You wake up in the recovery room following the surgery and feel great. Relief washes over you knowing that you’ve finally done it. Smiling you nod off to sleep and they take you up to your room.
Now what?
If phase one was years of dealing with knee pain, having a hard time walking, finally coming to the realization that you need a replacement, actually scheduling it and showing up, then phase two begins now. Likely your surgery was in the morning and by afternoon they bring you a lunch plate. The knee still feels great as the medications and or the nerve block are still in full effect. Soon, physical therapy will come to the room, introduce themselves and tell you it’s time to get up and walk. They bring a walker and a belt to put around your waist so that you don’t fall if you get queasy, weak or simply can’t stand up quite right. Usually that first walk is to the bathroom or to the door and back, possibly further if you feel like it. You get back into bed and it feels good as you’re tired. Therapy will hand you a sheet of exercises similar to the ones you’ll find at the end of this article and hopefully run through those exercises with you.
I recommend that you print these off as they are the standard exercises given by most surgeons and therapists to most patients. (Possibly some slight differences and if your surgeon or therapist gives you different exercises, you should obviously use those). In practicing them prior to surgery you’ll be better prepared to do them after surgery. This same pattern of therapy walks and exercises will be repeated for the next 24-48 hours until they send you home.
Going home:
Hopefully you’ve seen my other blog posts and read the post re: what you should do before surgery which includes home prep, meal/grocery prep and many other suggestions. It will make going home much easier. If home health hasn’t been ordered please ask your surgeon to order it for you. You’ll need another set of eyes on you and having nurses and physical therapists working with you will speed your recovery and improve your safety if something isn’t going quite right.
So what should a normal day look like? It’s better to get into a routine and let’s start with:
Pain medications
First and foremost this is a painful surgery. Respect that. If you need the medication, take it. And it’s better to be on a regular schedule. Frequently people want to wait until pain levels start to rise before taking their meds and this is a mistake. In the medical field we refer to it as being behind your pain or chasing your pain. If you’re behind it, it’s hard to catch up. You’ll want to stay on a regular schedule for the first two weeks. Usually doctors will order 1-2 pain pills every 4-6 hours. Figure out what frequency works for you and stick to it. You’ll sleep better and be able to move around and exercise more if you’re not hurting as much. No one wants to stay on opioids long term and it’s fine to start getting off of them as soon as you can, but the first two weeks are rough and regular pain medications will help. ***A quick side note re: pain meds – they can cause constipation. Everyone is different, but you will likely get constipated if you aren’t used to opioids so plan accordingly, speak with the surgeon and have foods/medication on standby if needed. Many surgeons prescribe a stool softener after surgery.
Icing and elevation
I tell my clients that they need to lie down in bed, with their leg elevated on pillows(higher than their heart and no, recliners don’t count) and with an ice pack a minimum of six 30 minute sessions a day. This will decrease swelling, decrease pain levels and improve healing. The more swollen you are the worse blood flow is (congestion) and the more pain you have. More swelling = more pain/Less swelling = less pain. It’s as simple as that. Set a routine and stick with it. If you have a CPM (continuous passive motion machine) coordinate your ice and elevation sessions with the CPM. Get in all 6 hours of the CPM if it’s been ordered for you.
Exercise/Walking
Twice a day is preferred for your exercises. You may have received a set of exercises from your surgeon or PT and if not click the link at the end of this article and print those. Perform your exercises twice a day and try to get as much bend and straightening as you can while performing them. These exercises really aren’t designed to build strength, but rather to wake up your leg muscles that are still in shock from the procedure. Frequently people will look at their leg and say “It’s not moving like I want it to.” All normal, just push through. For walking, try to get up frequently (1-2 times an hour) and take a lap around the house. We want you walking frequently but not so much you increase your swelling.
Sleep
For the first two weeks sleep will be a bit rough. Get what you can. We move around when we sleep and when you move normally at night you’ll wake up due to the discomfort. Sleep improves after the first two weeks. Just grab as much as you can.
