2019-2 Total Knee Replacement

2019-2 Total Knee Replacement

I started having problems with my right knee in the 70’s. I think it started after an incident on the adult psychiatric unit where I worked at that time. The patient was violent and staff were trying to move her to a “seclusion room” and in the mayhem, she fell against my right knee and apparently tweaked it a bit. I didn’t really think much of it at the time and didn’t even bother to fill out an “incident report” on it. Pain would come and go over a period of time after that.

After quite a while, I was still having intermittent pain in that knee and I went and saw Dr. Isakson, my physician in San Francisco’s Castro district. He had some x-rays done and came to the conclusion that it was “probably” arthritis. I was only in my twenties! I loved Dr. Isakson. He always took a lot of time with me. He was a smoker when I first started seeing him. I think he did finally quit at some point. I did not think he got the diagnosis right.

Next, I went to the Sports Medicine department at Saint Francis Hospital and they were very thorough. They watched me walk and told me that I “rolled” my foot when I walk. They thought this pronation was aggravating the knee and not letting it heal properly. They told me that I needed to buy a better quality shoe and they gave me inserts to put into the new shoes to keep the foot from pronating. That helped immensely.

Around 2005, I was still using inserts in my shoes and had minimal problems with the knee. Then, one night I was dancing at the “White Horse” in Oakland & I came down on my right foot and could feel the insert inside the shoe slip & when that happened, I felt another “tweak” to me knee. Soon after that, I was wearing elastic knee braces to give my knee support. I put off going to the doctor for several months but the pain was not going away.

We had planned a trip to Europe for that summer. I had been hobbling around for a while on that knee but it was obvious the knee was not getting better. I finally went to ortho at Kaiser and they did an MRI & discovered that I had a torn meniscus. They would not be able to get me in for surgery until after our trip to Europe, though, (and people talk about “wait times” in other countries!). When I finally did have the surgery, it resolved the pain for about a six year period.

In 2011, I started having pain again. I went back to Kaiser orthopedics but this time, the person I saw convinced me to have a steroid injection in that knee. Amazingly, I was pain free again for another six years!

In July of 2017, I was having consistent pain again and went in and received another steroid injection. That one seemed only partially helpful, relieving pain in only a small part of my knee. I went in again, a few months later and received another injection in my knee.

Knee injections are horrible. It is not like getting a shot in a muscle at all. The needle actually goes into the joint itself. For me, the injections were extremely stressful. I had some valium left from a prescription that had been written for international travel. The valium helped a lot to get through yet another steroid shot in March of ’18. The next injection in July of 2018 seemed totally ineffective. I reached out to my Dr. and he referred me to the surgeon that had done the torn meniscus in 2005. He did not believe there was anything he could do at this point. I asked him about a knee replacement. He didn’t do replacements but referred me to someone that did.

I made an appointment with the knee replacement surgeon and he ordered an MRI. When I went to see him to get the results, he said that he thought that I could benefit from a knee replacement. We set a date for March 12th, 2019.

We were up by 2:30am on the the day of the surgery. I was supposed to drink a high protein drink at that specific time & then was to have nothing by mouth until after the surgery. We left Vallejo about 4am & got to the hospital in San Francisco at 5am. We checked in with admitting & then went to the ambulatory surgical center. It seemed like everybody in the waiting room were coughing or had runny noses!! I was put in a gown & IV was placed.

I had told the RN anesthetist about the spinal tap I assisted with at Saint Francis years previously & he assured me the epidural would not be that bad. My friend, Mark, a nurse anesthesiologist (C.R.N.A.) assured me the epidural would’t be that bad, too. When I met my anesthetist, I asked the C.R.N.A., “how many of these have you done?” and he answered, “about 80” which didn’t seem like a lot to me at the time.cThe epidural turned out to be every bit as bad as I had imagined. Several people were holding me down as the guy stuck me again & again in the spine with, what felt like a knitting needle! It was horrible. I said, “I thought you were going to sedate me first & numb the area?” He said “I did!!” I wasn’t numb the least bit!! He stuck the needle into my spine about 5 times & then I don’t remember anything until I woke up in recovery feeing drunk & numb from the waist down post surgery. I hate that “drunk” nausea feeling but I think they gave me some Zofran to keep me from vomiting. They let me nod in and out & I slowly got more awake & less numb. They had me stand. I had been told repeatedly by the surgeon, in a class, in paperwork & everybody I spoke to pre-surgery, that I would have a “nerve block.” This was supposed to be a bulb of lidocaine through a catheter into the leg, above the knee, which would keep the knee numb for 72 hours. When I woke up after surgery, there was no nerve block. The idiot, nurse anesthetist had neglected to place it!! I asked about it & they went & got my surgeon & he came & talked to me. Of course, they had put something in the joint so it felt pretty good right then. The doctor said he didn’t think I needed the nerve block because I was doing so well. HE should have known better!!!! He does these things all the time!! This was my first time! What do I know?? Then they took me to a floor & Milton was there.

