Total Knee Replacement aka, TKR

Six months after my visit to Cincinnati, to see Dr Noyes, I had my total knee replacement in January of 2005. This was a big decision to make and not taken lightly. During that 6 mos period, I did extensive research on the internet for information regarding TKRs. I looked thru many medical journal articles ( such as on PUB-MED and Medscape), knee replacement websites, forums discussing knee replacement (to get customer satisfaction/ dissatisfaction opinions) knee replacement manufacturers ( there are many types of implants) and Kneeguru, etc. I even watched a 2 hour webcast on ORLive, of an actual TKR surgery. That was very informative. I also read all I could on the rehab involved with a TKR. I wanted to know everything...... the good, the bad and the ugly, of TKR.

I was particularly interested in articles pertaining to the type of implant my doctor was going to use on me. It is the Johnson and Johnson/DePuy Rotating Platform Knee Implant. My doctor told me he uses this implant on young patients. It provides movement very close to a real knee. It is designed to provide natural knee rotation, on the tibial component, besides back and forth movement. Most implants just provide the back and forth movement. This is known as a "fixed" implant. The rotating platform movement causes less wear and tear on the polyethyline insert/spacer. This means less particles breaking off and causing bone deterioration, called osteolysis. My doctor plans on retaining my PCL, so the femoral component he uses will be a femoral retaining component. Some doctors choose to remove the PCL and use a femoral sacrificing component ( one that has a mechanical PCL built in ). In my research, I found that whether the PCL was retained or sacrificed was more of a personal preference with the surgeon, although the PCL vs no PCL had something to do with the rollback and stabilization on the implant. I was told by my hometown OS that it was the ole saying....six one way, half a dozen the other, on this subject. The ACL is always removed when doing a TKR. The patella resurfacing is another do or don't issue, unless there is damage to the patella. In my case, the damage to my knee was all under the patella , so there was no question to resurface the patella. Many do not have the patella resurfaced with the plastic backing.

I arrived in Cincinnati, 2 days before surgery. The next day was spent going to the hospital for pre-op testing. This consisted of all the neccessary paperwork to be completed and signed, blood work,an EKG and physical exam from the hospital Doctor. I also had a urine test done for pregnancy and the following reason:

You do not want any UTI before surgery as it could become a risk of causing infection in the knee. Knee replacements are at high risk for getting infections, as anytime there is bacteria in your blood stream, the bacteria tend to adhere to the implant surface and surrounding area, where infection will take hold. An infected knee implant can be very devastating, esp if infection gets down into the bone, resulting in revison and many weeks or months of intensive IV and oral antibiotic therapy and removal of the poly spacer, which is replaced with an antibiotic spacer. During this time with the antibiotic spacer , you are NWB. This can be 6 weeks or longer. Antibiotics are usually given to a patient before and after any invasive procedure on their body, such as dental cleaning/work, surgeries, colonoscopies, GI procedures, skin infections or any other infection in the body, etc. Some doctor's differ on the antibiotics for dental work.

After the pre-op testing at the hospital, we drove 20 min North, to the doctor's office. I arrived right on schedule and got right back to see the doctor. He came in and the Fellow, to discuss tomorrow's surgery.I was told it would be MIS ( minimally invasive surgery) This means a smaller incision and no quad cut. My incision was about 10 inches long. When the quad is not cut, the rehab goes easier,early on. An uncut quad is less painful when doing rehab, but I've read where in the long run , between 6-12 mos post-op, quad sparing vs quad cutting were about equal with regards to function, at that point in time. I believe the reason why I was able to do well in rehab post TKR, where my flexion was 120 and extension at 0, 2 weeks post op , was because my quad was not cut....that is my opinion. We discussed how the TKR tibial cut would be done, in relation to my previous Delee osteotomy for patella baja and infrapatellar contracture syndrome. He said he would be making a special cut to the tibia to accommodate the osteotomy and if neccessary, he would revise my osteotomy for the implant. I was issued a knee replacement card.....a hard plastic card with a picture of the implant, the date of surgery, doctor's name. This was supposed to be my identification card to go thru an airport. The events of 911 changed that and these cards are virtually useless now. The doctor's intitials were placed on my left knee. I was given 2 prescriptions to be filled, one for pain medication and the other for coumadin. Coumadin is a blood thinner. For a surgery this invasive, blood thinners are neccessary to hopefully prevent a blood clot from forming. I was to start this the night before surgery. After the doctor's appointment, I went down to PT.