Other notes:
Keep your incision dry
It’s likely you’ll have a silver impregnated dressing covering your incision. If you have a dressing leave it unless instructed to remove it. Do NOT apply creams, balms, salves, vitamin E oil or anything to the incision. Do NOT soak your incision. No baths, pools or hot tubs. If you have staples they’ll be removed between day 10-14. Even after the staples are out you won’t want to apply anything to your incision until it is free of any scabbing (even little ones) and completely closed. Call your surgeon or therapist with any questions. If you run a fever higher than 101.5 degrees, call your surgeon. Some surgeons protocols are different ie: 101 degrees, but high fevers need to be reported immediately.
Clot prevention
A very real potential issue are blood clots and you don’t want one. You’ll either have compression hose, prescribed blood thinners (sometimes an injection), or both. If you’re supposed to wear hose, wear them. If you’re prescribed blood thinners, take them. Clots don’t happen often, but they can, so please do your part to prevent them.
I’ve been a physical therapist (PT) for 24 years. Good for me right? No, good for you! This means I get to share things I’ve learned and you get to keep your $25-$75 (…or sometimes more) co-pay. In this article I’d like to discuss falls, mobility and maybe, just maybe, how to live a bit longer. First of all, what is mobility? By definition mobility means “the ability to move or be moved freely and easily,” but I’d like to drill down and be a little more specific. Today I’m talking about joint mobility. Everyone knows that as we age our joints don’t move as well as they once did. This can begin the slow decline of “I’m not moving as fast as I used to”, followed by “I’m not moving as much” and then comes “It takes me longer to get around…” Eventually you’re moving less, you’re losing strength and you’re losing the ability to move around as you want. So begins the downward spiral…can you see the tiny little whirlpool above the bathtub drain and hear the sharp little sucking sound?
Wow, that’s depressing! There is hope. Please read on.
All this “not moving as well” and “decreased joint mobility” that we accept as we get older puts us at a higher risk of painful joints, loss of strength, more falls, inevitable fractures and a shorter life span. Not good… not good at all. I’m privileged to work with a wide variety of clients of all ages. I used to be surprised by the lack of joint mobility I would find in people in their 30’s and 40’s, but not anymore. Sad to say that nowadays I expect to find a lack of mobility in my younger clients ankles, hips and backs. It becomes even more restricted in older adults.
Let’s talk about the hips for a second. They are the second most mobile joint in our body only beaten out by the shoulder. Our hips are made to move in every direction, even to rotate on their axis. Quick question…can you sit Criss-Cross-Applesauce? It requires hip flexion and “external rotation”, (a big $10 word that we PT’s like to use when we’re trying to sound important) which means rolling the thigh outward. If you can’t, you should start. Try it while you’re watching TV. Lean back on the sofa and pull those tootsies up into your lap, let your knees drop down and feel the stretch. Better yet, sit on the floor in front of the couch and try it. Get those hips opened up; your back and knees will thank you.
“OK, so what’s this about a shorter life span? Are you saying that because my hips and ankles aren’t loosened up I won’t live as long?” No, I’m not saying it. In a study published in 2012, Dr.’s Leonardo Barbosa Baretto de Brito Claudio and Dr. Claudio Gil Soares de Araujo, et al, say it. For their study, participants aged 51-80 took what they named the “Sitting-Rising Test.” Study members would stand in the middle of an open area, get down to the floor and then get back up. Pretty simple, yes? Possible 5 points on the way down and 5 points on the way back up. Every time a hand, elbow, knee or any part of the body was used for stability or to push, a point is deducted. For example if you put two hands on the floor to get down, that’s a 2 point deduction. If you use a knee and a hand to get back up to a standing position, that’s another 2 point deduction. In this example you’d score a 6/10. The long and the short of the findings are that for every point drop in your score, your risk of dying increased by 21% over the next 6 years compared to someone scoring higher. In this example, your score of 6 puts you at a 42% higher risk of mortality in the next six years than someone scoring an 8.
Having said all of that I don’t believe the study is all encompassing, there are a great deal of variables and maybe even a few flaws (as can be found in all scientific studies). The study was large (over 2,000 people), looked at “all cause” mortality, (meaning if you flamed out on the highway due to an 18 wheeler smashing you, it still counted), but they collected a lot of data. With a study group that large you will begin to see trends. I’m not here to debate their findings, but I will say even if they’re only half right it presents a strong argument for working on your flexibility and strength.
