10. Revised TKRs and Good Physical Therapists: Lifesavers no matter where you are in the world

December 12, 2018

Today marks the fifth month after my recent revision TKR surgery (and ninth surgery on my left knee) and I am feeling very, very hopeful.  Today, auspiciously, I also forgot to take my walking cane with me to the local market about 92 meters to and from my apartment.  So, I walked home with two small bags of groceries and absolutely no need for a cane.  I was so euphoric that I wrote to my surgeon back in Milan, Italy and told him all about this new phase of self-sufficiency that I am clearly entering.

But, despite my progress, I remain resolute not to assume I can return now to swimming with flippers and swiftly walking long distances or dodging traffic and deftly sidestepping potholes. The key to my longevity with this revised TKR is to adapt a more sedentary lifestyle, punctuated with daily exercises and occasional visits with physical therapists (PTs).  In fact, my success lies with the PTs as much as with my own discipline to follow their directives.  Without PTs, I might be able to heal by relying on all the exercises I acquired over the years.  But with good PTs comes the coaching, the reality checks, and the encouragement needed for the long haul.  And without a doubt, my revision TKR has been a long haul.

my knee in machine
A common site the first two months after my revised TKR: an ice-pack while in a leg bending machine.

Yesterday, I spent 60 minutes in physical therapy doing a range of seemingly simple things:  walking up and down a short set of stairs and then a set of deep stairs; standing for minutes at a time on an incline in order to achieve an extreme stretch of my calf muscles; ‘walking consciously’ by activating as many of my core muscles as possible; standing on my toes ( 3 sets of 5) and then the hardest one, stepping forward on one foot, while tapping the opposite foot forward and backward (5 times each side) before taking another step.  To top off this seemingly benign routine, I rested while having a painless 15 minute ultrasound treatment followed by 20 minutes of a hot-packed bed rest.  Yet, I limped out of the clinic in more pain than when I walked in.  Even more odd was the fact that I felt light and happy, secure in knowing that I was once again moving forward in healing and closer to a cane free existence.

Every time I invest in exercise I also invest in proving the adage, ‘Two steps forward, one back’.  Every week I witness improvements in my strength, my balance, my stamina and my capacity to function confidently.  But, with a revised TKR I could not do it alone. I need a good PT.  

I deeply appreciate a good PT.  In fact, good PTs are so important to ones’ recovery that they can quickly earn the possessive title of  ‘My PT’.  If a PT does not earn my trust or regard, I find myself using  an article dubbing them  ‘The PT’ or ‘A PT’.  Over the years, the distinction between ‘My PT’ and ‘The PT’ / ‘A PT’ has made the difference between healing and thriving or just getting by.

Wh Woman and Bl PT

What makes for a good PT? I have come to believe that a good PT knows their science, first and foremost.  They punctuate this knowledge with empathy for the physical and emotional journey one takes after an injury and they convey that empathy easily, authentically and directly.  They have command of your repair program. Yet, they are also flexible, patient and willing to adjusting the specific program to your needs based on the inevitable daily or weekly issues that can interrupt it.  They know the subtle differences between coaching and teaching and between patronizing and encouraging the patient to push themselves as best they can.  For example,  today I actually could walk further and longer than last week.  But, I lost stamina half way through the toe tapping exercise.  So ‘My PT’, Pratayana quickly steered me back to the bench where I rested and where she substituted the exercise for another.  While I still walked out sore, I was confident that I was improving while not imposing unnecessary damage on the new joint.

In contrast, back in the USA when I was healing from my first TKR,  the therapist goaded me to finish every exercise no matter how painful it was because we needed to ‘stay with the program’.  She also insisted that she bend my knee even though I had been doing very well on my own with the use of a large ball to help me with this fundamental range-of-motion exercise.  Insisting that I lay on my stomach while she bent my knee, she clearly also insisted on being the one in control.  It probably didn’t help that I had the peculiar need to see my knee bend in order to bend it to its fullest range, and preferably with that ball right in front of me.  While I suggested using the ball she insisted on her own approach.  Sure enough, she also eventually and finally gave up trying to improve my range of motion and announced that “I can do nothing else for you!  I don’t know what else I can do.”  I returned to my ball, at home, and I did finish my thrice weekly program, with her, though often enough in tears. I was not only an object for the therapist to manipulate, but I was also responsible for upholding her program, regardless of my physical state while doing it.  I often left that clinic swearing, and swearing that I would never return, no matter how many patronizing “Good Job!” judgments were also lobbed my way.  In those days, I did not have the courage to definitively speak up or to leave.  Now, age and experience has its privileges.  Today, I would do both and without a doubt.  A good therapist conveys a desire to partner with you, controls the impulse to judge and has the knowledge base to try different approaches to the problem.

In turn, a good patient will team up with a therapist and communicate clearly and honestly what works, what doesn’t, and what aches from what pains.

2 PTs and bl patient

A therapist becomes a good therapist if they are also professionally allowed to design and manage the patient’s specific repair program. But this is not always the case wherever one lives.  In Milan, Italy during my ten-day hospital stay following the revision surgery, I had a very decent team of therapists who adhered to a generic tried and true therapy program, but they had to report to the surgeons and could not apply techniques without first consulting them.  After I returned home to Rome I teamed up with Angela who did her best within the limited range of responsibility prescribed to her by the surgeon.  But she was visibly frustrated when she could not move forward from incision management and apply additional techniques because she did not have written permission from the surgeon back in Milan.  When I finally intervened and asked the surgeon for permission to use Angela’s recommended program, he said no, I don’t need it, just carry on with incision management. Granted the incision was almost  9 inches long and needed management but the total joint and core muscle structure also needed attention (see blog 8).

