Knee Replacement E-Book
Total Knee Replacement
Is the family ready?
The problems and issues of after care starting post surgery were significant and we are writing this feature to help anyone prepare for this major operation.
My wife going through two total knee replacements one year apart and after care was an unbelievable experience for my wife and I. Keep in mind we ran a 200 acre farm with two roadside markets, 60 to 80 people employed. We know how to run things. I personally was flabbergasted by the amount of details I had on my shoulders for 2 weeks until my wife was able to get around a little. Burdening an old spouse with this process could be a foolish mistake, although I was able to call on all the faculties I had mustered over 40 years of business and did the job. Mission accomplished. She is doing great.
The Healing Process
When you completely sever the bones (top and bottom) and replace it with an artificial prosthesis as pictured above, you invade many areas of tissue etc. and the healing process is long.
There is also a very serious scar tissue issue internally that develops, that requires diligent rehab at home and eventually at a rehab center.
The Mean Old Surgeon
We had the surgeon come in the day after surgery and we thought brutally pressed down on both sides of the knee to "demonstrate" what we the family needed to do on a regular basis to straighten out the knee (the extension) and not have it lock into a permanent undesirable restrictive position from the gitgo. I came to the conclusion that the surgeon was taking that opportunity to actually effect a beneficial post op next day procedure.
Extension and Flexion
The illustrations below indicates the patients critical goal in straightening out the knee for a full 0 degree extension. In addition, bending of the leg past the 90 degree normal sitting position to approximately 120 degrees is desirable, but not always achievable. My wife at the end of her outpatient therapy on the first knee got to about 110 degrees flexion and pretty close to zero extension. We expect to do as well or better on the second knee as we are presently in the rehab process of the second knee.
Acceptable
straightening (extension) and bending (flexion) is critical in a successful knee
replacement. I believe that it goes further than mobility, I think that it
is imperative to the health of the area, hips, lymph and venous
circulation to
achieve the desired ranges of these two milestones, as the longer you wait
to do it, the harder it is to gain the optimum. A knee or knees that are
not brought to close to an optimum flex and extension will haunt you for the rest of your
life. Grit your teeth. Do what you are told to do.
The Deer in the headlights
We
are not doing this feature to be critical of anyone involved with our case.
There is a lot to be desired though regarding the organization of this process
and we personally take most of the responsibility for not organizing and
orchestrating a smoother process, by not doing our homework before the process.
You can't get away with breaking the law if you claim ignorance. Is there any
difference between getting caught at an intersection breaking the law and
claiming ignorance of the situation and claiming ignorance when it comes to the
welfare of a loved one?
More Homework and Home?
This feature will start you off with some homework and we only wish we could have landed on something like this feature before we started. In other words don't stand around like the deer in the headlights and expect the very seriously overburdened medical system we have, the best on this earth to burn the midnight oil for you.
We were in one of the better hospitals in South Florida, but the rooms they put knee replacement patients in post-op are regular hospital rooms with a limited amount of expertise from the nursing staff in regard to knee replacement post care. These rooms are geared for post op patients and the staffs role is to keep them from pain, infection and really keep them alive as in preventing deadly blood clots. Unless you are in a very special big buck hospital don't expect to get the very best in post op therapy in the first few days after your operation.
There has been a change in the entitlement format. Where most knee replacement patients before were sent to the hospital rehab area a day or two after surgery, now there has to be medical concerns that qualify a patient for in hospital rehab. Hospital rehab is another area of the hospital, where you are moved permanently too, not toggled back and forth from your regular hospital room. We believe on a 24 hour basis with the expertise in this area, it is a much better prepared area to handle post op replacement patients at least as far as knee therapy. When you are expecting a knee replacement check out the policy of the hospital regarding post op rehab. I am talking the first couple of days.
The only problem is after about a day after surgery and most patients standing on their own two feet to some degree they are looking to go home with their dog and their own bed and hoping that what they face at home will not be a nightmare, because it could very well be a nightmare if you do not have a little army of people there to help you. Your caretaker spouse wants to be in good shape as well. I personally lost 5 lbs taking care of my wife in the first two weeks.
Make sure when you get up in the morning if you are the caregiver to put on the best pair of shoes you have and invest in Dr. Scholls inserts as well. Don't walk around in your slippers or flip flops.
There are cases where the surgeon and social services may not feel comfortable with the perceived caliber of care at home and encourage some time in the hospital rehab. It really is on a case by case basis.
There are independent care services that come to the home that are not covered by insurance, although nursing and therapists are covered at least Medicare patients. They will be at your home the day after you arrive and the nurse in particular will be into see you everyday for a couple of weeks. The therapists usually take the weekends off and give you some homework that most patients slack off of. Not smart slacking off.
Cushion your feet before it is too late
One
more thing in preparing in advance and that is cushioning your feet on tile and
any hard surface. We had a Romanian tile setter that told us after
he got done doing tile work for us. "Get a pair of comfortable easy to get
into shoes/slippers, because if you don't this tile will kill your legs and in
particular your knees" That was 20 years ago and my wife and I have
been walking on our tile most of the time in our stocking feet. Don't let that
happen to you. Learn from our mistakes. In fact after you have your
knee or knees replaced it would be a good idea to continue using this principle
and that goes for general foot wear. Change those sneakers more often for
instance. Think about some of those Dr. Scholl's inserts even in a good
pair of sneakers. If you can find a good podiatrist it could pay off
having some professional inserts molded for your feet.
What a slipper we found....
