Fulkerson TTT & Possible MPFLr for June 14

[2cutekiddos]

So exactly one month from today I will be having my 3rd knee surgery and 2nd for my left. This will be my biggest procedure by far! Needless to say...I am pretty scared!!!

I have been to numerous OS's in my life and every time I move I usually seek out a new one. Well, last year I moved, so in the fall I found an OS I REALLY liked! He of course mentioned the Fulkerson which I wasn't surprised about (OS's for the last 5 years have been mentioning it, but with small kids I wasn't ready, my baby is now 5). When I asked about how many he had performed he said one. He really wanted to perform my surgery...said he meticulously prepares for surgery and was up for the challenge. My brain said,"Uh, I don't want to be a challenge!". He was really conservative and had wanted me to be in the hospital for 3 nights.

So, my quest for another OS landed me at Georgetown University in DC with an OS who has done 100's of osteotomies and said he had a 90% success rate! I thought this must be the guy for me...until I wanted to discuss things like "Do I have femoral anteversion?" "You say you have your own technique for a MPFL, can you explain it to me?" or "Do I have trochlear dysplasia?". He was so arrogant, smug, and condescending and he acted like I was too inferior to him. He gave me the line...you sometimes have to just trust the guy who has studied this and done it for 20 years. I of course agreed but then pointed to me knees and said, been there done that and that is why I am talking with you now! It got a lot uglier. If the man had just taken the time to help me learn about my unique knees then I could have trusted him! He was less conservative and was going to have me stay 1 night at the hospital.

These two doctors lead me to Dr. Fulkerson and he is who my surgery is scheduled with. I know he is skilled and knowledgeable in this area of orthopedics, so I am not worried about the procedures. My worry is because he does his surgeries as out patient. Now, both prior surgeries were out patient and I know what to expect but this will be different. I am out of state (7 hours away) having this procedure and completely worried about traveling home right after the procedure!!!

Can anyone who has had these procedures or traveled a distance immediately after surgery give me some tips or try and calm my nerves!!

I figure I will map out hotels and hospitals along the route but I am so scared of complications!!! Fulkerson's office staff suggest leaving while the femoral nerve block is still working...I just can't imagine how "with it" I am going to be right after... HELP...any advice would be greatly appreciated!!!

[kianiblueangel]

Hi,

I am traveling next Monday (well really Sunday) to see Dr. X at Emory College.  I know from my first three appointments that were all wrong that it is worth waiting to see a specialist.  I have heard of Dr. Fulkerson but we have not tried his office yet.

My dad has something in his knee last time he had surgery.  He has suffered through 8 TKR's and they put something called an ON-Q in/on his knee.  It was basically two bulbs of medicine with two tubes that went right into the knee.  The bulbs lasted 3 days and he replaced them twice after getting home.  Basically, it was about 9 days of relief. 

My dad has had more than twenty some major surgeries and his tolerance for pain medication is very high.  This really helped him for the first time because so many of the nerve blocks failed.  If they don't get the block right you wake up suffering.  He really liked the nerve block if it works.  He will not let them put him to sleep until he is sure the block is working. 

I hope your trip goes well and let me know how you make out with Dr. F.

Kiani

[2cutekiddos]

Thanks Kiani, I have never heard of an ON-Q...I will have to look into this. I wonder if it is something you have to ask for or the doctor just does it? I too am worried the femoral nerve block won't work..I am a little chicken of getting it though. I have had an epidural (for childbirth) and it wasn't bad so I hope a femoral nerve block would be about the same???

Good luck with you Kiani...I have read your post and numerous ones by your dad! I definitely think Dr. T or Dr. Mark would be the doctors for your knee! I will be anxious to hear how that visit goes!

Oh...I forgot to mention I will be traveling by car! Has anyone done that a long distance? I am trying to picture how to elevate my knee while traveling. I will be riding in my Dodge Durango, so plenty of space in the back.

Andrea

[KW]

Oh...I forgot to mention I will be traveling by car! Has anyone done that a long distance? I am trying to picture how to elevate my knee while traveling. I will be riding in my Dodge Durango, so plenty of space in the back.

Umm....Pillows across the back seat + a CryoCuff IC with a car adapter.

[captainruss]

Andrea,

The ON-Q thing is not new, but I had so many troubles as Kiani indicated that I would wake up in recovery screaming.  I have an implanted dilaudid pump and because of it, the anesthesiologist would not give me much medication in recovery.  My OS was there and I remember of TKR #7 him shouting "Bomb him....just bomb him so he stops hurting!"  He came up with the idea.  I guess it is old school.  They use it in shoulders, etc.  Very simple in design as you have a strap that goes around your neck holding the two bulbs of topical medicine.  It goes right into the joint wound and is adjustable by either the doctor or the patient.  My doctor adjusted it and I did nothing.  I awoke in recovery with pain, but not excruciating pain.  The system cam be used for only nine days as it can damage tissue if used too long.