PT Rome
‘My Pts’ at Salvador Mundi PT clinic, Rome, Italy

The fact is surgeons do not have time to ‘know it all’, both of their own surgical studies and of physical therapy.  Most physical therapists in Bangkok and in the States are in charge of determining the therapy program of each patient.  Their pride and skills show up in the programs they design and implement to meet patient needs.  And, that program is also subject to periodic team reviews assuring both the therapist and the patient that they are on the right track for full recovery.

Sometimes, the inabilities of a physical therapist have an effect on the clinic and on the surgeon in charge.  Again in Rome, following my first TKR on the right knee,  I was briefly in the hands of a very young and inexperienced physical therapist who clearly did not know the first thing about managing a total knee replacement. He was timid, applied inappropriate exercises to the fresh implant and paid no attention to incision management.  And, unfortunately, he was the only therapist in the surgeon’s clinic.  After I returned home from my first visit with him, I quickly set up my own gym in the living room, secured a stationary bicycle for daily use in the backyard and commenced with my own set of exercises –  and sought another therapist with whom to check- in occasionally.  I also informed the surgeon of my actions.  I am sure that I was not the only patient to communicate concerns about that particular PT, but I do take as evidence of the need for open communications the fact that the surgeon, a few years later, hired a second therapist who became the clinic’s Director of PT.  Kudos to the surgeon for eventually waking up.

A really good therapy clinic will provide handouts of the exercises they expect you to practice at home. This is an empowering element to any decent therapeutic program – reinforcing information back to the client for home-based use.  Yet,  surprisingly this form of education is not practiced by every clinic or hospital. Here, in Bangkok at the esteemed Bumrungrad Hospital, surprisingly they do not offer handouts.  Instead, I go to each session armed with paper and pen to write down what I have been doing. Back at the Galeazzi Institute in Milan, the head therapist sent me back home with several pages of illustrated handouts to follow.  Though back in Rome I had to ask for a written list from my gym and pool therapists.  But after two and one half months of waiting for it, I gave up.  Back in America on the other hand,  I was able to form a thick file of illustrated handouts based on all that the PTs gave me.  It was and is part and parcel of their service.  That file of handouts became the guidebook  I referred to years later when I ran away from the inexperienced therapist in Rome.  While I did not appreciate the lack of flexibility by my American therapist managing my first TKR, I do appreciate their orientation towards patient education.  All those handouts reinforce the skills learned as well as the responsibility to apply what has been learned.

 

webmd_rf_photo_of_woman_doing_leg_swings

 

Somewhere in-between these differing PT practices lies the same intention among good PTs world-wide: to help the patient recover and become physically self-sufficient. Good PTs have figured out the balancing act required between helping and hindering and between pushing and pulling a patient towards self-sufficiency.  Ultimately, a good therapist will say, “It’s up to you.  Practice, rest and then practice again.  I willingly serve as your guide until you do not need me anymore.”

I have less than a month left of physical therapy before I am on my own.  I am confident that ‘My PTs’  will let me go without my feeling concern for losing them.

AME and CanesFINAL
December, 2018

9. My Orthopedic Story

Dislocated Knee 1985
Dislocated Patella, 1985

Wanting to know what the author of a blog sermonizing about knee repair has experienced in her life is a very fair question.  And one asked by a reader of this blog.  Knowing other readers may feel unmotivated to read a stranger’s chronology of health care events, the below article is written to try to painlessly guide you through my orthopedic life leading to my current juncture: two total knee replacements (TKRs), one revised knee (RTKR) and several interventions in between.

My orthopedic story started when I was in eighth grade and living near Minneapolis, Minnesota (1971).  I tore the cartilage in my left knee while practicing for a hoped for spot on the cheerleading squad. Since those were the days before arthroscopy surgery  was available (the less invasive/small rod insertion approach to knee repair),  I underwent two general surgeries over the course of a year to remove torn and floating pieces of cartilage. The scarring that resulted told the first of several stories. Each story left a scar, lessons learned and plenty of memories.  For example, during the second surgery, the surgeon forgot the x rays and had to have me wheeled out of the operating theater for new xrays and during that same surgery he thought it best to also scrape all the cartilage off my young kneecap. Still those surgeries did not stop me from using my knee without restrictions.  Until my early twenties, I went  downhill skiing, cross country skiing, dancing and biking (no-handed) on my way to and from the local university and from work – a county hospital where I served as a nurse’s aide and where bounding up and down four flights of stairs delivering lab results was part and parcel of my work. It was also fun.

Yet, by the time I was twenty–two (1978), this unrestricted lifestyle ensured that my knee turned osteoarthritic. My  knee ached and swelled.  I  found myself arriving late to college classes if, between them, I needed to walk a great deal. The orthopedic doctors I consulted warned me that osteoarthritis would not improve unless my lifestyle adjusted or I would find myself wheelchair bound before I was twenty-five.  What they did not know, nor did I until I watched myself respond to their declaration of ‘arthritis’  in slow shocked time, was that the ghost of my grandmother settled into my perception about the diagnosis and its subsequent management. I absorbed my grandmother’s approach to severe rheumatoid and osteoarthritis having witnessed it first hand while growing up: she walked with a cane until she needed a walker which led to a wheelchair and eventually to her bed where she stayed bound for seven years before her death. With my prognosis,  I pictured Grandmother, and thinking I was being proactive, picked up a cane as my daily tool to slowly walk my way to classes on the University of Minnesota campus.  I parked my bike in my parent’s garage and let my pool pass at the gym lapse.  I also announced to my co-workers at the hospital that I would no longer run labs and I arranged to shift to a ward secretary position where I could sit my way through to each pay day.  I also slowly walked my way into depression.  After all, isn’t that what can and will most likely happen when a person is  forced to change their life against their will and when they see no hope for a reasonable solution to a problem?