Working on your flexibility and strength doesn’t have to be a major undertaking. Even the simple act of getting down on the floor and getting back up will do it. Ask anyone over the age of 60 “When was the last time you got on the floor?”. I ask this of all my patients over the age of 50. My favorite response of all time was “Do you mean voluntarily?”. Yes, voluntarily, when was the last time you got down on the floor? The usual reply is “I can’t remember.” or “I get down to play with my grandchildren but I have to scoot over to the couch so that I can get back up.”
Falls are a huge problem in the US (and the world). I don’t have the data to back up this next point, but let me ask you. Who is more likely to fall? Someone that actively gets up and down off the floor 10-20X a day, or the person that never gets on the floor and hangs onto furniture as they walk throughout the house? To be fair, there are many potential causes of falls in older adults, poor eyesight, poor hearing, medications, illness, diseases (think Parkinson’s, Diabetes or Stroke), throw rugs, comforters draped off the end of the bed…the damn cat. I’ll bet you $1 that someone who is used to getting up and down regularly is less likely to fall and more likely to get back up after said fall (barring serious injury, yes, I’m looking at you hip fracture) than someone who hasn’t been on the floor in months, voluntarily.
If you, dear reader, are feeling like you’re not moving around as you’d like or have a real fear of falling and want to begin, please check with your doctor or PT first. If the thought of getting on the floor and back up is scary, then I’m talking to you. Get with a PT that can assess you and teach you how to do it safely. If you’ve had a knee or hip replacement, it doesn’t exclude you, but you need to be careful. You’ll need instruction, seek it out.
If your thought is “What a pain in the a$*, I don’t need to do that!” then you NEED to begin. Clean your baseboards, hit a yoga class(es!), sit and watch TV in front of the couch “criss-cross applesauce”, simply get up and down 10X in the morning and 10X in the evening. Heck, do a Turkish Get Up! (I have no affiliation with www.exrx.net, simply like their explanatory video) The Turkish Get Up is my favorite “all body” mobility, stability and strength exercise. Perform two of them on one side and two on the other. Just do it without a kettlebell or weight until it gets easier. Much better than Burpees. (I love hate you Burpees).
There you have it. It is vitally important that you stay mobile and strong as you age. Falls suck. Lying on the floor for a long time after you fall, sucks. Hip fractures suck. Surgery sucks. Being scared of falling sucks. Spending a few minutes a day working on your mobility/strength, being more confident when you walk, reducing your risk of falling, putting yourself in a position to get back up after you fall, and maybe even living longer, most decidedly Does. Not. Suck.
That was my exact question going into the continuing education course I attended in early October. Obviously it’s about getting poked with a needle, but what does it do? What are the benefits? Does it hurt? How is it different from Acupuncture? Why is it dry?
The course I attended is based on the teachings and studies of Dr. Yun-tao Ma of the Integrative Dry Needling Institute. The purpose of this article is not to discuss what was learned, but rather to share the benefits of the therapy.
What is “Dry Needling” and how does it work? (This is taken from a patient information handout authored by Integrative Dry Needling) :
“Integrative dry needling is not acupuncture (traditional Chinese medicine), it is based on neuro-anatomy and modern scientific study of the musculoskeletal and neuromuscular systems. A very fine filament needle is inserted through the skin and into the deeper tissues that are considered trigger points to your pain. Dry needling works by causing a micro lesion within the pathological tissue thus breaking up shortened tissues, inhibiting a reflex arc from the nervous system to the tissue, normalizing the inflammatory response, and centrally mediating the pain. This mechanical and neuromuscular effect provides an environment that enhances the body’s ability to heal which ultimately reduces pain.”
What are the benefits? As noted above by normalizing the inflammatory response, inhibiting reflex arcs and mediating pain, people receiving the therapy can enjoy improved range of motion, increases in strength, decreased pain levels and many other health benefits.