The femoral block is the bomb if the anesthesiologist is not a horses butt.  If they don't use ultrasound to find the nerve, they must poke you until your foot twitches.  Just because your foot twitches, does not mean he put the needle with the med in the same spot.  Most times they like to do this when you are asleep so you don't react to being jabbed multiple times.  This keeps them from having you try to move the leg.  Normally, the doctor will be waiting for me in surgery so they rush through it or they get impatient because they don't find the nerve.

If it works, the block is the best.  I can't get doctors to NOT put me to sleep first.  I get so angry, but the On-Q is fantastic.  The doctor simply pulls out he catheters like he does the drain or you can do it.  I did  mine.

I will find the paperwork and try to get you the web site.  The thing about the On-Q is it works, it is adjustable if you need more or less, and it gets you over the bad part.  After the first five days, we seem to handle the pain better.

Russ

[2cutekiddos]

Thanks Russ for the info on the On-q...I am hoping the femoral nerve block will work. My epidural with both my children worked so I am hoping a femoral nerve block will be similar. I think I will take my chances and hope they put me to sleep before putting it in. I am a chicken when it comes to needles!!!

Thanks KW for suggesting pillows. I thought I would get some body ones too! I was looking into a wedge style one to help elevate my leg too. I am trying to see how I could jimmy a sling to be able to hold my leg up for me...anyone have ideas?

Did anyone have outpatient done by Fulkerson? I called his office to see when PT might start and the front office person said around 4 to 5 weeks post op...does that sound right for what I am having done?

Good night all!

[captainruss]

2cute,

The On-Q has no needles.  It has two soft tubes or catheters that are sewn up in the wound and dispense pain med into the joint.  The nerve block requires being poked by a needle sometimes multiple times.  Please don't get me wrong, when the nerve block works it is heaven !  The only problem I have is the anesthesiologist has trouble finding the nerve.  If the surgeon is waiting and he cannot find the nerve, they have sent me to surgery without the block.  The block is excellent, but usually with someone my size it takes an ultrasound to find the nerve.  He then must hit the nerve with the needle.

If he does not keep you conscious until you can make sure your knee/leg is completely numb, you have no guarantee of pain relief after surgery.

The On-Q is a simple anesthetic that goes right into the knee and reduces the pain short term (6-9) days.  Just think about it.  The catheters can be put in easily during surgery.  If you get to recovery and the block is ineffective, they simply attach the On Q bulbs and start the relief.

After the 9 days, I simply yanked them out like you would yank out a drain.  If feels funny, but not painful.  Just a thought....I won't have another surgery without trying the nerve block AND the On Q.

Russ

[lululocket]

In the UK, (at my hospital anyway), they normally just do a femoral nerve block with a needle and they do sometimes miss (not often, but occasionally. They put it in after you're already out, so they don't check it's working. This happened to me the first time - it's normally not a big deal, they just give you morphine/whatever and you get through the pain with something else instead of a nerve block.

Unfortunately I reacted really badly to morphine (hello food I just ate...) and so when I had my TTT on the second leg I asked if there was any other option. They said that they could use ultrasound to guide in the needle for the femoral nerve block (as captainruss mentioned). It is more expensive and slower, but has higher success rates. It also means they don't have to keep you awake to check that it worked. Given you have to get in a car, maybe you could request ultrasound to help, or anything else that will increase the reliability of the nerve block.

For me, since I knew I wanted to avoid morphine if possible, they were happy to make a note and prioritise the extra time to do the ultrasound since the first time the morphine made me so sick, I had an extra night in hospital. It's pretty unusual to react like that though, so don't worry!

This time, I asked to speak to the anaesthetist in advance. I talked over all the nausea and pain issues I'd had the previous time with the anaesthetist on the phone about a week before the procedure, and we made a plan for other painkillers, including this ultrasound. And then on the day, he checked in with me before scrubbing up and I made sure it was on my notes to take the painkillers we discussed. After that extra time planning, it all went like clockwork. I had my procedure late in the evening and stayed overnight (that is always my OS's protocol as he operates from 6pm onwards in that hospital). Outpatient would have been okay too if I didn't have an option to stay overnight.