We
ran across a slipper made by the Tempur-Pedic mattress firm. They claim
the cushioning in the slipper is the same material they use in their mattresses.
We purchased a mattress a few years ago and since then my wife's back problems
have disappeared. The slippers are the most comfortable pair of foot wear
I have every worn. It is like you are walking on air. I highly
recommend this slipper to avoid the problems hard floors will do to your knees.
They are not cheap, about 50 bucks a pair, but well worth the money.
Just enter Tempur-Pedic slippers in your search box and their site will come up
to order. I will be honest with you, the cushioning aspect with these
slippers are not forever. If you get a year out of them be happy, order
another pair or buy a good Dr. Scholl's insert for them as soon as the
cushioning starts to go down hill.
In fact after knee replacement it is critical that all of your foot wear is up to snuff. Keep in mind knee replacements may not be forever. You hear on TV Attorneys looking for patients who have failed hip and knee replacements.
I took my wife over to the Wall Marts recently and bought a brand new pair of slippers as the ones she was walking around a good part of the day were worn and had little cushioning. While we were there we purchased 3 sets of Dr. Scholl's inserts. The slippers didn't need any for now but could in time. In fact we brought a pair of scissors with us in case we needed to trim/size the inserts we were trying in different shoe wear.
When we came home we got out the two pair of sneakers she wears for Tennis and a pair of casual shoes she uses. In one pair of sneakers we left the existing insoles in and put the Scholl's right on top of them. They were perfect. The other pair a different make we had to take the existing inserts out and replaced them with a heftier Scholl as they were a little tight. We are retaining the inserts in case the sneaker loosens up a little. The casual shoes were a little loose so we left the existing insert in them and put the Sholl's right on top of them.... Perfecto.
Take care of those legs, knees etc. whether they are your own or prosthetics. They wear out with time and the better you take care of them the longer they will last.
The Surgeon
Picking
a good surgeon of course is extremely important. We researched the many surgeons in
our area and went directly to therapists that rehab knee replacement patients.
They know the good surgeons simply based on how well the patients do in post
surgery. We had the best in the nation. Give us a call we will give
you his name. 954-922-9181 before 8:30 PM. EST. please.
Bi-Lateral Knee Replacement
Bi-lateral
knee replacement surgery means that both knees are replaced. Patients who have
severe knee arthritis in both knees may be good candidates to undergo bi-lateral
total knee replacements. In general, there are two types of bi-lateral knee
replacement surgeries.
The above prosthesis I believe are the Stryker brand. They are one of or the leader in this field and we believe are much more durable than the devices used in the past.
Simultaneous Bi-lateral Replacement
A simultaneous procedure means that both knees are replaced at the same surgery,
in one day.
Staged Bi-lateral Knee Replacement
A staged procedure means that the knees are both replaced, but not on the same
day. The second surgery may be performed as early as several days after the
initial surgery, or several weeks or months later.
Who should consider bi-lateral knee replacement?
Patients who have severe knee
arthritis in both knees may be candidates for bi-lateral knee replacement
surgery. The same criteria used to determine if a single knee requires
replacement are used to determine if both should be done.
Are you ready for bi-lateral knee replacement?
What are the risks of a simultaneous bilateral knee replacement?
There are concerns about performing a simultaneous knee replacement because it
is a longer surgery and is more demanding on the body. Because of this patients
who have cardiovascular problems, pulmonary disease, or are over the age of 80
are often advised against a simultaneous knee replacement procedure.
Our Choice
My wife had 1 knee replaced 1-13-09 and the second replacement 4-14-10 and were much better prepared for the second replacement. For the first time in about 6 years my wife now can stand and walk on two legs without structural knee pain as in bone on bone. There still is soft tissue discomfort, but it is subsiding. Staples have been removed 5-1-10. Incision is closed and healing well and it appears like the other one the scar will be hardly noticeable. We daily take a small piece of Aloe Vera, take the prickers off of the sides, slice the piece in half and take the two half's and gently apply the aloe gel with a little down pressure, not much on the scar. Again this is after the incision is well healed and you have clearance from the nurse to do it. When you get done with the incision apply the rest of Aloe's magic over the entire area. If you don't have your own Aloe plants standing by (You should) ask around many neighbors have them in there back yards or in pots within their home.
Update 7-10-10
My wife has made a remarkable recovery in the second replacement. We attribute this to our experience in the first procedure, proper icing for one thing. (Detailed below) A very aggressive in home therapist at the start. The fact that she had a good leg from the first procedure made a huge difference. Having a recumbent bike (Detailed below) from the start of our second recovery that we purchased late in the first recovery period. The therapist had her on the bike a week after the procedure. Every knee replacement patient should have a recumbent bike as they will need it the rest of their lives, let alone the benefits derived in the recovery period. I say they will need it the rest of their lives because unattended knee replacements can be problematic in time, stiffness for one.
There is a bonus in keeping your knees in shape, it reflects on your entire being by enjoying physical activity that you would most likely not engage in if it wasn't for the knee implication.
Because of the factor above and the new knees my wife is a new woman and I can't tell you how delighted we are with her new life, because the last 4 years with those bad knees were a S.O.B.
Update 11-29-11
My wife is playing competitive tennis with her 2 new knees and is not experiencing any discomfort what so ever. Of course she was really a trooper doing her rehab on each knee and the more you read about knee replacements and the need for diligent rehab post op you will appreciate the out come and especially the consequences of slacking off on the rehab. If you meet someone that has experienced a bad result from replacement you can bet there is a good chance they didn't do enough rehab.