Does it hurt? The needles used for dry needling are very thin, think human hair thin. Sometimes people feel a slight sting when the needle enters the skin. As the needle is advanced sometimes people will describe different sensations, such as a muscle twitch. On a personal note, with several of the needles I felt what would be described as a deep and mild ache. This is actually desired and let’s the practitioner know they are in the right area. Over the course of the this past weekend I was “needled” close to 80-90 times. I can guarantee that I said “Is the needle still in?”, more than I flinched or said “I felt that.”
Why is it called “Dry Needling?” If you receive an injection, say at a doctors office or a flu shot at the pharmacy, a medicine is being injected. You have fluid being inserted into the body. This is “wet.” In the case of “Dry Needling”, no medicines or solutions are being injected, quite simply a “dry needle”, hence the name.
I can vouch for the decrease in pain levels. I was the class guinea pig for the section of the course that involved lower leg needling. I was needled 8 times from the knee down on my left leg. I personally didn’t experience the immediate relief that many people get, but when I walked into the clinic Monday morning I literally begged a co-worker to needle the same spots on my right leg. The difference was that significant.
The bottom line is that I’m extremely excited to be able to be able to offer this service to my clients. Since attending the course I’ve been able to offer this therapy to several people and I’m excited with the results so far. I’m not going to tell you that it’s for every client or for every condition, but for those it can help, good things are coming.
A lot has led up to this. You’ve been hurting for months and more likely years. You’ve had a knee scope surgery as it was required by Medicare before your replacement. You’ve been limping along both dreading the procedure and filled with hope that you’ll be able to get around without the pain that’s been limiting you for so long. So what do you do now?
You’ll get to that point, but first you have to respect the surgery. Your recovery will be measured in months, not days or weeks. Knowing this will help you settle into a routine.
You must have equal time up and down. What I mean by this is if you’re not in bed with your leg elevated it counts as “up” time. “Up time” is walking, eating at the kitchen table, sitting on the couch, riding in the car for your post-op staple removal, going to your grand-daughters dance recital,…whatever… Any time your knee is lower than your heart it’s “up time”. The circulation in your operated leg is diminished following the surgery and when you’re “up” your leg is going to swell more and thereby hurt more. (More swelling = more pain… this can’t be emphasized enough!)
By “down,” I mean in bed or on the couch with your knee higher than your heart and your ankle higher than your knee. Recliners don’t count since your rear is the lowest point and your swelling won’t go down. The fluid will stop at the lowest point (your butt) and back up into the knee.
Equalize your “up” and “down” time and you’ll have a much happier and less swollen knee. I’ve had a lot of patients over the years that will be cruising along two weeks out of surgery, and will go on an outing. After being up for 6 hours they get home and they’re miserable for the next 24-48 hours because their knee is much more swollen. Respect the surgery and give your knee equal time.
You’ll need to do your exercises twice a day (or what ever your surgeon or therapist has recommended). If you haven’t been provided with exercises there will be a link for a sample set of home exercises at the end of this article. Please run these by your surgeon for his/her OK before attempting them. They are the standard exercises that are performed in the first week or two following replacement. Please keep in mind that these exercises aren’t designed to build strength, but rather “wake up” the muscles in and around your knee that are in shock and not working properly following the trauma of surgery.
You’ll need to ice your knee regularly (no less than six times a day, preferably more, and 20-30 minutes at a time). I recommend a cold pack here, but a couple of bags of frozen peas or corn works well too. One on top and one underneath. Just make sure that you protect your bare skin with a pillowcase or towel!
If your surgeon has ordered a CPM (continuous passive motion) machine please use this for 6 hours (or the surgeons protocol) per day. Most people I work with do a 2 hour session three times a day. Some surgeons don’t order CPM’s and that’s fine as I don’t think there are any studies that show long term benefit, but I think there’s a lot of short term benefit. It gets you in bed and elevates your leg (think “down time” my friends) . You can even throw a bag of frozen peas or a ColPac ice pack on your knee and the combination of elevation, gentle motion and cold can be a little slice of heaven.
