that, once I find the right fill level, can be used and then popped in the freezer to prepare for the next use. A big gel pack is a fine alternative. In both cases, it’s mandatory to have gym pants or other thin fabric between the ice and the knee to prevent frostbite.

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The operation also messed up my alimentary canal. On top of that, the pain meds are constipating. This called for lots of roughage, peanut butter, and fruit. I’d also pop a prune or two with each oxycodone.

As to those pain meds: They are powerful and wonderful and dangerous. Sleep being of the first importance, my approach was to spend the last 20 min. before bedtime with an ice pack and fix the bed to make the leg as comfortable as possible (hint: small pillow under the wounded knee). And medicate if necessary. For the first few days, it was oxycodone and prune a half hour before bedtime. After that, pill (+prune) only if I couldn’t get to sleep. During waking hours, I’d avoid the pills. Discomfort is part of the deal.

Ancillary annoyance: Any oxycodone refill will require a caretaker to take my driver’s license, go to the Dr’s office to get a written ‘script, and then go to the pharmacy. In a happy contrast, MCV delivered the initial Rx to the room before I left. As a another happy note, I used less than a dozen of the pills, so I didn’t need a refill.

As to lesser drugs, they did NOT want any clots in the legs so they put me on a blood thinner. But they didn’t want any more than the prescribed thinning so they banned any pain meds other than the oxycodone and Tylenol. I hope Tylenol works better for you than it does for me.

Some wonderful news: In the Bad Old Days, they wrapped the incision with gauze that collected ooze and blood for almost a week, during which I was restricted to sponge baths. The New Way creates a much better incision and uses a waterproof dressing; I could shower as soon as I could get over the ledge to the shower.

Here is the dressing, three days after the surgery. No ooze; no blood.  It looked like that on the day it came off.

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When I removed it on day 10, the bandage was stained on the inside only by a few blood spots (and by the ink from the lines they had drawn for use in aligning the skin when they closed the incision).

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BTW: They really mean it when they say to remove that bandage by stretching it. That is merely painful. Pulling it off is torture, at least as to the more tender areas of the knee.

The incision itself was clean and dry.

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Compare this to the stapled knee on the Wikipedia page:

No stiches or staples to be (painfully) removed from my knee! Hurrah! There are bunches of stiches inside; they’ll dissolve in time. The final closure is glue.

I was considerably impaired immediately after the surgery. For example, I couldn’t reach the ankle on the surgical leg. Moreover, with that leg stretched out in front of the bed or chair, I couldn’t raise the toes, much less lift the heel. So I couldn’t even put on my own underwear. All that improved daily, such that by a week after Knee Day I could raise the toes and reach far enough to lasso the underpants or pants over them and drag the clothing up under the heel. In short, I could get dressed on my own. Little things can mean a lot!

I couldn’t deal with toenails for several weeks after the operation. Dr. Earnest took care of that, beautifully (and Medicare paid for the visit!). I didn’t need to mess with toenails for another month after his ministrations.

Aside from basic strength and flexibility and balance, the clear benefits of the pre-surgery exercise reminded me of the importance of preparation:

  • After surgery I had to be able to get up using only one leg, while the other one just stuck out and hurt. The three Big Issues there were the toilet, shower, and bed.
    • I had to have enough room in the bathroom to sit on the toilet with the surgical leg straight out.
    • One friend strung a rope between towel racks in her bathroom so she could pull up from the toilet. We don’t have enough towel racks for that; we do have tall toilets so I can push off. Next time I will make it easier with something like this.
    • We have a foldable kitchen ladder similar to this that works fine for a shower stool; it is fairly high and it has a bar above the top step for grabbing. That’s not the end of it, though: I had to have enough space to sit on the stool while the hurt leg stuck almost straight out. We have a shower with just enough room.
    • We have a high bed; I can push up with both arms and get out one-legged. With a lower bed, I’d be thinking of a chair for pushing off or something such as this for pulling up.
  • Then, there’s getting IN the bed. For the first week or so, there was no way for that hurt leg to swing up and into the bed. Indeed, there was not even a hope of putting both hands under the thigh and lifting. After the first few days I could cradle the heel of the bad leg on the other ankle and use that good foot as an elevator. If that hadn’t worked, it would have left one more task for the helper.
  • Ah, the helper! I needed one 24/7 for the first few days, and less intensely as strength and mobility and the remains of my mind returned.
  • Beyond those matters, I went for chairs with arms and soft cushions. Low chairs were easier on the hurt leg (pressure on the back of the leg was most unpleasant) and only a bit harder to push up from.
  • And in every case, I had to have room for that hurt leg to stick out; I did NOT want to be forced to bend it.
  • When in doubt (indeed, even when not) I recommend pre-need practicing one leg sit downs and standups (with the other leg sticking out) to make sure.