I continued to feel better & they brought me a sandwich. Then Milton went & got the Prius which the discharge planner had assured me I would fit into. The Prius has pretty good leg room but I am 6’4” & couldn’t bend my leg!! My leg was put on the dashboard with pillows around me and we headed home at 3pm, right at the height of rush hour traffic!!! It felt like it took 3 days to get home!! My pain started increasing. I felt every bump in the road. I felt I might vomit. By that night, the pain in my leg was excruciating.

I tried taking the Percocet they had ordered but it made me very dizzy & sick at my stomach. I took the Zofran for nausea but it didn’t help. The doc said I could take TWO Percocet but I couldn’t tolerate even one & still be able to get to the bathroom. It felt like I had drank a bottle if whiskey. The room was spinning & the pain was a 20 out of 10. The pain increased through the night and all I could do was moan. It was unrelenting. By 7am, I couldn’t take it anymore & was vomiting despite the Zofran and getting clammy. I had Milton take me to the Vallejo Kaiser ER. They put in an IV & gave me Dilauded & more Zofran. I started feeling a lot better & the pain went from a 20/10 to about a 3/10.

An anesthesiologist came in & explained that they don’t do knee surgeries in Vallejo so they did not have the same nerve block that should have been placed the day before in SF but they had a different kind of nerve block they used for shoulder surgeries that he could inject in my thigh that should block the nerve for 96 hours. I agreed to it and then saw him bring out this huge horse syringe!!! He used an ultrasound machine to find the nerve. I was freaking out because the syringe was so big with a huge needle. He injected about 40 ml into my thigh. Do you know how much 40cc/ml looks like?? It takes a minute to inject so much fluid. I was already having less pain because of the dilauded but still felt the needle.

This nerve block made my leg numb from the knee down but still had pain in thigh & hip. I did feel better & they sent me home with some Tramadol to replace the Percocet. That keeps the thigh & hip pain in check but doesn’t cause the nausea & dizziness. The Tramadol helped me sleep which I really needed since I had not really slept since the surgery. The home health Physical Therapist was supposed to come put but we asked them to wait until Friday since we were both exhausted. I was surprised I didn’t get any calls or texts, asking how I was doing post op. I had sent a text to Darlene about how horrible it was but no response. David & Leslie apparently forgot I was having surgery. Alex had disappeared. Donna sent me a get well card & DID check in on me & my cousin, Gail, had also sent a card & emailed me after the surgery but I still felt hurt that I didn’t hear from Darlene, Roger, David, my cousin, Nola, or Alex or Lynn.

I was having a lot if emotional pain on top of the physical pain. Tramadol does apparently affect serotonin levels in the brain so this might have contributed to my post surgery depression.

My Saint Francis friends, my Kaiser friends, Milton’s family & friends, & other FB friends expressed concern & sent “thoughts & prayers” which I deeply appreciated. Some texted me and asked if they could help.

It was excruciating if I tried to bend the knee at all despite the nerve block. It was very difficult to find a comfortable position to sleep. The Physical Therapist came out Friday & went through some exercises they wanted me to do 3 times a day. I did them on Saturday, Sunday, just twice. Each time, it took hours for the pain to subside. On Monday, I was determined to do them 3 times as the therapist wanted me to do. I was up all night with pain. I emailed the surgeon at 3am & he got back to me the next day that I could double the Tramadol I was taking. When the Physical Therapist came out on Tuesday, he said I could back off on the exercises & just try for once or twice a day which I was glad to hear.

My friend, Eileen, came out & visited on Wednesday & brought me lunch. She stayed a couple hours but my stomach was gurgling & I was sleepy from the pain med & she left.

That night, about 1am, I tried to get up to pee. It is painful to go from the bed to the walker & I had to support my right leg with my left foot to get out of bed. I guess I was tired & thought I could take a short cut & did not support the right leg properly, the knee bent & the pain went to a 20/10. I tried to lurch back onto the bed but landed on a folding table next to the bed. That folding table broke into two pieces & then I landed on the plastic trash container next to the bed & that couldn’t hold me so then it sort of bent and collapsed under my weight and I found myself on the ice water machine I was using to reduce swelling & it tipped over & spilled ice water onto the floor. At that point, I was on the floor, stunned and screaming for help.

Milton was in the other room sound asleep with the TV on and didn’t hear me. I used Alexa’s intercom feature to call him & he woke up & came in to help. The next day, I noticed the huge bruise in the pic & thought it was from the fall but Milton said it had been there since surgery. The Physical Therapist came out Friday. Milton picked up my new dose of meds & I started new med regimen which was more effective. I still couldn’t find a comfortable position to sleep & when I finally did nod off, I would have to get up to pee. At that point, too, I was still waiting for my bowels to get back to normal. The pain med was constipating & when I took a laxative, it gave me diarrhea.