Blood clots and preventing them. They are an uncommon side effect of the surgery, but blood clots can be a serious and fatal one. Most people are placed on a blood thinner such as a daily aspirin, a prescription medication like Eliquis or Pradaxa or at least wearing those white compression hose that seems like they were designed for a 20 pound toddler. Please use whatever your surgeon recommends and follow those recommendations to a fault.
Here’s link to a sample set of exercises that should be reviewed by your therapist or surgeon prior to attempting them.
Side note…If PT hasn’t been ordered, get on the phone and ask your surgeon to order PT. You need an ally in your recovery and a physical therapist is just what you need! These exercises are nothing crazy, just good movement and range of motion.
http://www.my-exercise-code.com then enter code Q9L9UBF
If you have any questions please feel free to reach out to me at www.chriseastonpt.com.
Thank you, and may God continue to bless you!
Chris
***This blog post is for informational purposes only and is not meant to replace the advice of a surgeon or your physical therapist. Please consult your surgeon re: all information included in this article.***
You’ve made the decision to have your knee replaced. You’ve met with the surgeon. Your lab has been ordered. You have to go to the hospital (or your family doctor) next “Tuesday” to have your blood drawn for labs. Your surgeon might want you cleared by a cardiologist. All the OFFICIAL medical wheels are set into motion so that everyone else is prepared for your replacement.
What about you? Are you prepared? Physically? Mentally? Is your house ready? What about the dog?…
There’s a lot that goes into getting ready for a major surgery like this. There’s a lot to think about, but some pre-planning will make the process easier.
First off you have to realize that you’re going to essentially be out of commission for about 3-4 weeks. Ignore the stories of your neighbor who had it done 2 years ago and was out mowing the yard and golfing in a week. That’s simply not true, and if he did, you didn’t see him rolling around in bed for two days miserable from all the excess swelling. Respect the surgery. It IS a BIG deal and you need to honor that.
OK, so keeping that in mind make sure that:
All your shopping is done and you’re stacked up on groceries. And yes, that also counts if you don’t do the shopping. I’ve heard many spouses over the years say “I didn’t know what I was getting into, and I didn’t even have the surgery.” Having shopping done for at least two weeks (and meals prepared in advance, think frozen casseroles) will be such a relief later on.
All laundry is done and bed linens are clean and changed. You’re not going to be able to do laundry or change your sheets for at least 2-3 weeks and clean linens are always nice!
You have ice packs at the ready. On my website I have a link to Amazon for a Col-Pac brand ice pack that I love, but you can also use a big bag of frozen corn or peas. If you’d like a recipe for a home-made icepack, message me and I’ll send you the recipe. Make sure your knee is protected by a towel and ice that baby no less than 6 times a day, yes 6! (20-30 minutes at a time).
Make sure your house is clean and vacuumed. “I hate looking at all that stuff on the carpet and I can’t do anything about it, it’s driving me nuts!” I’ve heard that more times than I care to hear and have gotten out someone’s vacuum on more than one occasion.
Please make sure all throw rugs are up, your bed comforter is up and off the floor at the foot of your bed and the floors are cleared. Trust me, you don’t want to fall after you undergo a knee replacement.
I thought about leaving this out, but I’ll mention this anyway. You will be constipated following surgery. You know your normal rhythm, so plan accordingly. Don’t overdo it, but be aware that this will be a problem. Your surgeon will advise you on what steps to take if he/she hasn’t already.
Hopefully you’ve found this helpful. All of this information (and a lot more) is available in my book “Knee Replacement Surgery, A Patient’s Guide: Before, During & After” available on Amazon. If you have any questions please reach out to me either on FB or here on my website chriseastonpt.com/contact/. I’d love to answer any questions you have or help in any way I can.
God bless
Chris
P.S. I might have mentioned the dog earlier. Make sure Fido is stocked up on food as well. Those bags are heavy and having it on hand is nice. Dogs (and cats) can be fall hazards too, so please be careful!
In my previous blog post I wrote about common foot issues. In this post, I’d like to talk about what you can begin to do about it.
First and foremost is to R.I.C.E. Rest, Ice, Compress (think ACE wrap) and Elevate. That’s the standard for what to do when we’re hurt, but the main two are rest and ice. The inflammation has to be controlled first and foremost. If it stays inflamed, you cannot move into the healing phase.