In addition to my wife's tennis (Doubles on clay) she is constantly on the run. It is amazing and we are really so proud of her.
Your GP
Not all GP's visit patients in the hospital. Check first and if there is a reluctance have your surgeon assign an in house Doc to your case. We had one and he was excellent. Don't expect that the attending physician on a floor is going to be covering every detail of your case.
My wife ran into a morphine overdose that was overlooked. We the family didn't know what the clinical signs or precautions for an over dose were, until after the fact and my delirious wife started to pull all of her tubes and intravenous needles out and told my daughter in the middle of the night that she was "getting the hell out of here and going home" Even with a controlled restriction on morphine there is the chance of overdosing.
The Bucket and Water Cuff.
Upon
entering your room after a short recovery room stay post op, you will find 2
devices, besides the usual wires and IV tubes etc. One is an ice bucket
and a wrap around affair pictured on the left that is put on in the recovery
room. No one in the nursing
staff we had knew how to operate it on the first knee procedure and a minimal
amount of expertise was displayed a year later on the second knee. We didn't have the foggiest idea
ourselves. I don't believe anyone can argue the fact that
ice properly administered is a critical part of post op care in a knee replacement
operation.
We didn't recall what the state of the bucket and cuff was when it was applied after the first knee, but on the second knee a year later we observed the level of water in the bucket immediately post-op and the level was considerably more than what was required to function properly, by the marking on the inside of the bucket. This level is critical in how well the process works and if the bucket is full of water and ice you are whistling in the wind. Don't take this lightly, it is extremely critical in how fast the patient recovers and what condition their leg and overall health will be for the rest of the patients life.
Keep this in mind that when you ice properly it keeps the swelling under control. When you keep the swelling under control you are able to do the necessary therapy, the bending and flexing, where the swelling interferes with this process. Sure continued flexing and bending prompts swelling, but icing periodically like 6 to 8 times a day or more in between therapy sessions whether they are self or professionally administered is the process.
In fact we the family tried to provide our best efforts in this bucket brigade, but it turned out to be a fiasco. After 3 days of fumbling with this device the night we were released after the first knee replacement, the attending Doctor came in, told us we were entitled to take the unit home with us and asked where the pump was for the ice machine (It is the little box on top of the blue wrap in the picture above). We did not know about a pump and it appears neither did the nursing staff. The Doctor looked under the bed and there was the detached pump. 3 critical days lost with out adequate icing, other than what we were heaving in it from the ice machine that turned out to be totally inadequate, meaning it just didn't do the job and I believe really set my wife back. If proper icing was done, she would have gone home in a lot better condition than she did.
In fact to give you an idea how important the icing operation is, we asked the evaluating therapist the first full day we were home "How many times a day should we ice?" He said "Every hour for 15 minutes" I said to myself "He must be kidding". Of course as the days go by and the swelling subsides you can lengthen the time between icings, but always after therapy.
We asked him whether we could use bags of frozen peas and ice packs, that would be easier than the bucket and the water cuff. He said nothing compares to the effectiveness of the bucket and cuff as it wraps around the entire area because the entire area has been breached. I was told that the surgeon uses cameras to see behind different areas around the knee.
Now this bucket, pump and cuff is a sophisticated device. When they give you the machine to take home, the instructions that came with a new machine have already gone in the waste basket when unwrapped most likely in the operation room. There are some instructions imprinted on the bucket but incomplete. The siphoning action requires a precise water level along with the ice that is put in it. We learned after taking it home, that the water level of course would rise after the ice melted when not in use.
In order for this device to work properly before use the whole deal must be taken to the sink and the excess water from the melted ice must be dumped out. (There is the plastic tube that is easily detached from the top of the pump so that you can bring just the bucket and cuff into the kitchen for water leveling and ice addition.) (A cup to remove excess water from the bucket and transporting ice to the machine is an option covered below)
After each icing session the bag should be emptied into the bucket (by elevating it over the bucket) then a half hour or so before the next icing session keeping the bag over the bucket, dump out excess water to the required level, and an adequate amount of ice is put into the container with the water. (About 15 to 20 cubes)
Now when the device is brought to the lying down patient we keep the bucket below the bag until we wrap the knee with the empty bag. (This is important) Please don't wrap the knee and surrounds with a bag that has water in it. This is probably one of the biggest mistakes that are made with this critical process as it upsets the compression principle of the device. The cuff should not have any water in it anyway, because if water was left in the cuff between icings, it would warm up from being at room temperature. Drain the water completely back into the bucket after every icing.
After the leg is wrapped you are instructed at that point to open the vent and raise the bucket over the bag. It doesn't take long for the water to migrate around the cuff. After the cuff is full, (20 seconds at the most) close the vent and place the bucket no higher than 15 inches above the cuff. The bottom of the bucket just about level with the knee is optimum. This is important for the siphoning and pump to work to peak efficiency. You then turn the pump on. In a short time you will hear the pressurized activity. About 20 minutes of icing is enough, don't over do it. More icing at shorter intervals is much better than long icing periods. Give that area a chance to work with the fluctuation of warm and cold. This is the principle of contrast bathing, warm, cold, warm, cold.
As soon as the icing is finished a new cycle begins for the next icing period, so it important that you raise the bag over the bucket, purge all the water back into the bucket and remaining ice. This will give you a good cold start for the next cycle that goes right back to bringing the whole deal into the kitchen with the empty cuff and pouring out the excess water to the line inside the bucket.
