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Author Topic: DeNovo NT graft - Recovery and Post-op Diary  (Read 7483 times)

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Offline stephlouise

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DeNovo NT graft - Recovery and Post-op Diary
« on: November 28, 2015, 10:14:45 PM »
Here's the first few days of my post-op diary. Surgery was 11/24/15 (Day 0). OS did a DeNovo NT graft to fill a 2cm x 2cm defect on my patella. He opted against the tibial tubercle osteotomy, despite the fact that most physicians do this in conjunction with the graft, because I do not have any anatomical defects affecting tracking.

About me: I am 31, female, athletic, living in California. My first traumatic knee injury was when I was 16 and fell while running. I was a runner and swimmer throughout school, then switched to cycling in my mid-20's. After a few very clumsy falls from the bike, my knee injury became too painful and I stopped riding. In the last 18 months, I've had three surgeries to my left knee, including this graft. The first two were debridements and diagnostic arthroscopies. I've been to three different orthopedic surgeons - the three surgeries were with 2 different surgeons. I've tried Synvisc, Orthovisc, cortisone, PT, and microfracture. Given the size and severity of the defect in my knee, combined with the failure of other treatments, my OS felt that an implant was the only option I had short of TKR.

Here's my diary. I will keep adding to it as I progress and things change.

Day 0:

Nerve block has pain at a minimum. Breakthrough pain is well-controlled with Dilaudid (4mg every 4 hours). I opted against an ice machine and in favor of gel bead ice packs. These have worked really well and Iím glad I avoided the ice machine because the bulky hinged brace I wear would have made it difficult to use the thing anyhow. So I am rotating between four ice packs, plus ziploc bags full of ice cubes when I run out. I ice more than 20 minutes per hour, which I realize I'm not supposed to, but ice is amazing for the pain and swelling.

Surgery started at 7:30 a.m. and took about 90 minutes. Within an hour, I was ready to start being discharged. No morphine was administered in the recovery room. I was in the car and headed home less than three hours after my surgery began.

Breakthrough pain set in about halfway through the commute home, which took about 90 minutes.

My alertness was moderate upon getting home, but faded after my first dose of dilaudid. Iíve had an appetite and have been able to use crutches to get to the bathroom about 100 feet away from the couch.

Doc is allowing minimal weight-bearing as long as my giant splint is locked at 0 degrees.

CPM is supposed to arrive tomorrow and begin treatment that will last six weeks, at 6-8 hours per day. Doc is starting me at 30 degrees for the first two weeks.

The pictures of the surgery were pretty impressive Ė though my family had to confirm that because I barely remember seeing them. Looks like everything went well though.


Post-op appointment is in one week. Until then, it is full bed rest. Dressing can be changed in three days at which time I can shower with assistance, but not bathe.


Day 1:

The nerve block started to wear off during the night Ė I took the OxyContin before going to bed as directed by the nurses. But I was still up every four hours to take dilaudid. The day started off alright, but as it wore on, it turned into the longest day of my life. I cannot get comfortable. No matter how I stack pillows or where I sit, there is pain and discomfort. The problem is that the knee has to be completely straight out. This is unnatural and uncomfortable. By evening the full nerve block wore off and the pain became excruciating. This caused anxiety. By the end of the night, I was taking six meds and was still in tears.

I am itchy from head to toe. Cannot place the reason for it. Benadryl helps slightly, but the drowsiness makes the whole thing a wash. It looks like Iím spider-bitten on my chest and back shoulders. This also itches.

During the night, I woke up hourly or more from muscle spasms in my left quad. These caused me to cry out in pain and nothing helps to ease the pain the spasms cause. The brace isnít helping and just feels constraining at this point.


Day 2:

Woke up this morning to more muscle spasms. Itís my birthday. And Thanksgiving. But I feel like Iíve been bed-ridden for weeks already and just want to rip this split off. Boyfriend helped me wash my hair after some combat and cajoling. That made a world of difference, if only because my scalp no longer itches.

All in all, today is a better day than yesterday. Pain is still strong, but more manageable. And Iím able to find comfortable positions occasionally.

Iím still taking OxyContin and dilaudid. Once the OxyContin runs out (I have two doses left) I will switch to tramadol to take the edge off as I wean off the dilaudid.

My mind is still very cloudy. It cannot quite keep up and my hearing is muffled. I can pass out at any moment, but itís likely a muscle spasm will wake me up. And thatís terrifying. Going to try bananas to minimize the spasms. 