Next is to find out if you’re lacking range of motion. Sit down with your legs out straight. Leaving your heels down pull your toes and feet back toward your knees. If you can’t pull them back at least 10 degrees and preferably 15-20 (the medical term is dorsiflexion), you’ll need to begin stretching your calves. I treat a great many people that can’t move past 0! That means their foot is at a 90 degree angle to the leg and they are not able to pull back at all. If you’re lacking motion in your ankles, it puts extra stresses on your foot (and on up the chain into your knees and even higher..hello shin splints, hello lower back pain).
Third, consider splinting at night. There is a picture of one on the products page of my website (I don’t sell them, amazon.com does). On the whole I’m not a huge fan of braces and splints, but there can be benefit to a gentle night splint that holds your ankle at a 90 degree angle (or 0 degrees of dorsiflexion). The benefit is there because as most people sleep their feet point at a downward angle. This means your Achilles tendon is shortened and the plantar fascia on the bottom of the foot is shortened. Sleep time is healing time. Guess who is healing with those tissues in a shortened position? Yep, and now you know why plantar fasciitis hurts so much first thing in the morning. The plantar fascia has been in a relaxed position and has begun healing….and then you take that first step. The tissue stretching back out suddenly is that knifelike pain you get with those first 10-15 steps. A night splint will help those tissues heal in a more elongated position than you normally sleep in and after a few weeks the pain will begin to lessen.
Lastly make sure that when you’re walking your feet are pointed straight ahead. 2. Make sure you’re walking heel to toe. And 3. Make sure you’re pushing off with your big toe! That big toe extending and pushing off is paramount to loading up your arch. I’ll expand further in an upcoming blog post, (if you like homework do a google search for the “windlass mechanism of the foot”)but an active arch is what locks in the bones of your foot, gives you something firm to push off of and dissipates forces. There is a reason bridges and doorways have been arched for thousands of years. Architects stole the design from our feet. Even 5-10 degrees of outward angle when you’re walking is enough to collapse your arch.(Medically we call that overpronation) Again, I’ll expand more on this later, but please make sure your feet point straight ahead when you’re walking. I mentioned Tarsal Tunnel Syndrome in part one and I’ll expand briefly. Sounds a lot like Carpal Tunnel and it is. Most commonly caused by overpronation or walking with a collapsed arch. This tugs on the inside of the ankle. If you’re taking the recommended 10,000 steps a day, that 5000 stressful tugs. Easy was to tell if the nerves protected by the tarsal tunnel are irritated is to sit down and cross the painful side on your knee. This will expose the inside of the ankle. Now with gentle to moderate force tap your index finger in the hollow between your ankle bone and heel. Like you’ve seen someone do to a soda can before they open it. If you get little electric shocks shooting into the foot, it’s irritated. So please try the above techniques and if it’s not helping, please go to the podiatrist or your physical therapist.
I hope you’ve found this information helpful. If you’ve implemented these techniques and aren’t getting any relief please see a podiatrist or a physical therapist for a “shoes off” evaluation of your walking (a gait analysis). The foot is incredibly complex and most foot issues are multidimensional. If you have questions just click here to contact me.
With this blog post I’d like to address some of the most common foot and ankle problems that physical therapists and foot and ankle (podiatric) doctors encounter. The foot and the foot and ankle complex are truly amazing structures. So much so that Leonardo Da Vinci (1452–1519) wrote the following: “The human foot is a masterpiece of engineering and a work of art.”
It truly is. There are 26 bones in the foot. Since we have 206 bones in our bodies, that means that almost 12% of all the bones in our body are in our foot. Oops, wait a minute, that’s only one foot. If we take both feet, thats 52 bones. I’ll spare you the math, but 25% of the bones in our body are in our feet. ***Let that sink in for a second.*** And all 52 are working in concert to support everything you throw at it during the day. (…and I didn’t mention all the ligaments, tendons and muscles that help support and control our feet and ankles)
No wonder podiatrists stay busy. With this much going on there are bound to be problems. In talking with podiatrists the most common issues they treat (and refer to PT) are:
Plantar Fasciitis (felt on the bottom of the foot, commonly under the heel)
Tarsal Tunnel Syndrome (this can mimic plantar fasciitis very closely)
Achilles Tendonitis (felt on the back of the leg/heel)
Posterior Tibial Tendonitis (felt on the inside of the ankle)
Peroneal Tendonitis (felt on the outside of the ankle)
Chronic Ankle Sprains (Rolling of the ankles)
Of course there are many more, and I intentionally left out other foot issues podiatrists treat such as nail fungus, gout, ingrown toenails, diabetic neuropathy (pain, burning and tingling of the feet) and Charcot foot.