We did have one nurse on the regular hospital staff that was some what acquainted with the fact that some water had to be removed to maintain a desirable level in the bucket. Twice in 2 days she came in and removed some water from the bucket with a cup and dumped it into the sink. She didn't bother to add any ice, but obviously someone had instructed her to try to maintain that critical level. The 6 or 7 other nurses we were exposed to didn't know about this level, and just relied on us the family maintaining the ice and water level. If we didn't take care of this icing we wouldn't have received any degree of icing. A patient that endures this rather major operation hopefully by a first rate surgeon as we had certainly deserves the best after care and proper icing is on the very top of the list.
So whether you want to remove water with a cup and transport ice to the bucket or bring the bucket to the kitchen as we do, dump the excess water and at the same time add ice we will leave that up to you.
We still have a question to be answered by the manufacturer as to how critical at least for a couple days it is to keep the cuff on the leg for just compression sake. Most surgeons recommend compression stockings to keep the swelling down which leads us to believe the compression cuff if applied correctly would be beneficial.
It is important not to over ice. Most therapists will recommend at least at the start every hour to do 15 minutes of icing. So you could conceivable turn the pump off, purge all the water back into the bucket and just leave the cuff on. We will inquire and update this section of the feature when we get this information. An hour goes pretty fast and it may be a lot more convenient, doing the cup removal and transporting the ice to the bucket for a couple of days.
I know this has been repetitive but it is so important that you understand this process. If you don't understand it find someone that will read these instructions and follow them to a tee.
CPM Machine
The
next device is what they refer to as the CPM machine standing for
"Continuous Passive Motion" This device almost
immediately is applied post op, for a number of reasons, blood clot
prevention for one. The hospital staff is required to put the patient
on this machine quite often during the day and for long periods. It
very slowly bends the knee and
returns
your entire leg to a fairly straight position. Don't expect the
nursing staff to come frantically running in to put this machine on.
It will be up to the family members to see to it that this machine is used
to the Doctors specification. Just call the nurse in and tell her/him
the machine should be on the patient and help them.
There is a control demonstrated on the right that allows
adjustment of the two critical positions, the "EXT" Extension or the leg
straightened out to some degree. You will notice the current setting
is 0 degrees. This would have the leg in a straight horizontal position
that is really distorted to a large degree by the fact that your rump is on
the bed or couch and this soft surface does have a bearing on how accurate
the setting is. The setting on the right the "FLEX"
Flexion determines how much
of a bend you apply to the knee. We are told that the
therapists shoot for something in the neighborhood of 110 to a 120 degrees
flex and 0 degrees extension, but again you cannot rely on the settings of a
CPM to give you an accurate reading. A Doctor or knowledgeable
assistant has an angular measuring device that tells you the true reading.
It is a good device, but our advice is to try and find someone in the
hospital immediately after surgery when they put you in it that knows what
settings should be used, when they should change, because no one said
anything and we were again like the deer in the headlights. My
guess is initially they should start you on about 80 degrees flex and
10 degrees extension and see how soon you should progress with some guidance
from a professional. We are not sure about this, so get some advice.
Our surgeon although giving us a script for a CPM to be used at home for the first knee has since soured on using these machines just a few days after their use in the hospital. He claims that patients take up valuable time with this "passive" device and do not do the necessary strengthening of the muscles the quads in particular naturally. We agree with this thinking although the best scenario would be to have a machine available for a week or so at home and use it for a warm up, preceding therapy sessions. I tried to sell this to the surgeon but he wouldn't buy it, because he believes that the patient would rely on the machine too much and actually substitute it for doing the real beneficial therapy. If you are given a script for a CPM for your home, don't be caught in the trap.
The Great Escape
The
Great Escape that wasn't so great. I am referring to the night, that's right the
night we were released from the hospital after the surgeon wrote us scripts for
medications and equipment that we needed to navigate with. A Doctor writes
a script at 6 o'clock at night in a hospital and by the time the nurses get
around to you it is like 8 P.M. and if you have a problem like we had without a
walker to go home with, by the time you reach the Doctor on the phone it is like
9 P.M. In fact being that we did not have a walker and were faced with
dragging my wife through the door of the house to the toilet and to bed, we
finally through an act of congress got the hospital staff agreeable to loan us a
walker until the next day when one was to be delivered to our home. It was
like pulling teeth and only after the Doctor over the phone gave them holy hell.
MAKE DAM SURE YOU HAVE A WALKER TO LEAVE THE HOSPITAL WITH AND DON'T WAIT TILL
THE LAST MINUTE TO DO IT! On release they take you to your car from your
hospital room , dump you in the seat, and if you get home with out
a walker it is like being up a creek with out a paddle.
In addition we were released without pain meds,
but had the script from the surgeon and had to wait in the parking lot of the
Pharmacy until after 10 P.M. We didn't have an adequate portable potty
until the next day
and
with an aggravated hernia pulling my wife off of the toilet.
Needless to say all of this should have been arranged a day or two before
release, I am talking equipment delivered to the house, medications in hand and
for crying out loud a daytime release. Don't be like we were a "Deer in
the headlights." If they want to release you late at night 2 to 3 days
after a major operation even if you are somewhat prepared, tell them to go to hell.
The all important Potty.
When you gotta go, you gotta go!
The two potty version below is a convertible affair. Some of you are acquainted with them, some like us were not. In fact we talked with a woman today that had a cracked pelvis, went on unnoticed for 2 months until they took MRI's, but no one ever recommended a potty as she was in sheer agony going to the bathroom. In fact the same day that the below convertible potty was delivered by a Medicare supplier we foolishly went out and purchased the version where you take the existing toilet seat off and bolt an extension in its place as the patient needs extra height. The problem with the one that we bought it did not have the handles that the above illustration shows. In some cases the potty without the handle is a good approach if you have a bath tub or something solid to push off on to rise off the potty because these potty's are higher than the portables.
