TKR 4 wks post op, slow recovery, but getting there

[Gertieprickles]

Hi,

I'm after a bit of advice. I had a TKR on 25th July. All seemed to be going well until last night when my operated on knee gave way twice in a row. The next thing I knew my dressing (I still have my clips in) was drenched in blood.

We rang the hospital ward who said this kind of thing was normal and to just replace the dressing. The same thing happened again half an hour later so rang them again and they said to go to A&E.

At A&E all my x-rays and bloods have come back normal. They have however noticed that my knee is extremely swollen so think that might be the cause of it giving away. They told me to rest my knee a lot (which is the opposite to what my physio said) and to lay off the exercises (again opposite to what I've been told to do).

Has this kind of thing happened to anyone else? The knee giving away I can cope with (it happened again a couple of times after we got home from A&E), it's the wound keep opening that concerns me.

Any help would be gratefully received. Thanks xx

 

[newlybionic]

Keep the dressing clean and dry. The fact that your knee is swollen is causing the wound to bleed. You need to elevate and ice your knee. Let me give you a list of short articles to read.
Knee Recovery: The Guidelines
1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now; they are almost certainly temporary
2. Control discomfort:

rest
elevate
ice
take your pain meds by prescription schedule (not when pain starts!)
don't overwork.​

3. Do what you want to do BUT

a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

the BoneSmart view on exercise
BoneSmart philosophy for sensible post op therapy​

5. Here is a week-by-week guide for http://bonesmart.org/forum/threads/activity-progression-for-tkrs.14334/

Activity progression for TKRs​

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?

Energy drain for TKRs
Elevation is the key

Ice to control pain and swelling
Heel slides and how to do them properly

Chart representation of TKR recovery
Healing: how long does it take?

Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds

We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery. While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.

 

[Josephine]

They told me to rest my knee a lot (which is the opposite to what my physio said) and to lay off the exercises (again opposite to what I've been told to do).

It's often been observed on here that physios tend to be somewhat over-ambitious when it comes to post-op rehab. In fact, I'd go so far as to say the membership here has pretty much proven that it's unnecessary and may even be harmful - as you have found!

I'd really like to offer you some structured advice but in order to do that, I also need to ask you some questions. Are you willing for me to do that?

 

[Gertieprickles]

Yes I'm more than happy, so ask away...

 

[kneeper]

I hope you are using a walker, cane or crutches. For many of us in the early weeks of recovery our knee will do a little buckle.

 

[Gertieprickles]

Don't worry I am using crutches - I have to anyway due to problems with my mobility.

 

[skigirl]

Think of it this way, your quads and hamstrings are not as strong as they were pre surgery. They are important muscles in holding up your leg. Since they are weak, standing and exercising is putting a lot of pressure on the joint itself which has to do more work to support the leg. Your leg responded to this pressure by "giving way" which was a message to you that you are asking too much of your new joint.

No matter what the PT wants, you will have to work within the confines of what the knee itself is capable of doing right now. At two weeks I was spending the majority of my time in bed or on the couch with my leg propped up on three pillows. I did quad sets and leg lifts which were done to wake up my quad muscles.

By week three and a half, most of the swelling was gone and I began very gentle exercises while standing.

If you stress the joint too much this early, you will be causing yourself trouble. relax, just let the soft tissues heal and let your muscles wake up. I am a ski instructor, and I was able to ski at 5 months---but you cannot rush the early stages of recovery, exercising too much in the early days does not help your recovery.

Elevation is the key to controlling pain and swelling

 

[Gertieprickles]

Thank you for reply. What you have said does make a lot of sense. Since it happened I've hardly moved - too frightened just in case my wound busts open again. However, resting my leg has dramatically reduced the swelling and I have been able to walk a couple of steps without it giving way.

It does make you wonder about PT. I know they mean well, but look where it's got me.

 

[Josephine]

Here y'go then!

It would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. Don't forget to factor in other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness).

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how swollen is your leg compared to these?