You’ll notice most of the above issues end in “itis.” That’s medical jargon for inflamed. Most “itis’s” are caused by overuse, imbalance, inadequate range of motion or lack of strength. (Or a combo of these). Great, so what should I do about it? That will be addressed in part two.
***This blog will be expanded for a revision of my knee replacement book to include a chapter on partial knee replacements vs total knee replacements as well as a chapter on the future of high tech in the operating room. Image guided and robotically assisted surgery, pressure sensitive initial components to assist with proper placement and gapping, etc…The following is a preview…***
One thing I love about my profession is that it’s constantly evolving and moving forward. Research tells us what best practices are, continuing education classes bring thought leaders on various techniques and theories into a classroom style teaching atmosphere. In Oklahoma I’m required to have 40 hours of continuing education every two years to maintain my PT licensure. I’m not going to say I enjoy the cost or that I enjoy giving up a weekend to attend a course, but I’ve never left one without learning a great deal. I always leave courses with more tools in my toolbox, and that is always a benefit to the people I get to work with.
Up until two years ago I would never have recommended a partial knee replacement. I don’t know the exact percentages, but almost every patient I worked with that had a partial, within 1-2 years, would undergo a revision to a total knee replacement. That means more opportunity for infection. It also means more bone loss and scar tissue as the old partial has to be removed down to good healthy bone for the new total knee prosthetic pieces. It also means more pain as clients would have to start their rehab all over again. Why recommend something that would likely result in twice the surgery, or worse?
So what happened two years ago? I went to an orthopedic symposium put on by a local hospital group. Several orthopedic surgeons spoke on varying topics from ACL reconstruction to minimally invasive spinal surgery. One of the surgeons speaking at the symposium performs partial knee replacements via something called Makoplasty. Dr. Paul Jacob performs these regularly and spoke to the group for an hour on Mako assisted partial knee and total hip replacements. Currently surgeons are performing Mako on partial knees, total knees and total hips.
Without getting too in depth, what sets Mako apart is that it is an image driven procedure. That means you have a CAT scan prior to surgery and the procedure is totally based on your anatomy. To indirectly quote him, We make the components fit the patients anatomy, not making the patient fit the components. In not so many words, the fit is much closer to your specific and normal anatomy. The end result of a Mako partial knee replacement is that it functions very much like your normal anatomy and is dialed down to the millimeter.
Briefly I’m going to list a few advantages and disadvantages to a partial knee replacement performed via Makoplasty. The list is indeed longer for both, but these are the high points.
Advantages:
The fit is much closer to your normal anatomy. Much closer!
All knee ligaments (ACL, PCL, MCL and LCL) remain intact.
The meniscus on the opposite side remains intact. The vast majority of partial knees are performed on the inside section of the knee (medial side), so you would retain your lateral meniscus.
The recovery is significantly faster. Mere weeks instead of months.
Disadvantages:
Radiation. You are exposed to radiation due to the fact that you undergo CAT scanning.
Possible pinsite fractures. (rare) During the procedure a metal pin is drilled into the shin bone (this is another way they make it extremely accurate), but a hole in the bone takes time to heal and can potentially weaken your shin bone, increasing the potential for fracture.
Possible incision injuries. People are recovering so much faster that there have been instances of wound dehiscence (incision coming open) due to people being able to push further, too soon following surgery.