In PT , both of my legs were measured in the calf and thigh. My quad strength was accessed. I was also measured for a pair of Tedhose. Tedhose are those white stockings one wears after surgery. It provides control of swelling and also helps prevent blood clots from forming in your leg thru it's compression ability. They are very difficult to put on !!!! I was given instructions on what to do before surgery, such as when to become NPO...this means nothing by mouth.I was told when to arrive at the hospital, crutch usage, and about the CPM machine. I was issued an e-stem unit to provide muscle stimulation to my quad after surgery. This was my first meeting, of many more to come, with this excellent PT department. I was already very impressed.

With the day's appointments behind me, now came the nerve racking wait time, before surgery. We tried to keep occupied by going to the mall and talking to the kids back home. It was about 6 pm when I received a call on my cell. It was from the Fellow. He was informing me my urine sample showed I had a UTI and surgery was cancelled. They would possibly do it 2 days later, after being on antibiotics......I was in a state of shock, from this news. I did not have one symptom of a UTI and had not had one for 20 yrs. I was very upset as I had traveled so far and knowing the amount of planning that went into leaving town, plus leaving a family at home. This surgery trip was a monumental, logistical task. They suggested I go down to the hospital in the morning and do another specimen. After a very sleepless night, we went back to the hospital for another urine test. I gave them my cell number and waited for the call and the verdict. We were just about to eat breakfast when my phone rang. It was the doctor's office. My repeat test was negative !!!! They had consulted with an Infectious Disease doc and he suggested I be placed on an antibiotic called, Bactrim, prophylactically and I could go ahead with surgery. We were told to hurry up and get to the hospital. We left the restaurant, fortunately, I had not eaten anything. We arrived at the hospital and went right up to the surgery prep area.

I took another dose of coumadin to get my blood levels up. I got into a gown and put on my lovely tedhose. I had paper booties and a paper cap to wear. The IV was started and I met with anesthesiology. I was all set to go, it was 1 pm and now we were told I probably wouldn't go til 3. UGH! more nerve racking waiting. FINALLY, the time came. I was wheeled into the operating room. I hadn't been given any drugs yet, so I got a good look around. I could not believe the amount of equipment, power tools and instruments to be used. You would have thought I was in a workshop, not an operating room. There were many people in the room. I got on the table and was connected to several machines with many wires, cords and tubing. The anesthesiologist told me he would be putting in a femoral nerve block in my left leg. I was given the sleep medications in my IV and the last thing I remember was the placing of the mask over my face and told to take deep breaths.....I was out by the count of 3.

I awoke in the recovery room 2 1/2 hrs later. It was somewhere between 5 and 6 pm. I was in pain but it was quickly taken care of with IV meds. My bandaged leg was already in the CPM machine, in a bent position. After about an hour or 2 in the recovery room, I was wheeled to my hospital room. I spent the night with my leg bent in the CPM machine and my feet in the inflatable compression booties for blood clot prevention. It was not only difficult to sleep with pain, knee bent in CPM, but also the intermitant "POP" of those inflatable compression booties! The compression booties are for the prevention of blood clots in the leg. I felt tethered down to something, everywhere.

Day 1 post-op...The next morning came and so did PT. It was time to get out and walk ! I was a real trooper, I got out of bed and walked with my crutches, 160 feet on the first try. I was so proud of myself, I did it better than I had imagined. I couldn't wait to crawl back into bed ! The day was spent getting pain meds via IV, feeling nauseated, doing PT exercises in bed, lots of vital signs and finally the CPM machine. When my knee came out of the CPM machine, I made sure I started working on extension right away. I was able to get to 0 extension fairly easy and maintain it. I was not going to be one of those people I saw in the PT room having their knee pushed down to gain 0 extension. PT in the afternoon was done down in the PT room, I was so nauseated. The nausea progressed nicely to vomiting. This went on several times until IV meds came to the rescue. The rest of post-op day 1 went pretty it always does before a storm.