Into this period of my life came an unlikely source of hope and motivation:  a university professor of Anthropology by the name of Dr. Harvey Sarles.  I was a student in several of his classes and had quickly learned after a few in-class disagreements, to keep him at arm’s length. However, distance was not possible since  I was required to meet with him about a project. At the appointed time I knocked on his office door, cane in hand, to attend the meeting.  Looking back, it is not hard to recognize that he had given some thought to my adopted cane and carefully steered the conversation from the project to the appearance of the cane in his class.  He asked me why I was using it and so I commenced with the chronology of events that led me to needing it.  I found myself quietly but earnestly listening for guidance and any nuggets of insight from his outside perspective.  Instead, he changed my life.  I cannot recall all that he said, but he did convey these basic messages:

1) We are what we think we are, but we can change to be what we want to be.  You are not your grandmother.  Who do you want to be?

2) Doctors are not the final gate-keepers of medical information.  Research all that you can about your condition and own it.  Seek horizontal, not vertical relationships with your doctors.

3)  And, the unforgettable final and clear message,  “Get rid of the cane. That one belongs to your grandmother”.

Even now, years later, I am still touched by his gruff but thoughtful care. I hobbled out of his office feeling confused but energized, struggling to absorb a new paradigm, a new way of looking at many things in my life. I did retire the cane and I began looking for a new doctor. I also kept my activity levels tame. I was still late to class if long walks were involved. Pain was still my companion, but I did not feel like its slave.  I got to work empowering myself with whatever I could find related to arthritis.  I also, eventually, graduated with a BA in Medical Anthropology.

During this time of hope, I never let myself stray too far from the views of orthopedic doctors since I truly believed they were the only kind of doctors suitably trained to deal with bones and arthritis. My search for a ‘horizontal’ relationship with an orthopedic doctor led to Dr. David A. Fischer (1978), who specialized in arthroscopy and the emerging field of Sports Medicine. Dr. Fischer had recently introduced both new approaches to  the Twin Cities and was considered the city’s expert on knees in general.  So began a  six year doctor – patient relationship that included one arthroscopy, followed by a patella repositioning procedure requiring a bone graft from my hip, three screws and a nice long scar, and a scar tissue breaking session under general anesthesia.  But, unlike my reaction to the diagnosis of ‘arthritis’, I embraced my newly restructured knee situation with vigor and steered my six-month post-surgery repair time towards returning to some semblance of an active life.

yoga reunion
Teaching Yoga 1994-2010

In those days the subject of total knee replacement or TKR never came up to me.  I thought I had achieved full and permanent joint health.  Sports medicine personnel were not inclined to tell young people to stop their activities so I returned to biking, long walks and yoga.  I  also lugged a full knapsack through Europe for another six months. Thanks to Dr. Fischer, who advocated on my behalf, I was eventually accepted into a demanding Peace Corps assignment in a particularly  remote and isolated area of the Philippines. There I squatted for two years among members of the T’Boli community of Lemsnolon. I  comfortably climbed hillsides, owned a horse for local  transportation, climbed up and down from my stilted bamboo hut and walked great distances.

Taking new PC Vol to her village behnd Lemsnolon 2
Upland hiking, T’Boli, Philippines 1981-1983

I returned to the States and pursued professional work, married and had two children.  We eventually settled in the Washington DC area (2000, 43 years old).  Until then and since my last surgery with Dr Fisher, my left knee orthopedic incidences included very infrequent moments of catching and locking and one dislocated left kneecap (circle dancing during graduate school. I ruined the party).  I rebounded from those incidences with physical therapy and rest. Over time the incidences included grinding pain and swelling…the usual symptoms of a distressed joint. By this time, orthopedic science had progressed in leaps and bounds with TKR procedures becoming commonplace.  Dr. Ubelhardt, my then orthopedic doctor of choice in Washington DC and with whom I would occasionally check in, began to press me to accept the need for a total knee replacement.  He believed I would be happy with the new removable  ‘pop in and pop out cartilage’ TKR model.  I balked.  I had studied them and their lifespan. Psychologically I could not embrace the fact that my bones would be deconstructed, once again, and my energy channels would be permanently interrupted by two walls of metal.  His enthusiasm always met with my mortification,  and I would leave his office determined to avoid that final solution. I continued to take matters into my own hands.  I pursued acupuncture for pain, simple yoga for muscle strengthening and stretching and physical therapy exercises for muscle strengthening and alignment issues. But bone on bone does heal by itself.  By the time he gave me one more pitch for a knee replacement (2004, 47 years old) I  was at the point when my knee was controlling my lifestyle more that I wanted it to.  In fact, one day a hill got in my way and the option of a TKR suddenly felt possible, even necessary.  My two boys and I were walking back home from a nearby pool that sat at the base of a hill and I knew that I could not walk up it this time.  I returned to Dr. Ubelhardt and told him I was ready for a TKR. He assured me that I would not regret this decision and we commenced securing a surgery date (September, 2004). I was surprised by the amount of relief I felt in having made the decision to replace my joint.  I found myself preparing for the surgery with the exuberance of someone packing for a new adventure: positive energy, hope and confidence that this would be the right thing to do went into my overnight hospital bag. My eyes were wide open about the demands of physical therapy and of the repair time at home.  My family was also set and ready to support my healing. Thankfully, my sister Deb also flew in to help out. We both did not know at that time that her assistance would be the first of three times she would be asked to help post-operatively.