Bruise down right side of right leg

 

I was assigned a Physical Therapist that would come to the house. He came out to the house to teach me exercises to help me gain range of motion (rom). The exercises were excruciating. They wanted me to do them three times a day but that was just too much for me to tolerate. I did as much as I could. The therapist came out about once a week for the next four weeks or so. He measured the bend in my leg each time he came. The goal seemed to be 120 degrees of knee bend. I started out at about 80. At the end of his visits with me, the therapist taught me how to get into the passenger side of the Prius.  I couldn’t wait to get out of the house!!

Of course, through all this, Milton was incredible. He finally did go back to work, though, about two weeks after the surgery. The Physical Therapist came on that first Tuesday that I was by myself. In that session, he taught me a better way to go up and down the stairs which was very helpful as I had been pretty much stuck upstairs until that time. My friend, Eileen, came out that Wednesday & my sister-in-law, Leslie, came by on Thursday & Friday. I was getting more confident going up and downstairs by that time and was able to make myself meals.

By the 29th of April, Milton was driving me to Kaiser for my Physical Therapy. At the hospital, I would get into a wheelchair and he would push me to the Physical Therapy department. There, I would do more excruciating exercises to gain rom. Through May, I slowly gained some rom and was now at 112 but when I saw the surgeon on June 3rd, he looked at my leg and suggested that I have “manipulation under anesthesia.” With this, he would put me under anesthesia and then force my knee to bend and straighten. He wanted to schedule it for the week before the San Francisco gay pride celebration.

I have probably been to every gay pride parade in San Francisco except for one or possibly two. Milton and I had been to every one as a couple for 37 years. It was something that was important to us to participate in. The surgeon seemed to think that I must have the manipulation at that particular time. Essentially, they were going to “squeeze” me in so that I could have the manipulation.

Two days later, I had my Physical Therapy appointment but this time, my therapist was on vacation and there was a substitute. He had me do a few different exercises than I usually did and then when he measured my range of motion, he got 116 degrees. This was the highest number I had reached since surgery and I was pretty excited about it since it was only four degrees from the goal of 120. I emailed the surgeon about this and he was impressed enough that he thought we could cancel the manipulation. This was great because Milton and I had reservations at the Embarcadero Hyatt Regency for the pride weekend and would be able to enjoy that without the residual pain of a manipulation.

So, for the next nine weeks, I continued my physical therapy but now my regular therapist was back and only getting 112 degrees, nowhere near the 116 degrees the substitute therapist was getting. Over the next nine weeks, at one point he got a 114 but then was back to 112. I was getting pretty frustrated by this time and discouraged. I was having pain every day. I took 1000mg of acetaminophen with my morning coffee. As soon as I could eat something, I would take 600mg of ibuprofen. I would repeat this in the afternoon. Sometimes I would still take the tramadol and still icing the knee. The pain was not really in the knee at this point, though. It would go down the outer shin and calf muscle and up from the knee into the back of my thigh.

From my experience, I would recommend several things to others:

  1. Keep insisting on general anesthesia. You will be told the various advantages of a epidural but, in my case, the epidural was the worst part of the surgery. It was horrible. If they insist on epidural, demand a physician anesthesiologist over a C.R.N.A.. You want someone with a LOT of experience. The C.R.N.A. that did mine was too inexperienced.
  2. Keep insisting on staying overnight in the hospital after you’re surgery. They will most likely want to discharge you the same day as your surgery but if there are going to be complications, as in my case, those complications will probably come up that first 24 hours. IF there is no way they will let you stay overnight, insist on being taken off the I.V. pain meds so you can try the oral pain meds to see if you can tolerate them and if they are effective.
  3. If you live in suburbia but are having surgery in an urban area with “rush hour traffic,” be sure you are not discharged during rush hour and stuck in traffic post surgery! Make sure that your vehicle is big enough to fit your body comfortably! If I had it to do over again, I think I would have rented a van so I could have laid down for the trip home. The other option would have been to book a hotel room near the hospital.
  4. Make sure you have something ordered for nausea. Sometimes doctors will discharge patients without anything for nausea.
  5. Make sure you have a laxative available. It is very likely you will be constipated post-op.
  6. Schedule your surgery early in the week if possible. Avoid Friday surgeries as doctors are notorious for disappearing on the weekend. If something happens on the weekend, you will probably speak to someone “covering” for your doctor that may not have all the info about your surgery.
  7. If I had it to do over again, I would have rented a CPM machine (https://www.mykneeguide.com/the-hospital/cpm-machine). A friend of mine told me about the one she used after her knee replacement. There is some question about their efficacy but it only makes sense to me that it could contribute to range of motion. My health plan wouldn’t pay for one but, in hindsight, I think it would have been well worth the price to rent as it contributes to better range of motion. The exercises the Physical Therapist will instruct you to do can be pretty painful. Be sure you have adequate pain control!

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