4. what is your ROM - that's flexion (bend) and extension (straightness)

5. are you icing your knee at all? If so, how often and for how long?

6. are you elevating your leg. If so how often and for how long?

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

8. are you doing any exercises at home? If so what and how often?
This is the most crucial question so please help me by using the format I have left as an example
(which means please make a list and not an essay!)

Exercises done at home
- how many sessions you do each day
- enter exercise by name then number of repetitions of each
etc., etc.

Anything done at PT
- how many times a week
- enter exercise by name then number of repetitions of each
etc., etc.

 

[skigirl]

I think that some PTs do not have current training in rehabbing a TKR. The old was was more aggressive, but most facilities like Mayo Clinic have cut back on early PT.. In Europe is is common to do not PT for the first three months. so, give yourself lots of time to heal, there is no race. Once the swelling is gone,you will feel better, but if you overuse the knee, it will swell again---giving you a message.

 

[Gertieprickles]

Thanks for taking the time out to help me Josephine. I really do appreciate it. I notice from reading some of your very good articles that you've had some surgery in the Sunderland Royal. I'm from Sunderland. I had my first THR (1998) there and also it out (2009) due to an infection. My TKR was done in Durham – long story as to why.....

Q1: Since been told by A&E (and yourselves) to have complete rest, my pain has reduced considerably. Before Saturday night it was about 8/9 (it was really swollen, aching and throbbing). Now it's about 4/5 – the aching and throbbing have settled down a bit.

Q2: Prior to my TKR I was on medication anyway due to chronic back pain so they just let me continue taking it as before with no real changes in dosage. I take:
OxyContin 10mg modified-release tablets – 1 every 12 hours
OxyContin 40mg modified-release tablets – 1 every 12 hours
OxyNorm 5mg capsules – 1-2 as required for breakthrough pain (before TKR every 4-6 hours, now every 2-3 if required)
Ibuprofen 400mg tablets – 1 three times a day
Paracetamol 500mg tablets - 2 four times a day

I also have to take the following due to the various side effects of the above: Lansoprazole 15mg – 1 daily, Lercanidipine (high blood pressure medication) 10mg – 1 daily, Senna 7.5mg – 3 at night. I also take HRT.

Q3: Here are two photos which show the level of swelling.
First one was taken on Saturday night when my wound burst open. The other one was taken this morning not long after I got up.

Q4: ROM: I can comfortably bend it 90 degrees. It will go further but it's painful to do so. When I had my first PT assessment last Wednesday, they managed to get it well over 100 degrees but it was painful. I can straighten my leg without discomfort.

Q5: Yes, I have been icing my knee. It's usually been breakfast, mid morning, lunch, mid afternoon, dinner, late evening for about 30/45 minutes or until the frozen peas go soft.... If my knee has been really hurting/throbbing in-between then I'll ice it again.

Q6: Up until my A&E visit I was elevating my leg during breakfast, lunch, dinner and during the evening on a couple of beanbags. The PT's at the hospital didn't hold with a lot of elevation. I was told to only raise it mid morning and mid afternoon. During the day I was told, by guess who...., that I could do normal everyday things like sitting at a desk or prepare dinner as long as I had my knee bent at 90 degrees or more.

Post A&E visit I've been spending my time with my leg elevated to what yourselves have recommend. I also sleep with it elevated, which, again, is opposite to what my PT told me to do.

Q7: I had mobility problems prior to my TKR but I still tried to be as active as my mobility would allow so try my best with the usual household tasks etc. I walk with two elbow crutches and have to use a wheelchair for outside.

Q8: Yes I have been exercising as the PT told me that aided recovery....