Though healing from the TKR was an unusually long and torturous six-month intensive process, I was, overall, a lucky beneficiary of Dr. U’s construction work. I’ll only footnote  an unfortunate episode when, two years later, I slipped on a thin veil of water and fractured the kneecap on the same TKR, requiring the cap to be wired shut, crutches for four months and half a year of physical therapy.  Aside from that, I enjoy 14 years of an active personal and professional life.  Dancing and snow sports were eliminated entirely.  Instead, I happily swam my way to a Master’s level, hiked gentle trails and walked a great deal wherever we lived.

Hiking, Italy
Gentle hiking, La Storta, Italy 2015

My right knee had been working exceptionally hard over the years and rarely complained. But about ten years after the first TKR, signs of similar decay showed up on my otherwise sturdy right knee.  While I had by then learned of adult stem cell therapy, I was  not be able to afford to travel to the United States, stay in a hotel and receive its benefits. Instead, I subjected myself to another TKR (2014, 58 years old) buoyed by the overall positive experience I had with my left knee.

Relationships, no matter how they appear, are rarely static.  Underneath the surface of the left TKR, standard daily activity was slowly but surely forcing  natural debris, produced by friction between metal on bone and plastic, to float and settle between the structures, loosening the metal from the bones, dissolving portions of the remaining ligaments and disrupting my life with episodes of giving out, catching, and swelling, or ‘failing’ in orthopedic parlance. Finally, my left knee had enough and gave out one excruciating morning in March, 2018, never returning to normal.  That July, I had a Revised TKR complete with a longer, heavier set of metal devices into bones that were also freshly trimmed to hold the new joint.  My particular recovery from this surgery continues and has been exceptionally painful, especially during the first five months – and complicated by also moving to another country. The probable need to repeat a Revised TKR on my other knee in due time is a thought that hovers and haunts, but I try to keep it at a distance.

I am no longer in my twenties or late forties.  Clearly, this 62 year old body needs more time to recover and more assistance than before.  Still, I am forming another revised life with this new knee, one that maximizes isometric exercises, weight lifting and swimming while minimizing any walking whatsoever.  I enjoy pursuing interesting stationary activities such as writing, reading, photography and bookmaking. Political punditry from my armchair is fast becoming a role I play in the home and with an interest group here in Bangkok.

In reality,  finally adjusting to a more stationary lifestyle has taken all of my life to achieve.  And though this kind of adjustment is still not easy to accept, it is easier than it would have been if I were any younger.

So, there you have it. My orthopedic story in less than 7 pages!  Lessons I learned along the way:

  • Knowing your diagnosis by its name does not mean you share everything related to it. Know yourself and you can truly heal yourself holistically.  Taking time to understand how and why you react to your diagnosis/prognosis as you do helps build your arsenal for healing the joint and the full person it affects.
  • Bodies speak to us in their own and varied languages. Stewarding our bodies requires us to learn its languages in order for it to help us heal.
  • Finances are often a key issue in ones’ healing, especially if pursuing uninsured therapies. Consider tapping personal fundraising options including online ‘crowd funding’ sites and homegrown fundraising dinners. People want to help and will if asked. I wish I had.
  • Bodies are not easily replaceable nor painless if they are replaced. No matter what professionals say, metal and glue in bones, like screws in wood eventually deteriorate.  Deterioration hurts. Entering a marathon (Brooke Shields, 2018, Florida) after a knee replacement is just plain…unwise. Youthful energy and ability to heal has its benefits and its consequences but striving to return to our previous activity level after a joint changing surgery is not always a sign of success. Returning to ‘Go!”  is not respectful of the stress that surgery has on the body over time and often sheds a dim light on the person’ s inability to adapt, to learn, and to mature as a steward of his or her body.
  • Shop for medical professionals who try to understand the above even though they work within their own constraints, defined in part by insurance requirements and standardized prognoses and surgical procedures.
  • Adventure differently. Use your creativity and venture into sedentary activities you have only wondered about. And then, when you have to or want to ‘go!’ go wisely: walk less, be driven more.  Wheelchairs allow you to go further, longer. Canes come in crazy, coordinating designs. “Go” where you have not gone before using different strategies, fueled by the power of knowing that you are protecting yourself for a longer, and equally interesting, future.

 

Family in Maroc countryside
“I made it half way!’ during a family hike outside Marrakesh, Morocco 2016

 

8. CMs: The open secret about maintaining health and achieving recovery

It is no secret that I believe it is critical to ones’ overall health and safety to avoid surgical intrusions into the knee to begin with.  Intrusions include those “Quick and easy”, “Simple”, “Just a cleaning” surgical strategies that require incisions and insertions of metal ranging from exploratory arthroscopies to partial knee, total knee and eventually, revision knee replacements.  Successfully avoiding a knee replacement until it is absolutely your last recourse is worth any effort and energy required.

“Easier said than done when you have knee pain!” you may understandably reply. True, if every step or two you take leaves you wincing then something is wrong and something needs to be done. My last blog (#7) discussed the need to review all options to ensure that you have a fair and decent diagnosis of your pain before making potentially life-changing decisions. But, what do you do in the meantime, before, during and after a decision? Invest your time in building up and maintaining your core muscles, or CMs.  I would also add-in calf and ankle muscle strengthening exercises for full-measure.