The bottom line is this is a decision that you and your surgeon have to make. Mako trained surgeons have a VERY specific set of criteria to be met before someone is even considered for a Mako partial. Including imaging, area of pain complaints, age of the patient, and other factors. No surgeon wants to perform a partial, only to have to go back within a year or two to convert it to a total knee. As noted above, until 2 years ago I would have never recommended a partial knee replacement, but due to advances in technique and improved tech in the OR, I wouldn’t hesitate to recommend a MAKO partial knee to anyone who meets the criteria.
If you have questions or need further information please reach out to me. I’d love to help.
Importance of minimizing swelling after knee replacement (and other surgeries)
As I sit here writing I’m being given a constant reminder that post-operative swelling needs to be minimized as much as possible. The constant reminder is due to the fact that 4 days ago I had a chondroplasty and medial meniscus repair on my left knee. Yep, PT’s get hurt too and sometimes our best efforts to remain as limber and strong as possible don’t protect us from injury. I hurt mine in Karate doing a round kick. We’re taught to pivot our planted foot and at the end of the kick, our planted heel should have spun around and be facing our target (this prevents injury and gets our hips more involved in the kick; I can’t wait for you to read some of the hip info I’ll be writing abut later). I got lazy (or in a hurry…or didn’t pay attention) and felt the tear when I kicked. DOH!!! Fast forward 8 weeks later and here I sit with a bit of time off, recuperating and writing.
In no way is my injury or surgery as invasive as a knee replacement, nonetheless I have a great deal of swelling and pain. All normal, but post-op edema (Fancy term for swelling and again, totally normal) does need to be controlled as much as you can.
First the “why” and then the “how.”
When you’ve had your knee replaced (or any surgery for that matter), you swell. As noted above it’s normal but “why” is excessive swelling bad?
First, what is swelling?
It’s fluid (think of the clear or pinkish drainage you get from a scrape) that escapes the circulatory system and moves into our tissues. There it sits. Yes, our immune system is utilizing white blood cells to clean things up, but there’s a lot of congestion just sitting there. Here’s a couple of reasons you want to limit it.
Why is it bad?
It’s painful! There’s probably not a bigger pain intervention you can make than to reduce your swelling. If you are up on it too much, it’s going to swell more, it’s going to get stiff and your pain will increase. My son had a basketball tournament on my post-op day 2 and by the time I got home (after 6 hours of driving and sitting watching hoops) I felt like I had 10 lbs of sausage stuffed into a 5 lb casing. It hurt more and it was much more stiff. 2 hours of elevation and ice helped a great deal.
It can possibly slow down healing. Think about it, when you have your knee replaced (or shoulder or hip, etc…) there’s a lot of cutting. Blood flow gets interrupted. Even without the addition of swelling you’re not getting as many groceries in and as much garbage out. Now add increased swelling on top of that and it’s adding more pressure into/onto the system. I will guarantee that your little capillaries aren’t flowing as freely when your doing a pufferfish impersonation.
It puts you at increased risk of a blood clot. I touched on this above, but when blood flow isn’t as good, blood tends to pool (sits there) and that’s when clots can form. There are many more reasons, but these are the big 3.
How do I limit it?
Equal time (with elevation). I mentioned above that I was up for 6 hours on day 2 following my knee procedure. That’s waaay too long. What I mean by equal time is that if you are up for 2 hours you need be down for 2 hours. With it elevated and with ice on it (30 mins on/30 mins off for the ice). The leg (if it’s your knee or hip) needs to be elevated on pillows and your chest needs to be flat. Recliners don’t count. Swelling does gets removed via the circulatory system, but it also gets removed via the lymph system. If your butt is the lowest point, the lymph drainage will stop and back up there. Get that knee higher than the pump (your heart) and get the ankle even higher.
Do your exercises. I’m having to constantly remind myself of the same thing right now as my knee is swollen, and frankly the exercises hurt. But you need to do them as it get your muscles firing and they act like little pumps helping to move fluid as well.
Walk. I’m not contradicting myself here. I do want you down more than you think you need, but I want you walking around as well. It gets the circulation circulating and wakes up those muscles that are just lying there trying to get the tag number of the truck that hit them.
In conclusion, be good to yourself. This surgery is rough enough without adding insult to it. If you have any questions please reach out, I’d love to help.