The PT folks recommend a walker over crutches and I can see why: The walker is MUCH easier to use and MUCH more stable. But it has to fit through the bathroom door and maneuver once through. The alternative is to switch to crutches at the door.

And the walker needs a basket or pouch to carry things because the hands will be busy holding on. One caution: There are at least two styles of basket. Here is the one that fits my walker, the sort with a curved bar in front.

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I put tennis balls on the back legs of the walker (skids also work); the rubber nubs that come with it tend to scuff hardwood floors and stick on rugs.

If stairs are part of the system, crutches (and a second walker) enter the picture. A friend loaned me another two walkers (home is a tri-level). For my upstairs walker, a repurposed apron provided pockets to supply carrying capacity.

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Crutches are difficult on the flat but a crutch is mandatory for stairs. Indeed, if you have steps to get in your house or stairs to get around inside, they’ll make you demonstrate on stairs before they’ll let you out of the hospital. You’ll be doped up and weak then so some preliminary crutch practice would be a good idea.

The crutch Rules of the Road for stairs are simple: Good foot goes to Heaven, bad foot goes to hell. Thus, going upstairs, weight goes on the banister and crutch and good foot goes up a step; then bad foot and crutch go up with good foot furnishing the lift and banister the balance. Going down (much harder and more dangerous), crutch and then bad foot go down; weight then goes on crutch and banister; then good foot goes down and retakes the weight. All this is possible (or, at least, much easier) if you’ve been doing your dips at the gym.

Note: Banister is mandatory. The process works better with the crutch and bad leg on the side away from the banister, so one banister on each side of the stair is even better.

I knew I would be bored and in pain. The first line for dealing with pain is keeping focused on something else. That calls for setting up the bed and a soft armchair with reading materials, TV control, laptop, Amazon Echo, and/or whatever else will help keep me occupied (when I’m not exercising, sleeping, or going to/from the bathroom). Also charging cables for all the gadgets.

I found a tablet pillow on Amazon that worked well for keeping the tablet bottom and controls out of the bedclothes.

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It turns out that the laptop is nearly useless in bed: The keyboard angle is wrong. The tablet pillow fixes that.

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At the second post-op appointment, PA Justin Latimer warned me that I might have one or more sutures pop out through the skin. He said I could either pull them on out or clip them and wait for Nature to take her course. In fact, I had only one. It came in a tender little mound. Tweezers only fragmented the end so I couldn’t pull it out. As I write this, the area no longer is tender and it looks like Nature is doing her thing.

Note added on 11/1: At the 3-month appointment yesterday PA Laura Giambra took one look at that little mound, unwrapped tweezers that are ridged at the business end to grab slippery things like sutures, and extracted a quarter inch of suture. A blessing upon her!

I knew the operation (mostly the anesthesia) would mess up my thinker. I got my finances and todo’s in order before the knives came out.

At 2+ weeks after knife & saw day I got back to driving and returned to the gym. Squats were off the list and I reduced the deadlift by over 30%. The other exercises were off by up to 20%. I’ve been titrating back up ever since. Some weeks later, the knee would tolerate the recumbent bike; I am just now back to my standard 20 minutes at 60 rpm and low resistance.

Last week, 12+ weeks after knife & saw day, I asked the PT folks whether I could get back to Yoga. They worked me at getting onto and, especially, off of the floor and sent me off to Renee, the successor Mistress of Masochism. Renee was kind and helpful, esp. as to protecting that knee. I was able to do ca. 80% of the exercises. I was a sore puppy the morning after but ended up, I think, stronger and more flexible. So Yoga is back on my calendar.

When I had a “uni” (unicondylar arthroplasty = partial knee replacement) some years ago, it was two months before I was walking down a sidewalk and not noticing discomfort in the knee. The operation this time was a total; the PT folks tell me it will be at least several months to get to no discomfort. That said, as I write this at 13+ weeks, the gait is smoothing out and the pain level is onesie-twosie except during and after exercise.

Giving Thanks!

I can’t say enough about Dr. Golladay and, indeed, all the troops at MCV. Special mention goes to every one of them, except there was no way to get all the names.

I do have the names of, and would particularly like to praise, Dr. Golladay’s PAs, Laura Giambra and Justin Latimer. They are worlds apart in approach: Latimer is Chatty Charlie; Giambra is focused and quiet. Where it counts, though, both are smart, efficient, effective, and kind.

The nurses, PT, and other folks were uniformly kind and helpful and, where necessary, demanding. Everybody responded well to a little cheerful humor.

And, most of all, Ms. Penelope! This was a difficult process; without her it would have been impossibly ugly. She remained cheerful and helpful, even when I was withdrawn and/or grouchy.  Just the interest on the debt I owe her is daunting.