The core muscle group includes all muscles in your back, abdomen, hips and upper thighs.  They enable you to balance, to remain stable or resume stability after a twist, a leaning, or a fall.  Core muscles support and stabilize the spine while also enabling the shoulder, spine, pelvic, hip and knee joints to fulfill their duties, and usually with less pain (among others: Journal of Orthopedic and Sports Physical Medicine,  www.jospt.org/doi/full/10.2519/jospt.2018.7365).

core-muslesBy their large group sizes, CMs offer the illusion of leading us to believe that they are in decent, if not excellent shape.  They continue holding us up, keeping us walking, allowing us to lift and twist.  Aqua gym, carrying groceries while closing the car door, and lifting the grandchildren seem to offer few or no problems.  Hmmm…Knee pain has a way of seducing our minds, as well as our CMs, into believing they are strong when, in fact everyday that they are not specifically exercised their strength diminishes. If you suffer knee pain and naturally reduce your activity level but do not maintain specific CM exercises, you will soon learn that these diminished muscles contribute to your knee pain and affect knee rehabilitation, especially after a surgical intervention. This fact became painfully clear to me when I was ordered to lift my leg after knee revision surgery. For three days,  I not only struggled with this simple exercise, I strained a groin muscle trying to activate my thigh muscles and then lift my leg.  I had been protecting my knee from pain for so long that I neglected the rest of my body, and especially my core muscles.  Better to keep your CMs fit and ready for anything than to allow them to rest along with your painful joint.  Like throwing the babe out with the bathwater, too much is at stake and too much is lost by ignoring this vital group of protectors when you have specific knee joint pain.

Simple Quick CM check

Lay on a firm surface. Bend one knee and place that foot on the surface next to your other straightened knee. Keeping your feet 90 degrees from your ankle, lift the straight leg about 30 degrees and hold it for ten seconds.  As you lift pull your navel back towards your spine,  Slowly bring the leg down all the way to the floor.  Repeat ten times.  If your thigh muscles begin to shake, if your lower back begins to ache, if your stomach muscles feel the strain, then you know more attention to your CMs is required.

Better to know now than later so you can do something about it.

women-who-plank-together_4460x4460

I have been relearning over the course of these past nine months that building up and maintaining my core is what allows me to walk, and then to walk evenly. Core muscles have ensured that my thigh muscles can lift and hold my leg, bend my knee and bear weight at different angles. Core muscles compensate when the joint is loose, offering balance and leverage.  My tendency to fear being jostled or pushed, actually tripping, or worst of all, falling (Blog 4) has decreased the more I have increased time building my core muscles.  Four months after my knee revision surgery, I have actually begun forgetting my cane occasionally since my CMs are – now- doing their job. Twice this week, I had to walk back to get my cane that, for so long, was an extension of my arm.

Many core muscle exercises are offered online and at your local gyms, YM/WCA’s etc. Your physical therapist will certainly be able to show you a collection of exercises tailored to your particular therapeutic needs.  The investment needed to get that kind of advice, and the discipline you will need to maintain your exercise program will not let you down.  Without trying to be cute, ‘get a leg’ up on self care by paying attention to your CMs.  Doing so will bring a certain kind of agility, strength and physical confidence that can make the difference between suffering and repairing.  Slowly but surely.

young-woman-stretching-in-a-park_4460x4460

Additional Resources among many:

7. Total Knee Replacements leading to revisions. The Stats. The Questions.

Back in the early 1970’s, I recall Mr. Keever, a robust, good old family friend sitting in the passenger seat of his parked pick-up truck in our driveway.  His wife was inside having a quick catch-up coffee with my mother.  When I went out to say hello to him, I found him uncharacteristically leaning on the dashboard close to tears.  He pointed to his knees, mumbled “Knee replacements” and added that he was in too much pain to join us.  He waved me away. “Wow!” I said to myself. “I hope I never have to have that!”

Image result for photos, knee replacements

In fact, in 2003 when I was 47 years old, memories of Mr. Keever came back to me when I was struggling with chronic knee pain.  My then tried and trusted orthopedic doctor, Dr. U. cavalierly declared after my umpteenth visit to him:  I really wish you would just allow yourself to have a total knee replacement (TKR).  They are easy!  We implant the metal and the plastic cartilage.  When you wear out the plastic, we just pop them out and pop in another set!  Admittedly, his confidence and that last line sold me.  I later learned I was one of his first TKR patients. He needed the experience as much as I needed a resolution my pain.

Fast forward to early spring, 2018 when my orthopedic surgeon, Dr. B. broke the news to me that ‘popping in and out’ a set of plastic discs was not possible, that I had been fed the wrong information.  Instead he enthusiastically described a revision procedure calendar:  Yes, there are risks, but let’s assume the (first) revision will last ten years.  You will be 72 by that time.  You can have another revision then.  In fact, you will still have time for another after that assuming you are…you know, still here (alive)!

Image result for photos,revised  knee replacements

Deciding to have a total knee replacement and then a total knee revision is more complicated than that and should be more thoughtfully decided – although current and projected numbers suggest otherwise.

TKR AND TKR REVISIONS STATS.  THEY MAY SURPRISE YOU.

Various sources have published statistics on long-term primary and revision rates for TKRs.  Sources I have found useful over time include:

The Total Knee Replacement (TKR) procedure, in the USA, was developed in the 1970s and then disseminated across referral centers and then community hospitals in the 1980s and 1990s.  By 2014, TKR utilization exceeded 650,000 cases annually in the US and many more worldwide (Katz JN, Editorial, Arthritis Rheumatol. 2014 Aug;66(8):1979-81. doi: 10.1002/art.38688).