Hospital exercises:
Knee bending: 10 reps, 3 times a day.
Knee straightening – up to 15 mins or until knee became uncomfortable, 3 times a day.
Muscle activation: pushing thigh muscle down – 10 reps, holding for 5 seconds, 3 times a day.
Muscle activation: lifting knee off a cushion – 10 reps 3 times a day
Moving leg out to side whilst lying on bed – 10-15 reps 3 times a day

PT exercises:
Heel slides – 20 reps two sets, 3 times a day
Qaud set – 8 reps, hold for 5 seconds, 2 sets, 3 times a day
Calf stretch with towel – 3 reps, 30 seconds hold, 3 times a day
Qaud set with towel under heal – 1 rep, 1 second hold, 1 set, once a day
Straight leg raise – 8 reps, 1 second hold, 2 sets, 3 times a day
Hamstring stretch – 3 reps 30 seconds hold, 1 set, 3 times a day
Long arc quad – 8 reps, 3 seconds hold, 2 sets, 3 times a day

I was also encouraged to do knee bends, straight leg raise and muscle tightening throughout the day.

I was due to attend a knee circuit training session this afternoon at the PT gym but have cancelled all PT until I've seen my consultant, on the advice of A&E.

I hope this all helps.

Many thanks

Marie

 

[Josephine]

Since been told by A&E (and yourselves) to have complete rest, my pain has reduced considerably. Before Saturday night it was about 8/9 (it was really swollen, aching and throbbing). Now it's about 4/5 – the aching and throbbing have settled down a bit.

I am very pleased to hear it.

OxyContin 10mg modified-release tablets – 1 every 12 hours
OxyContin 40mg modified-release tablets – 1 every 12 hours
OxyNorm 5mg capsules – 1-2 as required for breakthrough pain (before TKR every 4-6 hours, now every 2-3 if required)
Ibuprofen 400mg tablets – 1 three times a day
Paracetamol 500mg tablets - 2 four times a day[
I also have to take the following due to the various side effects of the above: Lansoprazole 15mg – 1 daily,

sounds good but I really wouldn't take ibuprofen as it has some rather bad side effects Medications: acetaminophen (Tylenol, paracetamol) and NSAIDs, differences and dangers.

Q3: Here are two photos which show the level of swelling

Yes, pretty large. But you do know that your PT pushing on your knee was what made the swelling and thus caused the wound to open up, don't you?

Q4: ROM: I can comfortably bend it 90 degrees. It will go further but it's painful to do so. When I had my first PT assessment last Wednesday, they managed to get it well over 100 degrees but it was painful. I can straighten my leg without discomfort.

If it'spainful, do NOT let them do it. Not ever! Considering all, you have pretty good ROM.

Q5: Yes, I have been icing my knee. It's usually been breakfast, mid morning, lunch, mid afternoon, dinner, late evening for about 30/45 minutes or until the frozen peas go soft.... If my knee has been really hurting/throbbing in-between then I'll ice it again.

Excellent! But I do suggest you get some big gel packs to freeze. For one they freeze a lot colder and also they last a lot longer than peas! And get two so you can freeze one whilst using the other.

Q6: Up until my A&E visit I was elevating my leg during breakfast, lunch, dinner and during the evening on a couple of beanbags. The PT's at the hospital didn't hold with a lot of elevation. I was told to only raise it mid morning and mid afternoon.

Dafts things"!

During the day I was told, by guess who...., that I could do normal everyday things like sitting at a desk or prepare dinner as long as I had my knee bent at 90 degrees or more.

Oh for pity's sake! How stupid!

Post A&E visit I've been spending my time with my leg elevated to what yourselves have recommend. I also sleep with it elevated, which, again, is opposite to what my PT told me to do.

Good. Much better.

Q7: I had mobility problems prior to my TKR but I still tried to be as active as my mobility would allow so try my best with the usual household tasks etc. I walk with two elbow crutches and have to use a wheelchair for outside.

That's okay but take it gently - very gently!

Q8: Yes I have been exercising as the PT told me that aided recovery....

Guess what - they are wrong again!