The
convertible aspects of the potty has an open sleeve that
fits on top of the existing toilet seat. You can do without the
sleeve shown to the right as it is troublesome detaching. Without the
sleeve there still is a clear opening to the toilet and makes it faster to
put on the closed pot in an emergency where the patient cannot make it to
the John. The second option is the closed pot (On
top left) that you can use near the bed if the patient does not have good
mobility at the start.
I mentioned above in the feature that we relied on the walker at night when the patient slid down off of the bed and grabbed a hold of the walker. You need the walker for awhile just to turn 90 degrees and back into the potty that is placed there by the assistant.
The best scenario would be to have two of the convertibles, even if you had to purchase one. You can use the one in the master bath, and move it closer to the bed for night time use by easily switching to the closed pot. The second potty could be used in a second bathroom in a closer location during the day , and use it in an emergency in just about any place in the house. It can be positioned opened over the bowl, but have the closed pot real handy.
Now there comes a time when the raised potty is actually a hindrance to healing. At first when you are really hurting it is a God send. We stayed with the raised potties until one day the rehab folks put her through exercises that really simulated getting off and on a potty. In fact they insisted that there were no hands used. The height of the benches were just about normal potty height. I told my wife forget about the raised portable potties. In fact doing about 5 up and downs from the potty at the normal toilet seat height as long as it didn't hurt her "much" would be good exercise and she did that.
WARNING Raised Potties can be a serious health hazard.
Now this may not be on the surface a very important issue in this affair, but it happens to be critical and involves your bathroom habits. Our head therapist warned us that we were lingering too long with the raised seat and that we could be hampering proper urinary and bowel eliminations.
There are health advocates that actually believe that the height of a standard John is not conducive to the proper elimination of wastes. Now to support this, observe any animal going through a bowel movement. Notice the degree of bend. Of course the animal does have the luxury of "doing it" anywhere they like and most of the time on the turf. If you compare the animals angle to one sitting on a standard John let alone a raised affair you can easily come to the conclusion that this has to be addressed. Addressing it means at the least getting back to the normal height with a standard seat A.S.A.P.
The
"In Home" Therapist
You will be assigned a therapist that will visit your home for 2 to 3 weeks. I would insist on at least 5 days a week as they will try (they being the medical and insurance establishment) to limit you to 3 days a week. Fight like hell for 5 days, you will get it and it will be worth it. You will be started on Out patient therapy as soon as you are done with In Home. They gave us a tentative schedule of 3 days a week for 4 weeks. With the progress my wife has made and the experience and especially the recumbent bike we have now in the house, we believe 3 days a week will do the job.
In our first knee experience we had a therapist that was good but we believe over cautious with the needed aggressive therapy. In our second knee we asked the home service company to provide us with another therapist and voiced our disappointment with the first one we had with knee 1. The service found us an excellent therapist and the difference in results was like night and day. For anyone in South Florida that would like to know the service and therapist we used our contact information is at the bottom of this feature. We will be more than glad to help you in anyway we can.
Range of Motion
Home care therapy starts immediately after an initial evaluation. Home care therapy as stated can last anywhere from 2 to 3 weeks depending on the progress of the patient, before you are assigned to a professional rehab facility. They have the works. Home therapy is limited, but again it all depends on the caliber of the therapist and the competence level of family home care after the therapist leaves. We believe that we could do as well or better if we had our entire rehab done by the in house therapist we had with the second knee.
Rehab at a professional facility can last for about 4 weeks (3 times a week) although rehab facilities are under a lot of pressure to move patients out that want to become glued sort of like a security blanket. There comes a time where you can achieve as much at home as you can at a rehab facility. The problem is the therapists are so nice, you hate to part with them as they have taken you through some very difficult times. After our second knee experience, I told the therapist "We have just plumb run out of knees".
REHAB Ultimatum
We
were given in the first knee experience an ultimatum, that if we
didn't do better with our therapy flex and extension that we would have to
under anesthesia have a very aggressive manipulation to break the scar
tissue that had been built up by not doing the necessary therapy. We believe
this is a necessary
mind game the surgeon plays with a "lazy" patient as we stated we decided to opt out
of the manipulation and the threat really motivated us. Although we know of patients that have gone
through this manipulation and it isn't pretty. When they came out of
it they were really laid up and it is questionable regarding the value of
it, versus the consequences. My advice, do the therapy. Grit
your teeth and do the therapy. The manipulation and after effects are
a lot worse than doing your homework at least in our opinion.
If you want to go the economy route, we have gone to the extent in trying to stiffen up conditions with a 1" by 6", 3/4" thick board about 3 foot long that fits under the edge of the rump and under the leg and allows the patient to do a fairly good job in extending the knee downward (The downward flex set exercise) as patients who have been dealing with problem knees before replacement seem to acquire a bent over posture, that includes a bending of the knees that do not straighten out in the walking process. The replacement is suppose to correct it, but therapy is needed big time to do it. The first thing out of the box from the surgeon and therapist is to get that knee flat as possible in what they refer to as 0 degrees extension. Note the bevel on one side of the board to fit under the rump. You don't need a sharp edge under anyone's rump. My wife at this point 6 weeks post surgery is about 2 to 4 degrees extension without assistance doing downward quad sets on a firm surface, as in a firm rehab table or board. At 12 weeks she is pretty close to zero, if not zero and the rehab folks are satisfied and in fact 3 months post surgery she is somewhere between 105 to 110 degrees flexion with out much cranking from the therapist. The board works nice for flexing as well, with a little booty sock you can slide back nicely for flexing This is covered in more detail below.