Healthline conducts their own surveys using Medicare and private pay records as well as data from the U.S Department of Health and Human Services Agency for Healthcare Research and Quality (AHRRQ).  They also rely on meta-analyses of worldwide joint registry databases. Healthline data indicates that growth in the use of TKRs has occurred primarily in patients 45–64 years of age. TKR utilization increases dramatically in the age group 50–59 years of age and primarily among women

To assess revision rates, Healthline analyzed approximately 1.8 million (USA) Medicare and private pay records to find that the rate of revision for all age groups within five years from surgery is about 7.7 percent. The rate increases to 10 percent for those age 65 and older. Healthline also found a somewhat parallel number WORLDWIDE based on a meta-analysis of international joint registry databases (2011):  the revision rate is 6 percent after five years and 12 percent after ten years.  People are turning to revisions worldwide and the numbers are not decreasing.

Leaping ahead, the American Academy of Orthopedic Surgeons (ASSOS) anticipate that by 2030 projected growth of dependency on TKRs will increase by up to 189 percent, or 1.28 million procedures annually. (The ASSOS clarifies that these numbers are always shifting but not substantially from the pattern set)

Similar gains by 2030 are expected for revision TKRs, growing by 190 percent or 120,000 procedures.

By 2060, primary TKRs  are expected to reach 2.60 million (382 percent increase), while revision TKRs s are expected to reach 253,000 (400 percent increase).

The mean age for primary total knees has declined significantly from 68 years to 65.9.

Females continue to make up the majority of patients at 55-62%.

It is interesting to note that a study in Europe found approximately 20% of all TKRs were judged to be inappropriate when using a combination of assessments including a formalized Osteoarthritis Index pain and physical function scores, radiographic features, knee motion and laxity measures, and age factors from patient pre-surgery histories.  The same research was completed in the USA and found that one-third of TKR procedures were deemed unnecessary.  (Riddle DL, Jiranek WA, Hayes CW. Arthritis Rheumatol. 2014 Aug;66(8):2134-43. doi: 10.1002/art.38685).

[In an editorial rebuttal to the above study, it was pointed out that, because a universally shared set of assessment criteria has not yet fully been developed and therefore not shared, the findings should not be considered conclusive.  (Katz JN, Ibid)]

OK, THOSE ARE THE STATS.  NOW WHAT?

How do we, the clients, make sound decisions about our health before we become the patients?  We can begin by exploring our true options. They tend to be wider than the traditional orthopedic community is able, or in some cases willing, to lead you to think. Knees are connected to hips and spines, core muscles, ankles, shoulder blades.  They are responsive to climatic humidity and emotional highs and lows, diets and/or lack thereof. Cells have memory.  What is a flinch? A shudder? Anxiety, but a physical response to deep empathy or remembering trauma or disgust.  What your body is struggling with is an ecosystem full of important issues we, as body stewards, have to understand before we sign off on an irremediable change in our lives and in our lifestyles.

YOUR PERSONAL CHECK LISTS

Consider the below unofficial checklists following your first round of traditional x-rays.

A.  You have chronic pain but your Scans show NO structural changes to the joint:

  • Test for rheumatoid arthritis, bursitis, fibromyalgia, lupus etc.
  • See Osteopath for body alignment issues and corrections
  • See Podiatrist for foot/ankle/knee issues and corrections
  • See a Physical Therapist for muscle strengthening and additional alignment exercises
  • Meet w/ Stem Cell Orthopedic Specialist to assess options (For trained doctors in your area go to http://www.regenexx.com)
  • Soften or remove high impact physical activities, incorporate core muscle exercises
  • Add-in alternative low-impact activities
  • See Acupuncturist for pain management
  • See Dietician for nutritional assessment
  • Lose weight for joint health
  • Adapt home layout for easier movement
  • Consider replacing manual car with an automatic one

B.  You have chronic pain and your Scans SHOW structural changes to the joint:

  • Accept that lifestyle changes must be made
  • Assess Orthopedic options
  • Assess Stem Cell Orthopedic options (For trained doctors in your area go to http://www.regenexx.com)
  • Incorporate all healing activities (Osteopath, Nutritionist, Podiatrist, Physical Therapist) listed above
  • Replace all high impact physical activities with leg/core muscle strengthening exercises
  • Lose weight
  • Adapt home layout for easier movement
  • Replace manual car with an automatic.
  • Then decide on joint repair options and /or continue with modified lifestyle

Full body scans, if affordable, can be considered for assessing bone on bone relationships not only in the knees but elsewhere in the body that affects your ergonomic stature.  Osteopathic medical doctors offer holistic points of view on these scans and accompanying strategies.  Changing your physical patterns of behavior may be critical to your long term joint life: does an afternoon of downhill skiing really need to be on your agenda?  What about the pleasures of simple yoga, swimming or isometrics?   If limited knee flexion and instability prove to be the outcomes of arthritis does a change in diet, strengthening of your core muscles and use of acupuncture help, for now? Remember,  certain kinds of (older) manual cars automatically (pun intended) create a persistently odd hip/knee/ankle alignment.  Can you exchange cars for your long term mobility’s sake?

Does fear of chronic pain veil periods of painlessness? Does the undesirable demand to change personal behavior first cave to the desire for a professional, aka legitimate and  immediate ‘fix’ now – when, in the back of your mind, might be the nudge to wait? In the end, do the gains (from surgery) outweigh the harms now and into the future?