Hospital exercises: 3 times a day
Knee bending: 10 reps - I take these are heel slides? Heel slides are an easy thing to do badly - check this out Heel slides and how to do them properly.
Knee straightening – up to 15 mins or until knee became uncomfortable - you said you're at 90 and can get it almost straight in which case you don't need to do these
Muscle activation: pushing thigh muscle down – 10 reps, holding for 5 seconds - this is also an extension exercise so you don't need to do these either!
Muscle activation: lifting knee off a cushion – 10 reps - and yet another extension exercise - stop this too
Moving leg out to side whilst lying on bed – 10-15 reps - this isn't appropriate for a knee!

PT exercises:
Heel slides – 20 reps two sets - see article above
Quad set – 8 reps, hold for 5 seconds, 2 sets - these are also unnecessary
Calf stretch with towel – 3 reps, 30 seconds hold - nope, unnecessary
Quad set with towel under heel – 1 rep, 1 second hold - same again
Straight leg raise – 8 reps, 1 second hold, 2 sets - a tip about SLRs, once you can do them, you don't need to do them any more!
Hamstring stretch – 3 reps 30 seconds hold, 1 set - only necessary if you have right hammstrings
Long arc quad – 8 reps, 3 seconds hold, 2 sets - again, unnecessary
I was also encouraged to do knee bends, straight leg raise and muscle tightening throughout the day - none of which are necessary!

I was due to attend a knee circuit training session this afternoon at the PT gym but have cancelled all PT until I've seen my consultant, on the advice of A&E.

And I suggest you keep them cancelled permanently! Had it not been for all this exercising and pushing, your knee wouldn't have split open in the first place.

Read this Saying no to therapy - am I allowed to?

 

[Gertieprickles]

Thank you so much Josephine for your help.

I am not a happy bunny that all this has been caused by PT so I WILL NOT be going back !!!

It really has knocked my confidence with walking as I'm terrified it's going to give way again, and to be honest I don't feel safe walking, even with the help of my husband. I'm hoping once I've seen my consultant he can put my mind at rest.

 

[sistersinhim]

I have had 11 knee surgeries, 2 of them kneecap removals which are almost as bad a tkr. I never did PT or exercises after any of those surgeries. I used my knees as they were intended to be used in my daily activities. It was all my knees needed to rehab them. All this unnecessary PT that causes pain and swelling is heartbreaking. Rest, ice and elevate as much as you can. I did the whole time I sat and slept. My knees never got above moderate swelling. Get that swelling down is your first priority. When that comes down, it will start to feel better.

 

[Josephine]

It really has knocked my confidence with walking as I'm terrified it's going to give way again, and to be honest I don't feel safe walking, even with the help of my husband.

If you feel like that, you should be going back to using your crutches or walking sticks. But a walker would be best.

 

[Ruby9297]

Ooh, scary picture! You poor thing. I sure hope everything works out


Sent from my iPad using BoneSmart Forum

 

[Gertieprickles]

If you feel like that, you should be going back to using your crutches or walking sticks. But a walker would be best.

I have to use elbow crutches to walk any way (previous medical problem). Sadly I don't have a walker as the physio's in hospital said I was walking ok on my crutches.

Once I know that my wound won't burst open again if my knee gives away, I'll feel a lot more confident.

 

[Clipless]

Hi, I would just like to mention that walkers are readily available for purchase in any large drugstore, medical supply, or even from Amazon.com, at least here in the U.S.- presumably in the U.K., too? I received mine in the hospital. I suffered knee giving way ("buckling") for a couple of months after each TKR. I absolutely felt safest using my walker during that vulnerable time. My OS wanted me to give up it up early, but I ignored him and continued to use it until I was safe, stable, and ready to progress to a cane. Be safe, okay?

 

[Gertieprickles]

I've just checked online here in the UK and walkers are available to purchase at reasonable cost, which did surprise me. I'll see how things go when my clips come out tomorrow and if I still don't feel safe then I'll buy one.

 

[Josephine]

You don't have to buy one. Social services will supply - or if not, try St John's Ambulance. They will hire one for a very reasonable fee. However, if you do have to end up buying one. make sure you go to a Motobility store. You'll not only get a good product but also god advice and at a very reasonable price with zero VAT.