On our last day at the hospital we took a walk through the hall way and in a little room leaning against the wall was a replica of what we had made with the 1 by 6 board including what I will call the bevel for the rump. It said for PT only.
The Step
We discovered another great means to bend the knees, using a step. We constructed one that we use in the house. (Pictured below) Remember there comes a time where professional rehab runs out and you are expected to continue rehab at home. We have been told that knee replacements as good as they are require regular exercise for the rest of your life. If you think you are going to finish professional rehab, and you will be good to go for the rest of your life without exercise diligence you are dreaming. Knee replacements are imposing a foreign object within, that the body has to deal with. It is like a stranger in the house "Who is this guy" Most knee replacements work fine and most cannot tell there is any difference before and after other than the replacement feels a hell of lot better, but again if you are at the age for replacements and old arthritis is hanging around, you need to keep that body moving Mom/Dad.
If you have stairways in your home and most have banisters this is perfect for flexion exercises. If you don't have a stair way a step can be easily assembled with 2" by 6" lumber. Making a box 24 inches long and 11" wide is adequate. 11" wide accommodates 2-2" by 6"'s for the top platform. With the 5 1/2" width of a 2" by 6" and 1 1/2" high (thickness) on the two 2" by 6" s laying on the platform of the box, plus a piece of shower matting purchased at Wall-Mart, you have the perfect step of about 7 1/2 " high and the traction you need to do the job with the cushioned matting. You will see where you use one foot that is planted on the floor so again sneakers are needed for good traction. It is not bad idea to glue on shower matting on the bottom of the structure to eliminate slippage. Gluing is better than metal fasteners that could scrape your floor.
Remember it is the traction
and tension that does the job and once you get on a step of your own or at the
rehab facility, hang the uninvolved leg in the air, you will quickly experience
the dynamics attached to the step. You can bend with one foot planted on
the floor or as you progress you can suspend one leg with the involved leg in tension mode, you then start to
bend the knee
to the max of what you can tolerate and progress in time
toward a desirable flexion. (Warning on this one, go real easy when you
start) You will see in the photos below that you can
even do some backward extensions, (the third photo down) but the
quad sets on the board will be your best source of extensions as pictured on the
right. Note the rolled up towel under the ankle. It helps.
Now you do need something to hold on to and it has to be fixed and solid. Just as you step up you again are holding on to something secure and rock back an forth similar to the wheel chair method. You will find that you can achieve a rather nice bend. Go easy at the start. Your muscles will need some sensible conditioning for awhile. Take some advice from your therapist on this step affair.
#1 Photo
The number 1 photo is showing the subject stepping up on the step, but leaving the uninvolved leg planted on the floor.
#2 Photo
The # 2 photo shows the subject applying tension on the step and doing a rocking procedure loosening up and preparing for the next action. In this mode still leaving the uninvolved foot on the floor to facilitate the rocking motion and for that matter the same position to do the flexions. You can suspend your uninvolved leg in the air and really put some tension on the involved leg, but I wouldn't do any serious flexing without supervision, as the tension is greatly increased in this mode. You must be very careful early in your rehab as to bending with tension. Seek advice and go easy. If you take particular notice in the photo above I think you will see that the flexion angle goes past the 90 degree mark and my guess is that the above demonstration hovers at 110 degrees or more.
#3 Photo
The # 3 photo shows an extension mode. You will note the short wall that we are using for purchase. Actually in this mode you are really pushing on the wall, not pulling. It is important that you find some area in your house to be able to hold on to and it has to be secure. Again doing these extensions measure up to close to what you can achieve with the 1" by 6" inch board on the couch, the quad set, but it is a different dynamics and we feel it is very beneficial.
#4 Photo
The # 4 photo shows the subject standing with both legs on the step. This position can be used for strengthening the muscles by stepping up and down without much bending although in time you may want to be creative with again some guidance from the pros. Don't take the word of this fruit peddler, you could wind up back in the hospital. In this mode it would be smart to hold on to something when you step up, but in time stepping up without something to hang on is a goal as there are many cases where you are required to use steps that do not have hand rails to use.
This mode would be a good opportunity to do some balancing on one leg. Just pick up one leg and with a little security of the wall to hang on to, try to release your hands entirely for a short period. The balancing will be critical to getting you started on a proper walking regimen.
When
you walk even in the house get in the habit of a little heel to toe motions.
A therapist showed us a shoulder rocking motion as you walk and this worked
great as it translated into a very nice erect walk, something my wife has not
practiced for a couple of years. My
opinion is you can't beat a treadmill and doing it in your stocking feet.
I personally do 5 minutes everyday. It is a little boring, but I
add my facial exercises to the session to move lymph fluids into and
out of the all
important Alzheimer's related areas of the upper extremities.
A treadmill can also create the counter balance we referred to
in the first part of this feature as well, for those who are suffering
from repetitive activities and complications from it. I have developed
a pigeon toe motion on the tread mill that I feel will counter some of the
repetitive actions that I constantly engage in. In the process I cross
one foot over the other a little and press down on the toe and then come
back with the other leg and toe. You don't do this the entire session,
mix it with conventional walking. One important practice you can bring
into the mix is bending your knees back while walking on the treadmill. When knees start to give you
problems the first thing that happens is you start to favor them, by
dragging your legs instead of bending your knees.