Day 3:

Dressing change day! The incision is about 5.5 inches long, down the front of my thigh and kneecap to my shin. Not sure if itís staples or sutures because I didnít remove all of the gauze, but it looked pretty smooth, so Iím guessing sutures.

The compression stocking kept my calf from swelling like crazy, but as soon as the brace and stocking were off, everything swelled a little out of control.  After about 15 minutes of ďfreedomĒ, I put the compression stocking back on with the new dressing and returned to the locked brace. Itís pretty nerve-wracking to be out of the brace because Iím not allowed to bend the knee at all Ė and any movement is excruciating. 

The CPM was never delivered, but I think thatís a disguised blessing. I canít imagine moving or bending my knee, even with the assistance of a machine. Iím still only lightly weight-bearing and only with the brace on and locked straight. Doc says this will be the case for two weeks.

Pain seems to be improving overall. And Iím sleeping better. So Iím optimistic about getting off meds soon.


Day 4:

Today, I got a shower. A real shower. It was heavenly. Then the pain set in and I had to get my brace back on. But never underestimate the importance of daily hygiene in your overall well-being.

I was optimistic about the reduced pain, but it has come back with a vengeance. Iím resigning myself to the fact that the pain is going to take quite awhile to go away. The incision itself hurts a lot, but itís also internal pain right behind the kneecap and surrounding the kneecap. Muscle spasms have improved, but havenít gone away completely.

Iím more alert, and have extended the time between pain meds. I went off the Oxy early (Day 2 was my last day) and am glad that I did. My pain levels arenít much different without it, but Iím much more coherent. Since NSAIDs are out of the question, Iím supplementing with Tramadol (staggered with the dilaudid) and that helps a little bit. But mostly the pain is treated with ice and ignored through sleep.

I still need assistance for any movement. I use crutches, but still need help standing up and laying down because my leg with the brace is too heavy for me to lift. Any activation of my quads is extremely painful Ė and they are too weak to do much good anyway. According to my discharge paperwork, Iím supposed to be doing leg raises by now, but thatís out of the question.

The hardest part about this so far has been resigning myself to the ďlong-termĒ nature of recovery. Prior surgeries have laid me up for only a few days and Iíve been off meds and mobile within 3-5 days post-op. The fact that this is obviously not the case here is frustrating.
« Last Edit: November 28, 2015, 10:25:32 PM by stephlouise, Reason: Added background information »

Offline dal_knee

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #1 on: November 29, 2015, 06:32:52 AM »
Did you get CPM machine ?? This aspect is absolutely critical to success for patellar defect cartilage restoration. Cannot be underestimated.
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #2 on: December 01, 2015, 01:43:40 AM »
I actually didn't. My doc recommended it and told my family it would be delivered the day after surgery. I'm almost a week post-op and I haven't heard anything. I plan to ask my doc about it at my post-op appointment in two days.

In what way would you say it is critical? And should I rush to get it sooner rather than later? I am curious because I've heard mixed reviews on the use of a CPM, but my doc insisted I use it and I am happy to oblige. But he wasn't able to describe specific benefits except helping shape the cartilage (which makes sense and is a huge benefit, but wasn't sure if there is more).

Thanks for the insight!

Offline dal_knee

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #3 on: December 01, 2015, 03:19:02 AM »
The patellar surface is the most recalcitrant to cartilage regrowth. The CPM provides the proper loading needed by the newly formed cartilage, helping to turn it closer to normal, hyaline or hyaline-like. It's an investment in terms of longevity and durability of the regrown tissue.
If I were you, yeah I would work on getting that sooner rather than later. 
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #4 on: December 01, 2015, 04:11:17 AM »
That's all I needed to hear. I've put a call in to my OS. Sometimes it's really about how the information is delivered - and you put in a language I understand. Thank you so much.

Offline willrunagain

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #5 on: December 01, 2015, 02:29:16 PM »
I hope your a healing nicely! I am assuming your insurance finally pulled through? Congrats!