The more boxes you tick off that complete a full scan of honest mind/body/ environmental concerns, the more confidence you will have going into your total knee replacement, if that is the final solution.  The same absolutely applies for when you assess the need for a revision of your knee – though by then the evidence tends to be unquestionable.  The emotional collateral that you amass on your journey to the operating theater is the collateral you will rely on during the repair phase, both times.  Protecting yourself from undue joint replacement is worth the effort and the money and the time since once you start on this path there is no turning back.  Take it slow if you can.  For now, you can be the client, not the patient, looking for answers that are right for you.

This is a big topic.  More can be said.  What do you say?

6. An Alternative to Knee Replacements

Legs, Walking, Walk, Limbs, Motion

My husband and I recently strolled the Rome film studios of Cinecittà. As film buffs we found the tour fun. I also found it sobering. Walking is a privilege I, of course, took for granted most of my life. Even my joint replacements offered good years of exercise though I should have slowed down some in order to give my joints more ‘shelf-life’. Now, I am thankful for days that are pain free.

Please consider a few lessons learned about knee replacements for ridding yourself of pain: orthopedics is an industry as well as a medical field of study and one currently tied to implant manufacturers first, regenerative medicine, or stem cell therapy, second or third. Knee replacement should only be a decision made when all else fails. In the States, replacements are being offered at far too young an age when in fact, they only last between 10-15 years before your bone or their metals begin to crumble. Mine lasted 14 good years. The revised surgery I succumbed to four months ago, with a non active lifestyle, will give me another ten years I am told. The options after that? Revised replacement of my revised total knee by perhaps age 72, joint fusion, and/or a wheelchair.

If I could do it all over again, and now with stem cell therapy as a viable option, I would invest in stem cell therapy and as soon as a joint problem becomes chronic. My older brother took this route a few years ago with his left knee and within three months of a week’s worth of medical care, returned to biking, skiing, and windsurfing.  By investing in adult stem cell therapy, he also invested in more time to rely on his own body’s natural resources during his later years when invasive surgery is unarguably more traumatic. In comparison, I have used up my body’s options by relying on metal joint replacements and see a future surrounded by equipment, and limited exercise options currently including swimming and weight lifting.

Consider saving for stem cell treatment for inevitable joint pain. Look up the newest research by visiting www.regenexx.com, the Mayo Clinic, or the Galeazzi Institute in Milan where I completed my revised knee replacement and began once again with hands-on lessons in the relationship between body, science, and health.

5. Chronic Pain

Natural pain

The doctors said that healing from a revision knee replacement surgery would take at least 6 months to a year.  I nodded in agreement before I had the surgery.  Now, I hang my head in frustration, almost despair.

These feelings are not because of the days, weeks, and now months spent hoping to awake to feel nothing.

They are not in the quiet glances or overt stares at me by people on sidewalks, restaurants or public transit here in Bangkok.

It is not in my audacity to demand a seat on the metro or in my carefully slow pace forced on others so that I do not trip, fall or twist on the uneven pavement or as I go down stairs.

And it is not in finding myself sensitive to the irony of  infinitives that now require careful renegotiation:  To Walk, To Move, To Meet, To Hike, To Run, To Shop, To Sightsee, To Sleep.

It is in the pain. Chronic pain.  Four full months after surgery, the physical and acute squeezing of a negative life force through the tendons, up the muscles and between the fascia is the ‘it’ that brings me and my daily life to a halt. Gripping the cane or the crutch ferociously, I strive to find a chair, a bench, or, caught  on the road, the fastest way to get home so I can put the bloody leg up to rest, hoping a phone doesn’t ring or the bathroom does not need me so that I can have some uninterrupted time to rest.

More to the point, I rush home so I can stop.  Stop moving, stop straining, stop feeling the pain.

After months of this kind of pain, I review my life and dismally realize that I feel like I have stopped contributing, stopped being in the stream of lives around me. Stopped exploring, stopped chatting.  Stopped seeking the company of others – stopped being meaningful.

Not too long ago I used to find shelter in my aloneness.  It did not feel lonely, it felt essential to my healing. Now, this pattern of aloneness does not seem to abate:  I feel the confines of my apartment as much as I feel the doubts of success this surgery promised to provide.  For many more than six months since the metal joint first slipped,  I have been wrestling with pain, with mobility – negotiating with it every moment of the days, and sometimes the nights.  It always wins.  My life is in the hands of the worst part of my physical self.  Bodily pain: mobility captured, caged, controlled, limited.  My reaction, left unguarded, allowed to be undisciplined, becomes the worst my mind can generate: depression, despair, loneliness, irrelevance, nothingness as I sit within my walls.

Of those who ask about our lives since we moved to Bangkok,  I try to keep the answer honest but upbeat with alternative news that from time to rare time is a form of truth.  The pool is a sanctuary, a haven; the food, incredible; the sites, unbelievable.  Some might call this flick of truth diplomacy.  In truth I simply crafted  a story lived by the someone else I had hoped to be by now.  Yes, my life has overall been rich, full, lucky. But, my reality is underwritten by an unfortunate outcome of the surgery.  How long inquiring people remain in my life depends on their capacity to believe that I am more than the pain that stifles my life.  And success in my life requires moving beyond the pain and crafting a revised lifestyle that does not allow pain to be its centerpiece.  That feat, however remains a daily, sometimes mountainous task.

Some days are better than others.