When you start to drag your legs you may temporarily alleviate the pain, but
in a short time things will start to go down hill and pain and stiffness
will escalate.
The walker and the cane, you need them big time!
The
walker is used immediately after surgery and make sure again you have one to
go home from the hospital with. It
is not long after the therapist
will or should encourage the patient to give up the security of the walker
and the wheel chair for a straight cane. Make sure it is adjustable
and read the instructions thoroughly as there is a proper height setting
relative to the patients height.
It appears we hung on to the walker too long and lost some valuable time in balancing as the cane if handled right will provide an almost immediate path to balancing and consequently freedom from anything.
Using a walker as a "crutch" makes sense when the patient is really unsteady on their feet from the trauma of the operation, but there comes a time when the cane is the ticket. Don't get hooked on the walker let alone a wheel chair. Note, when you first go to the cane, keep the walker handy especially for going up and down steps. We used the walker very successfully at night when using the potty. Sliding off the bed, gripping the walker turn 45 degrees and backing into the potty worked like a charm, because making it to the bathroom for a week or two is not possible for most patients.
A few pointers on the cane that
were somewhat surprising. The therapist when viewing my wife walking
with the cane for first time said "Why are you using your right hand
with the cane?"
Now it would seem logical that first my wife being right
handed
and having her right knee replaced that she or anyone for that matter would
deploy the cane on the right side using the right hand, right? Wrong! Unless you have been exposed to the
phenomena of the cane, if you seen someone walking down the street with a cane
in their right hand, you would or at least I did, automatically believe the
individual had a problem with the right leg. NOT SO! Now this may
not seem to be relative to the problem of recovery, but my wife and I have
studied this issue to the point of obsession. We have because we now know
that this issue is so critical in the physical and mental recovery of a knee
replacement patient. You could spend weeks and weeks doing the wrong thing
and that is why you may have to read the below information over and over again,
along with experimentation to really get a handle on this.
Now all you would have to do to "go to school" on this issue is grab a cane and start to simulate a walking patient. You will immediately discover that holding the cane and deploying it with your opposite hand (opposite to the leg that you are favoring, the operated leg) will take the pressure off of the involved leg, not only on the step forward, but on the backward motion and bend of the leg. Yes, holding the cane in the opposite hand does the trick. Try it! It is like a third leg.
So what do you do? WEAN YOURSELF OFF OF THE CANE, A.S.A.P. Although the therapist may want you to hang on for a short while with the cane so that you do not put excessive pressure on your hips.
Anti-inflammatory
We had an experience with pain
medications during the rehab process and recently learned that after we got
off of the heavy stuff, Vicadin etc. we went back to an over the counter
medication for Arthritis. We were told by the surgeon to go on Aleve for discomfort of the
knee that was not operated on. Aleve is a true anti-inflammatory and
we believe would serve the anti-flammatory aspects of a new replacement.
We would advice seeking advise from your surgeon regarding your individual
needs.
You could be on Coumadin for blood
thinning as there is always the potential for blood clots. The dosage
etc. will be in the hands of your nurse who reports test results twice a
week to the surgeons office who promptly adjusts the dosage if necessary.
This could last 4 to 6 weeks. In fact Coumadin may have to be taken
after your in house nurse releases you, and you will either have to go to
the hospital lab for a few weeks or have your GP do what they refer to as
the PT/INR that tests the thickness of your blood etc.
The Bike
We purchased a recumbent bike after we were well into home therapy on the first knee. If we would have known we would have purchased one before surgery and had it ready once the therapist gave us the go ahead. In fact the therapist on our first knee had a little portable bike where you sat in one of your own chairs and put your feet in the portable. It was better than nothing, but a good recumbent bike is really the way to go. The back support is great, the adjustment on the lower bar is critical, nice little fan, the one we have has a resistance setting.
Keep in mind that investing in a recumbent bike is not just for temporary post surgery it has to be used forever as doing a knee replacement/replacements requires a life long regimen to keep things in top shape.
We have ours right in the dining room of our house. The therapists on our second knee put my wife in it every time they came with the other therapy they did. Cycling that knee eventually all away around (full cycle) and having the apex of the flex up around 90 degrees really prepares the patient for the other therapy. It makes the other therapy more tolerable as this isn't a piece of cake folks. A recumbent bike puts the CPM machine to shame, although again there is short period where the CPM is invaluable in our opinion.
We purchased a recumbent bike to replace the CPM when our therapist told us it was time. Don't get hung up too long with the CPM machine as we did. It is not as easy to use and after about a week you are wasting valuable time where you should be doing things that are more strenuous and beneficial than what the "passive" CPM can do for you.
Our surgeon on the second knee procedure wouldn't even write us a script for a CPM. He said he would prefer taking the time and using your own muscles rather than the passive aspects of the CPM. Now again the CPM has its place right after surgery and we believe if handled right can serve as a warm up to serious therapy sessions. We couldn't convince the surgeon of this and guess what we believe now he was right. A recumbent bike that can increase resistance and build up your quads etc. is what you need and getting around full cycle with the peddles is important as well.
of every group of parts, nuts, bolts, clips what
have you. Write the part on the note by referring to the parts list.
Most of these parts lists have picture in their actual size. Put
them all on the piece of paper and write the part and part number.
Make sure you have the count the give you on the parts list. You
start assembling parts and use the wrong ones, you will be in deep doo doo
in a hurry and pulling your hair out.