The first week is the toughest with these types of surgeries, but I promise it gets better!  I will second dal-knee here.  The CPM is very important for stimulating proper cartilage growth.  It also significantly helped me to regain knee flexion and reduce stiffness.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #6 on: December 02, 2015, 03:41:40 PM »
@willrunagain: Thank you! I actually decided to pay out of pocket. I weighed the duration of a fight against my insurance company (that had already lasted a year) + possible attorney fees, against the actual cost of the surgery and benefit of getting treatment sooner and having control over my healthcare. The surgery (and debt) won. My OS and the surgery center worked with me and so far I'm at $15K for costs that hopefully will not increase much more.

Thanks for the additional vote in support of the CPM, too. I'm still waiting for my OS office to figure out where the ball got dropped - multiple phone calls and I'm still waiting. My post-op got pushed back a day as well, but I'm hoping to have it by the end of the week.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #7 on: December 02, 2015, 04:02:48 PM »
Day 8:

Woke up this morning with unbearable pain. Days 5-7 were rough, but the pain came and went and was overall improving. Nights were OK; I slept through most of them with the help of muscle relaxants to curb the spasming (quads, I think) that began around Night 3. I did find that when I was in pain, there was no getting comfortable, no matter what I did - brace off? Pain. Brace on? Pain. Lots of ice, but I was still able to reduce my meds overall.

Today, I feel like I was set back nearly a week. I barely slept throughout the night. The slightest movement sent a shock of pain through my knee. But I stubbornly opted not to take any meds during the night. And I'm paying for it this morning. Over an hour after taking Dilaudid, my pain is easily at a 5/10 resting, spiking if I move at all.

Otherwise, progress is slow, though my knee looks good. I have near constant assistance from boyfriend and family. They work in shifts. Without it, I don't know how I'd get through the day.

I've changed the dressing a few times and the incision is swollen, but clean. Looks like my OS used clear sutures and steri-strips to close the wound. The incision is tender, but not excessively so. I can touch my whole knee (sides, back, top bottom) and there's no pain on contact, with the exception of the patella itself. The pain in the patella is deep and starts on the edges, at the top, and on either side, radiating inward and up.

I removed the compression stocking and just have the Ace bandage over the wound dressing underneath my brace.  Showers are a chore, but worth the effort. I wrap the knee in Saran Wrap to minimize water contact, then I wear the brace into the shower, sit down on the bench that I never saw the purpose of until now, remove the brace, then turn on the water with the handheld shower head. I have help every time.  There is no way I could do this by myself.

I've been engaging my quads a little more and rotating my ankle to keep my calves moving. But I can't put hardly any weight on my foot (in locked brace only) and I haven't been able to do any of the PT exercises included in my discharge paperwork. On day 6, I did three tiny straight-leg lifts without pain - but the excitement of my victory has since dulled, as I can't replicate those results.

Supposed to start working from home today, but with the meds, it's doubtful I'll be able to. The fatigue has dissipated a lot though, and the fogginess of the first few days is almost all gone.


All in all, there's more good than bad at this point. Post-op is tomorrow, and I'm anxious to hear what my OS has to say about the progress. But once I silence the over-achiever athlete in my brain, I realize I'm in pretty good shape for 8 days out.
« Last Edit: December 02, 2015, 04:07:36 PM by stephlouise, Reason: Grammar fixes »

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #8 on: December 04, 2015, 05:57:24 PM »
Day 10:

CPM arrived this morning. Apparently I live so far away (2 hours) from the real world (SF Bay Area) that they couldn't find anyone to deliver it.  The machine looks like a medieval torture device, but that just means it matches well the giant brace from ankle to hip. (Photo attached)

For two weeks, I'm doing 30 degrees of flexion, 6-8 hours per day. I'm frustrated by the 1 1/2 week setback of not getting the machine sooner, but better late than never.

Post-op went well.  The stitches are dissolvable apparently, which was a nice surprise. OS ordered one more week of absolutely no weight-bearing (back-pedaling somewhat from the minimal weight-bearing he previously allowed), followed by two weeks of minimal weigh-bearing. No weight-bearing unless the brace is fully extended and locked. Bedrest and, if I do move around, crutches only, for at least another three weeks, then I go back to the OS for another post-op.

My pain has returned to tolerable levels. The OS prescribed a relaxant for the muscle spasms which he expects to diminish with the CPM use as well. I'm again reducing my intake of the dilaudid - trying to go from 4mg every 4 hours to 4 mg every 6 hours, then reducing it to 2 mg every 6, then only taking it at night. NSAIDs are still out of the question, so I can't supplement with a non-opioid.