Day 2 post-op, the storm.....I woke up with pain, behind, in my left calf...uh oh....not a good sign. I told the nurse and an ultra sound test was ordered to see if I had a blood clot. I was wheeled down to radiology. I layed on a table, sans tedhose, while the tech placed cold gel on my leg and moved the ultra sound wand around the painful area. After a few minutes the tech shows me an area in my vein where the blood flow is very narrowed and sluggish. It wasn't a full clot but the very early beginnings of one. They had not caught one in this early stage of formation. She called in the radiologist. He was amazed at the early stage too. It was very clear to see on the screen. After the test I was wheeled back up to my room. The next surprise of the day, my hemaglobin was low at 8.0. I found out I was going to get a blood transfusion that day. As if that wasn't enough, the nurse came in with a shot. She informed me because of my ultra sound results, I would be starting additional blood thinning with Lovenox injections. Lovenox is a quick acting form of heparin, another type of blood thinner. These shots are given in the easliy reached, fatty tissue, of the stomach. Normally these injections will be administered by the patient because of the duration of the prescription. I was informed I would be doing thses shots for 2 weeks and I would be giving them myself. While I was still in a state of shock, the nurse gave me the first shot in the stomach. It was painful, like a bruise. You must remove the needle as straight as you can, because you will cause bruising to the skin, from the blood thinning qualities, of the medication. I was going to get these shots 3 times/day. Oh, joy..... One nurse left and another one came with my blood transfusion. Lots of preparation goes into a transfusion. There is paper work, constant checking and rechecking that I am, who I say I am and the blood matches up with my name, birthdate and blood type on my special ID band for blood transfusions. Vitals are taken. A nurse needs to be present the whole time, while receiving blood. The dark red fluid was hung on the IV pole and connected to my tubing. I watched the dark red fluid run down thru the tubing all the way, into my vein. Vital signs were taken every 15 min. I eventually didn't notice this routine, as it took several hours for the blood to run in. Before I knew it, it was time for another injection to the stomach. By this time, I was looking forward to the solitude of the CPM machine. Night time came and that meant another injection to the stomach. This time I had the pleasure of giving myself the injection !!

Day 3 post-op....Blood was drawn very early in the morning. I had very little sleep because of constant vitals, medications, and CPM on, CPM off....then the constant POP of those inflatable compression booties. I am being followed in the hospital by an Internal Medicine doc. He is very nice. He comes in and informs me that my hemaglobin is now 9.3, but I am now too high on my blood thinner level. This is measured as the INR level, on the blood work. I now have to stay in bed because I am at risk to bleed out, if I were to fall or even do PT. That is a very scary thought. It takes awhile to get this INR level just right. The parameters for this level are very narrow. I just layed in bed, feeling like I was a ticking time bomb.I was informed I no longer needed to do the Lovenox injections....DUH!

Day 4 post-op....this day went better than all of them. Blood levels showed I had improved the INR level, this meant I could get out of bed and go down to PT. Hemaglobin was 10.4 Even though I still had some nausea, I went down to PT. I did several quad exercises and ROM. I got to 105 on flexion and still 0 on extension. This day progressed unevenfully, something I welcomed.

Day 5 post-op.....I am getting out of the hospital !!! It took forever to get all the papaerwork done, doctor's orders, and home instructions. But at last, we left !