Today, I am staying home for a “Knee-First” day (see Blog 3) to rest completely, having cancelled my plans to visit a Thai language school. What ‘staying home’ means is that I am to do nothing, absolutely nothing that requires walking except to complete a few exercises. The pool sits above me, on the 8th floor, waiting.  I drool over it but keep myself locked in this apartment to give this leg, once again, the time it needs to stop aching, to stop speaking in the various dialects of pain: pain when standing, pain when walking, pain when leaning too far forward or too long in a sitting position.  While my Thai language is very limited, I have become quite fluent in the language of pain.

I can assure you that this knee will heal enough to give me the pleasure of a few minutes of painless walking, and just as quickly, the illusion that I have passed into the phase of full repair, now able to thrive, plan, ‘do’. This is when I am at my best.  I make plans. I see the possibilities in front of me with the excitement of a starved person in a grocery store.  But then the tendons freeze, the muscles ache into shooting pain and rise to meet my new metal knee seemingly with a malignant laugh.

Pain like this teaches you to let go of plans, and start over. It teaches you, despite it all,  to never give up on the day that will come when the pain is marginal at least or non-existent, at best.

And so the wrestling match continues. Today, I must live in the pain and allow it to master me. Tomorrow, I will live with the pain and get on with life joining how many others in this world who struggle with the same: pain and less pain.

4. FEAR

Stairs and LightDaily fear.  Given options, I typically prefer a  “Be Calm, Soldier On” attitude when repairing from a physical trauma, especially if the entire process is relatively brief.  But, to return to full mobility, a revised joint recipient needs to maintain a physical discipline of bending, strengthening and lengthening stubborn body parts up to and beyond a year to experience decent results.  But physical therapy is not all that is required, by a long shot.  Added to this regime is the need to calculate walking distances, arrange alternative forms of transportation, allow the house to collect dust until ready to use hard-earned mobility to clean it.  Plain and simple acquiescence to the norms of this new regime also is a critical requirement to this revised lifestyle.  I find that fear, now, is a norm and takes on more poignant, ‘ever present’ attention when managing recovery.

Perhaps prior experience lends to my stubborn hold on fear.  Working full-time after my first knee replacement, I turned a corner in a recently mopped, but no warning signed hallway, and promptly fell on all fours, fracturing my kneecap on the two-year old knee replacement. I was immobilized for four full months, bearing no weight on that leg, still raising two boys and managing a townhouse, while taking work disability to try to make up for my lost salary.  I returned to work in a knee brace that required an additional two months of wear and then proceeded with 6 months of physical therapy.  Al tol, I added another year of recovery to my recovery process.  Thankfully, I did repair.  But I have no illusions about the change of lifestyle a break forces on adults, their families and their professional lives.

We know that fear serves the important purpose of sensing danger and threats to ones’ existence.  Joint revisions naturally incorporate fear to sense real threats found in everyday life: fast moving crowds, uneven pavement and steps, intrepid traffic, disrespected pedestrian walk-through zones (‘zebra-stripes’) and slippery walkways all contribute to daily worries, daily fears.  Slipping in the shower, banging the knee into a coffee-table, getting up from a chair too quickly can all result in acute moments of pain and possible damage to the joint. These daily fears, week after week, now three months running wear on me. Never have I wanted to incorporate more mind shifting substances (marijuana, medicinal and otherwise, sleep enhancers, alcohol, mediation, relaxation music, massage, etc…) into my daily life as I have now, following joint revision surgery.

Threaded through these management methods lies a cemented acceptance that whatever happens, has to be accepted.  Seeking to absolutely control present day dangers and their accompanying speculation, forecasting, and anticipated consequences is an illusion.  Fear creates the concern and alertness, as well as produces the strategies, the diligently designed ‘protection plans’ needed to potentially alleviate each situation.  But these plans cannot ensure avoidance of all possible accidents. They help us move forward though.  And, put into practice, these plans become behavioral patterns now common in ones’ life.  When I got on the back of the motorcycle the other day (Blog 3) and easily placed the crutch between my shoulder and my chest, and rested its base on my foot, that was a quick, almost mindless act culminating from weeks of practice. I looked comical, but I felt secure – as much as one can on fast-moving motorcycles weaving their way through moving traffic at rush hour… We can only try to minimize threats to ourselves with strategic planning and ‘safety-first’ decision-making, put into practice often enough to create confident, adjusted, behavioral patterns – ideally supported by calm-inducing moments in the day, as we live our revised lives.

Today, my husband and I will use the metro system to meet a real estate agent in a southern section of Bangkok.  I will put on my light-weight cross-shoulder bag, and walk an additional 400 meters from the metro to get to the door of the apartment complex.  This will be the first visit of 5 we will make today in the same neighborhood.  While I have point-blank reminded the agent three times that I have limited mobility she continues to assume that I can walk as far as she can, youngster that she is.  Lack of empathy, determination to succeed in her profession, stubbornness or dull headedness motivates her as much as fear of pain and of damaging my joint again motivates me.  We will take a metro and Tuk Tuks or small electric rickshaws as often as we can. I will let my husband see the apartments while I sit in a coffee shop waiting for his reviews and his photos.

So, again, fear and strategic thinking must go hand in hand, never trumping the other. Otherwise, ‘housebound’ will be my lifestyle far too soon in my mind and in my life.

EXERCISES today

Saving myself for the adventure later today, I limit my morning routine to straight-legged lifts and knee bends.  When we return, and depending on my pain threshold, I will try to go up to the pool for the rest of my routine as listed in Blog 2.

Onward readers!  How is your day going?