The OS hasn't yet ordered PT. He told me to start doing quad exercises at home. Right now I have no quad control at all. At first I'm just engaging my quad without movement until I can do so consistently and without pain. Then I can start doing straight leg raises, up to 10 at a time, 3 times per day. All in the locked brace.

Seems the OS is taking a very conservative approach to rehab, which makes sense given the delicacy of the implant. Without the pain, I'm getting more optimistic - daring to think this could actually work  ::)
« Last Edit: December 04, 2015, 06:02:16 PM by stephlouise, Reason: Add photo »

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #9 on: December 06, 2015, 06:53:23 PM »
Day 12:

Got tangled in my CPM yesterday. Doc recommended sleeping while using it. But apparently I am a klutz even in slumber. My knee twisted, machine kept going, and with the brace unlocked that meant some weird angles and a lot of pain before I finally woke up. I'm still in pain today - and scared. I don't know how much or how little it takes to dislodge this graft, but there was definitely a crack when I straightened out.

Otherwise, I've continued to scale off the pain meds. Even with the setback from yesterday, I'm not increasing my dose. I enjoy the lucidity too much.

Still icing frequently. That's the best bet for the pain, though right now the incision hurts more with ice than without - another stage of healing.

Sleeping is still difficult at night. Though I have little trouble during the day. It's a cycle that's familiar to depression, which has me worried. Not that I'd be surprised if depression kicked in after being cooped up - it would just be one more complication I'd rather not deal with right now.

There are other residual effects of sitting/half-laying down all day, like back pain, skin irritation - haven't yet figured out how to balance resolving these minor issues without compromising my recovery. Changing position frequently seems to help, but there's still the constraint of the CPM.

Otherwise, I'm still about 90% dependent on another person. My family take shifts of sorts, depending on who is free, which also means spending all day alone with an occasional visitor in the morning and evening. But those visits are mostly because of my exuberant 90 pound dog. He's the greatest hazard in my house right now, and feeding and letting him out is out of the question for me. So his feeding time has become my feeding time and the remainder of the day I ration water and snacks next to my CPM.

No changes otherwise. Hard to believe not even two weeks have passed since surgery. Feels like a lifetime.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #10 on: December 13, 2015, 11:01:30 PM »
Day 19:

Pain still fluctuates constantly. I've had two sleepless nights in a row. Initially, I was baffled by the sudden resurgence in pain, but I finally figured out it's because the muscles are starting to work again. I've been relying on my quad more and more each day, but I pay for it in the evenings.

If I slack with the CPM, I pay for it. Yesterday I got out of the house for a few hours (on crutches, no weight-bearing, locked straight leg brace) and didn't use the CPM - bad idea. By dinnertime I was in tears and did not get any pain relief until I strapped my leg into the CPM this morning. Lesson learned.

Technically I can start weight-bearing as of Thursday - 30-40 lbs tops. But the pain levels have been too high for me to attempt it. Instead, I've been working on standing with minimal weight on my left leg, focusing more on balance and building quad strength.

The incision is healing well. Replaced the steri-strips/butterfly bandages to keep it from separating with swelling. It is still painful to the touch, but it's tolerable. It's looking like the scar won't be much more than a thin 5" line down the front of my kneecap.

Swelling varies, but corresponds directly to the pain level. The more pain I'm in, the more my knee and foot swell. In contrast, my calf is the smallest it has ever been due to muscle atrophy. The same goes for my slack left quad.

Days are repetitive now. Working from home, CPM all day, muscle relaxants and pain meds at night. Still no driving allowed. Mostly, I just wish I could peek inside my knee to see if the graft is doing what it's supposed to. I've been able to kick the depression that was creeping in thanks to visits from family and a conscious effort at attitude change (this too will pass, have faith it will work, think positively).

Offline Torao

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #11 on: December 14, 2015, 06:14:45 AM »
The CPM machine is so much fun. I never trusted myself to try to sleep in it, so I had to do my 6-8 hours a day while awake. Which made the dog very curious about what it was. Trying to shoo him away when he really wanted to know that that strange thing was ended up being a little awkward. Fortunately the other dog was afraid of it.

Good luck with your continued recovery.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #12 on: December 21, 2015, 04:39:18 AM »
@ Torao: I also use the CPM only during the day. Luckily, I've been working from home, so it's possible. But balancing a laptop is impossible, so it gets awkward. Interestingly, the CPM is also the only real pain relief I get, so there's a definite love-hate relationship with it. (My dog can't decide what he thinks either. Though he does snuggle markedly less when I am using the CPM. Kind of disappointing. But he's an exuberant 90-pound Weimaraner, so there's been a concerted effort to keep him from me during recovery. Not easy since he's usually like Velcro.)