[allyd]

My Femoral Nerve block worked great. Like mentioned in previous posts, ultrasound works the best. They used it to guide the needle into the nerve, in addition to visibly watching my leg twitch in the right places. I was still awake when they did all this, in pre-op. Took maybe ten minutes start to finish, no big deal. I think every anesthesioligist just has a preference on how they do them. Probably will be the way to go for you. Mine lasted 10+ hours before I could REALLY feel my leg under my own power. Start taking the pain killers right away so that there isn't a gap between it wearing off and getting the drugs in your system. It won't be a 'fun' trip, but you'll manage. 

[2cutekiddos]

Thanks Russ, Lulu, & allyd for your responses!!!

The On-q doesn't sound as scary now that you have described it Russ! I will talk to the anesthesiologist about it and having the ultrasound for guiding the nerve block in. I definitely want to talk to him about pain killers that are easy on the stomach. I have thrown up on Vicodin and Darvocet with past procedures. They offered me percocet with when I had a c-section but I refused any for fear of throwing up!

I have read some posters who have taken fentanyl... is it easier on the stomach? Anyone have some great pain killers they would like to suggest? I would love a list to talk to the anesthesiologist with.

As June 14 is nearing I am trying to get as many things lined up before hand...so I called Dr. Fulkerson's office to ask if I will need a CPM (I had one with both prior surgeries) and they said no. Didn't concern me too much since I have read a lot of posts of people who didn't have one. Then I asked if I would get an ice machine/cold therapy unit (cyro cuff) and again she said no and that the Dr. doesn't use them.

Now this made me wonder why? Especially since most on here rave about them! So I did a little research because if a well known Dr. doesn't use them I sensed there must be a good reason. Upon my research (Google) I found that there have been many problems with incorrect use of the machines. Some people have been burned, frost bit, and even had nerve damage.  Some articles suggested that in appropriate use could contribute to developing CRPS!!!

I am not sure my research has lead me not to use a unit...but I thought it was pretty interesting. Obviously, I would only use it as directed. The articles said the biggest problems were that patients were numb from surgery and could not feel if the unit was too cold and also from leaving the unit on for too long.

I am looking into buying the Breg Polarcare Kodiak with the battery pack (so I can use it on the way home!). I would love to know everyone's thoughts on this unit and if you think a cold therapy unit is a good or bad idea???

Lastly, tomorrow I go for my pre-op physical!! It is starting to get real for me...

[oohheykate]

2cutekiddos,

I have the Polar Care Cube, it's like the Kodiak but bigger and without a battery pack. I love it and it still works over a year later after using it almost every day for six months for more than 12 hours a day. You shouldn't get ice burn if you use a protective barrier-- I use an ace bandage and have never had a problem. I adore my ice machine. The compression plus ice is an amazing feeling. It made recovery so much better. I actually bought another accessory for it so I could use it on my hip. It's definitely worth getting one if you can afford it. Also, if you decide to get one, use frozen water bottles instead of ice. It saves a ton of money and stays cold much longer.

Good luck!

[2cutekiddos]

Thanks Kate! Glad to hear the ice machine was a success for you! About how long did you keep it on your knee right after surgery? I hope my doctor doesn't get mad at me if I buy one... I am hoping he doesn't prescribe them for liability reasons only!!!

...by the way, I have read all your diaries and posts and they have been very helpful!

Andrea 

[oohheykate]

Andrea,

I'm glad my posts have been helpful to you! About the ice machine-- I woke up from surgery with the ice machine running and had the pad around my knee 24/7 for about twelve days until I had to go back to school, then I just used it as soon as I came back from school. I even slept with it on. Most advice is to ice for 20 minutes per hour but my OS didn't have a problem with me icing that much and I didn't have any ill effects from it. When I started becoming more mobile, I only iced throughout the night.

[2cutekiddos]

Yipee...just spoke with Fulkerson's office and they said if I bring my own Cold Therapy Unit with me then they will put it on in the operating room!!! Since the Kodiak is the only model with a battery pack, I am ordering it right now! The best prices I have found on machines are at MMAR medical distributors. http://www.mmarmedical.com/Breg_Polar_Care_Kodiak_p/106xx.htm.

Thanks Kate, I am glad to hear that you used it for long periods of time with no problems! ...has anyone had any issues with these devices?

Also, I would love to know of painkillers that people thought were easy on the stomach. I hate throwing up because of them!!!

[oohheykate]

I'm assuming you've tried taking anti-nausea medications along with pain meds? I've never had any problems with pain meds other than getting ghostly white, as my father put it, when I take them on an empty stomach. If narcotic pain meds are a problem, in general, Tramadol is a great alternative. It's non-narcotic but still provides great pain relief. I was using it when I went back to school about two weeks after surgery because I wasn't allowed to take Vicodin there. I honestly didn't feel any difference between taking the Tramadol and Vicodin. I'm also able to take that on an empty stomach and feel perfectly fine.