Summary
1. Prepare for your operation in advance
2. Cushion your feet on hard surfaces now.
3. Pick a good surgeon. There are good surgeons and superstars.
4. Have your GP on top of the whole affair from start to finish. Don't rely on the surgeon to take care of all the details, he is under a lot of pressure. You may have to have an in house Doc see you every day, the surgeon will find you one.
5. Post surgery flaws there are many. Go back in the feature and read them again.
6. The ice wrap machine. Understand how it works before the operation, you may be the only one that knows how it works properly, especially at the critical period right after surgery.
7. Have a walker delivered to the hospital bed at least a day before release, so you have it to get home with that day.
8. Have the portable potty delivered to your home in advance. Buy an extra one as we recommend 2 portable potties if you have two bathrooms. The handles on these portables are invaluable.
9. Monitor and understand the Morphine dosage. If you rely on the nursing staff, you could be sucking wind. My wife even with the restricted dosage method they had for her was overdosed, twice as much as she should have had and the second night went delirious. It was a good thing our oldest daughter was there as my wife started to remove all of her wires and tubes and said she was "getting the hell out of here" Keep a chart of all medications given and what time they are given. Review them with the staff, your Doctors and the janitor too.
11. Emphasize with the Doctor that you want an early release during the day. It they want to release you at night tell them to go to hell and back. You may have to settle for early evening.
12. The Great Escape. Every one is so glad to get out of the hospital they do not plan. We did not plan. We were ignorant of the snake pit we were entering. Get your ducks in order, go back in the feature and read them again Houdini. Make sure you have the Doctor/surgeon give you a script for the pain meds a few days before release from the hospital. Don't wait in a pharmacy parking lot for an hour like we did.
13. Range of motion. This along with communication to your nerves and moving parts will be the biggest challenges of your life. Concentrate on mobility the sooner the better with both legs. It is critical. You can do it. Be understanding with the patient, this is an enormous issue and lots of love will conquer it.
14. Home therapist. Interview a few, don't take pot luck. Some are dedicated, some not. Some use the excuse that they don't want to push you, when the truth is they are lazy because other than the patient there is no one that monitors their efforts.
15. The bikes. There are many different versions. With knee replacement and the stiffness you will have for the rest of your life you need a good bike ride every day besides the rehab center bikes. We recommend a recumbent bike.
16. Rehab facilities. One of the most important factors in your recovery. In metropolitan areas there are multiple facilities. You should be able to choose one. Visit the facilities before hand. We had a good one, the Memorial Regional East in Hollywood Florida. Great people and we owe our remarkable recovery to them along with a great surgeon.
17. Don't rely on a treadmill that is in a part of the building you are in or a facility on the other side of town. Put one in your home anywhere you can place it, where you can see it and remind you to use it. It is that important. Include a good recumbent bike. Buy it before the operation, you will use it soon after getting home and for the rest of your life.
18. If you leave a loved one alone for 1 minute in a hospital, have your head examined. I left my Mother for a few hours with a broken hip. I came back to find her dead and that I will carry to my grave.
Below is our recommendation for home therapy. It is a limited amount of methods compared to the amount of methods thrown at you from all angles before you are officially released. We certainly would clear this post home regimen with your therapist while doing professional rehab and perhaps after as we certainly are not qualified to recommend a specific regimen for you.
Every patient requires certain exercises for their particular condition and only a qualified therapist can make that judgment. In other words make sure the therapist knows what you are doing, don't keep it a silly secret. Again this is what we do, between rehab sessions and most likely after we finish rehab and retreat exclusively to the home.
A. We rely on our exercise Recumbent Bike for loosening up to start our sessions. Most therapy professional sessions are preceded with a bike.
B. On the couch with the 1"by 6" Board for quad sets, getting the back of the knee down on the hard surface (You can do it). You can also use the board for slides, where with a sock you can slide your foot back and get a real good flexion.
C. In addition to the quad sets while on the couch using some Ankle Weights, a few pounds, we do leg Raises in different modes, laying on your back leg raises, laying on your stomach leg raises and side leg raises. Make sure you get professional guidance before you do any of these exercises.
D. The Step for flexion bending and some extensions, but primarily flexion bending. Keep in mind the better degree of range of motion you achieve on both flexion and extension, the better you will walk and the better your overall health will be for the rest of your life.
E. A Treadmill is one of the best exercise machines you can rehab at home with. It is excellent to deploy heel to toe motion, as well a flailing your ankles back comfortably that will not only improve your walking, but also move wastes up from your lower extremities from the specialized designed pumping action of the foot. Wastes are moved by the lymph and the lymph does not have the luxury of a pumping heart. The heart delivers the nutrients to the cells of the body via the lymphatic network. It is only the lymphatic net work that rid the waste.
If there are any questions that we can help you with do not hesitate to call us before 8:30 P.M. EST. 954-922-9181
Below is the link for this feature if you want to share or view it on our website. Please feel free to pass this information out to anyone you choose. The link is http://www.blueeyedcurse.com/Kneereplace.htm
In addition to this knee replacement feature we have a feature http://www.blueeyedcurse.com/knees.htm that covers many ways that you may be able to avoid "The last resort" surgery.
Before you pump yourself with dangerous high powered pain killers for years the way we did, keep your options open and replacement is in some cases a good option in our opinion
This information is intended to heighten awareness of potential health care alternatives and should not be considered as medical advice. See your qualified health-care professional for medical attention, advice, diagnosis, and treatments.