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #13 on: December 21, 2015, 04:59:30 AM »
Day 26:

Although the worst seems to be behind me, my new routine consists of sleeping for a couple of hours, then waking up in excruciating, throbbing pain. I then head to the living room couch and turn on the CPM, which is the only answer to my pain. Even pain meds (dilaudid + Soma + codeine) do no more than take the edge off. 

The CPM has been adjusted to 40 degrees flexion. It feels like my knee is going to explode as it nears 40 degrees. The swelling has nearly disappeared, except for a baseball sized lump where my kneecap is supposed to be. I don't know if it's fluid, or inflammation, or what ... but I don't like it.

If I'm not using the CPM (at night, for example) my knee gets very stiff very quickly. I felt bold and went to a movie and dinner with my significant other this past weekend (Day 24, for anyone counting). I took a wheelchair, which helped, but it was too soon. My leg swelled up and the slightest movement by the end of dinner was tear-inducing. I only took codeine before the movie started to fend off pain ... but didn't want to keep taking meds. Got home, turned on the CPM, and within a couple of hours I felt better. Until 2 hours after I fell asleep when the pain returned. So it's a cycle.

My four-week post-op is Wednesday. I'm anxious to hear if I can start weight-bearing more and if my range of motion on the CPM will increase.

Offline stephlouise

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Re: DeNovo NT graft - Recovery and Post-op Diary
« Reply #14 on: January 04, 2016, 04:49:53 PM »
Day 41:

Tomorrow will be 6 weeks post-op. I can hobble a few feet with a cane and the brace. But still not truly mobile. Haven't driven since the surgery.

My OS gave me the DeNovo rehab protocol. It calls for me to be at 90 degree ROM on the CPM by tomorrow. Looks like I might get there. I increase by 5 degrees every day for the last two weeks. It also calls for me to completely ditch the brace cold turkey tomorrow. I'm less comfortable with that idea given my weakened quads and hamstrings. But, I will try - maybe use an Ace bandage to limit the amount of twisting that can happen until I'm stronger.

My wound is healing beautifully. I've been using Mederma and finally got the last of the undissolved stitches removed. Despite being over 5 inches, I don't think the scar is going to be very noticeable a year from now.

Physical therapy begins January 11. Living in a small town there aren't many options so I'm not starting as early as I wanted. Had to wait for an appointment. In the meantime I'm allowed to do isometric closed-chain exercises. I don't know what these are and Google is not my friend on this. So I'm continuing with straight leg raises and basic quad flexing for now.

Apparently I'll be able to start low-resistance stationary biking at Week 8  ;D   So now I have a concrete goal.  At week 12, I'm supposed to ditch the cane and be able to walk without a limp.

The protocol covers 18 months of recovery, all the way up to jogging and running on a treadmill. I don't plan to do any jogging again - not ever - but it's encouraging to see the protocol go that far. I'm hoping I can find a protocol more tailored to a cyclist, given the unique challenges we face on the road. Admittedly though, I'm terrified of a fall, so the wind trainer will be "road" for awhile.

I am still having trouble with sleep. Anxiety seems to be playing a big role in that, combined with stiffness of the joint within a few hours of falling asleep. I'm still getting up in the night to use the CPM which helps after a few rotations. Pain meds are a last resort.

Moving around, traveling, basically doing normal, everyday things including leaving the house - all are extremely difficult and put a lot of strain on my knee. Swelling is still present and gets worse if I'm out for too long. Car rides are painful after about 15 minutes. It's hard to pinpoint what exactly causes the pain - lack of flexion is an issue... but so is too much flexion. A lot of it seems to have to do with the elevation / angle of my hip. My circulation gets cut off pretty easily and everything from my knee down turns purple when I try to sit like a normal person (e.g. in shower, in car, in restaurant) or if I'm up on my feet too much.

I'm trying to regain some independence this week. After 6 weeks of constant care, and stressful holidays that I couldn't participate in 100% (no traveling), I'm ready to figure this out on my own.

If all goes well, I will be walking with a cane, no brace, and driving, by the end of the week and returning to work on Monday.