Day 5 post-op night......When evening came a heart problem I have, reared it's ugly head. I have atrial fibrillation. I had an episode of this or what I thought was atrial fib. It started out that way with irregular palps and fast irregular beat. I also developed shortness of breath. I never had that happen before. I tried to sleep , hoping it would just calm things down. I slept for about an hour, but my breathing became more difficult. I found I couldn't even lay down, as this made it worse. I was starting to get worried and the thought of a pulmonary embolis ( blood clot in the lung) was in the back of my mind. Especially with the events in the hospital. I gave this 4 hours, with breathing getting worse. I finally got to the point where I said, I need to get to the hospital. We were about 10 min from a hospital. Ten minutes driving felt like 2 hours. I thought I would not make it. I went thru the ER doors, told them I had difficulty breathing and I was 5 days post op TKR. I gave them my history and the events in the hospital. I was put on the heart monotor, an EKG ordered, chest xray taken. I was on O2, with blood gasses and blood work done. In particular, there was a blood test ordered called, a D-dimer. This reading tells the probability/risk of having a pulmonary embolis. My test results came back. The high reading for the test is 2.1. My reading was 5.3. I had twice the high reading. This showed I had a very high risk and probability of having or had, a pulmonary embolis. This meant I now had to have a CAT scan spirometry of my lungs. This was the test from H**L. I was wheeled to a special room with a very large machine. I had to get over to this machine, which was not easy, having just had a TKR. I layed under this machinery that would be moving back and forth, over the top of me. The tech announced she would be running in a dye that would make me feel alittle "flushed", then I would be holding my breath( easy to do when you are short of breath) when she tells me to , while this machine goes back and forth. She runs the dye in the IV and the most God awful feeling is running thru my body. This molten lava, flowing thru me , provided a wonderful lesson on the circulatory system. I felt it go down my arm, into my heart , out to lungs,back in heart, up to my brain, to other arm, and down thru my chest, abdomen. When it came to my bladder, it felt as if I had passed urine all over, it proceeded to go down my legs and to my toes. The test then proceeded. I was returned to my husband, with tales of horror to tell. After all the results came in , the doctor informed me I did not have a PE at that time, but that didn't mean I didn't have one earlier. Because my blood work ( INR level) showed I was sufficiently anticoagulated from the coumadin, I was able to go back to the hotel, but had to return and be hospitalized, if shortness of breath symptoms, chest pain, returned.

We went to the hospital ER at 4am and returned back to the hotel at 11am. I called the doctor's office,I was supposed to have my first PT session that morning. I explained what happened. We both then collapsed and fell asleep.

The next day was therapy day. I had PT everyday for the 2 weeks, I was in Cincinnati. I did quad sets, SLR, heel slides, calf stretches, hamstring stretches, e-stem. I eventually progressed to doing wall sits for quad strengthening, calf raises, cable column and my favorite , the balance machine. Then I was aquainted with ERMI. This is a very simple and great machine for flexion ( It is done with passive flexion work. I developed a love/hate relationship with ERMI. It hurt to do it. I really worked hard on flexion and even though it hurt to do, I actually felt better afterwards. I couldn't wait to use the ERMI each day. I was told I needed to reach 120 degrees flexion, before I left Cincinnati, and by God , I reached 120 degrees on my last day of PT. When I was at the hotel, I did quad sets, SLR, stretches, e-stem and I had a CPM machine. I used it 3 times/day for 2 hrs each time, for 2 weeks. I had just learned how to knit, so I knitted a whole scarf for my grandaughter, while using the CPM machine. I wore the tedhose for 6 weeks. I was on coumadin for 4 weeks. I had to have twice weekly blood draws for my INR level. My coumadin dose was adjusted depending on what my INR level was. It became very difficult to draw blood from me and my poor arms and hands looked like I had been severly beaten. I had horrible bruises everywhere on my arms. Because it was difficult to draw blood, I had to be stuck many times, because my veins would "blow". They ended up using a very tiny needle called, a Butterfly needle. This is usually used on pediatric patients. Despite all the blood draws, I hated to leave the excellent PT dept of Cincinnati Sports Med. It wasn't just PT, it was a whole educational process. They were super.

I did very well post op once I got home. I even got a script from the doctor, to rent the ERMI, for home use. I used it 5-6 times /day for 15 min each time. Using this machine kept me ahead of the daily stiffness, one battles with a TKR. I eventually got to 130 degrees flexion. That was to be the highest I ever got on flexion. It was a sad day when ERMI had to go back. I rented it for 3 mos. I was doing PT, 3 times a week, at my rehab facility.

TKR rehab is brutal. It takes total dedication to daily rehab and alot of patience, to get thru it.

Six weeks post-op, I developed a painful snapping to the posterolateral side of my knee.....but that is another story, about my knee.

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