TKR My Story<

[Josephine]

I need a few more details

when the fibula misbehaves

pain along the fibula during flexion stretching

How do you know it's the fibula? And can you expand on what you mean by 'misbehaves'?

Does anyone know what the pros and cons are of each?

Ask a dozen surgeons and you'll get a dozen replies! It's a bit like asking any group of people why they cook a certain way. Because that's all it is - a matter of choice. Some people are 'in to' technology and others aren't. Those surgeon that are will navigate towards robotics like moths to a flame. But they are only in the minority. The rest of the surgeons do tend to stick to the traditional ways for a variety of reasons

1. they are accustomed to doing it that way
2. changing means there is a protracted and extensive learning curve which will probably impact on the patients recovery and outcome
3. The equipment is expensive and the hospital may not be willing to fund its acquisition​

 

[NoShortCut]

How do you know it's the fibula? And can you expand on what you mean by 'misbehaves'?

I first learned about how the fibula can cause discomfort in the leg well before my TKR as it seems that I was favoring the medial side of my knee by asking the lateral side to work overtime. I was put on some stretching exercises and asked to monitor the movement (or lack there of) of the fibula with my hand. After the TKR, my PT observed that my fibula was moving, but locking-in when trying to flex the knee which was causing a bit of pain. Instead of pushing the flexion, I've eased up with gentler stretching movements that seems to help. But at times I feel a popping sensation during flexion. When I put my hand on the fibula, I can literally feel it jumping positions. Jumping might be a strong word since the distance involved is probably not large, but it is sudden rather than smooth and it introduces pain when it jumps.

Ask a dozen surgeons and you'll get a dozen replies! It's a bit like asking any group of people why they cook a certain way. Because that's all it is - a matter of choice. Some people are 'in to' technology and others aren't. Those surgeon that are will navigate towards robotics like moths to a flame. But they are only in the minority. The rest of the surgeons do tend to stick to the traditional ways for a variety of reasons

1. they are accustomed to doing it that way
2. changing means there is a protracted and extensive learning curve which will probably impact on the patients recovery and outcome
3. The equipment is expensive and the hospital may not be willing to fund its acquisition​

​

Thank you for the insight! I think my OS does a lot of TKRs and is very comfortable with how he does them. He had me go to a hospital that had the Mako robotics in the OR because he needed to have some extra tools to remove some hardware from previous surgeries. But robotics doesn't seem to be his way of doing it. I find the idea of a shorter incision appealing, but otherwise, as long as the OS has the skill to get the right fit and a great outcome, I don't know if I have a preference. Technology always sounds good and efficient though, at least to me.

@NoShortCut, the pros and cons vary, I think, depending on the nature of your particular procedure. My PKR was done robotically (Mako). The surgeon is still actually doing the surgery but the robot helps to guide. For PKR, my research convinced me that robotic assist was the best approach as it helped to ensure the surgeon only removed the portion of damaged bone needed to achieve a good fit with the implant prosthetics. I also believe the incision size may be smaller (mine is about 4-5” long whereas I’ve seen some that are 8” or more). Beyond that, recovery is the same in every way.

Thank you for your reply! I had heard that robotics helps to achieve an optimal fit and shorten the incision scar, which is definitely appealing. Mine is around 8" long and I suppose I would have preferred a shorter scar. That said, however my OS decided to put my skin back together is leaving a fine line. In most places there is very little skin bump and it almost looks as if 2 pieces of paper were pushed together at the edges without overlapping. And this is at 3 weeks.

A lot of times when a new technique becomes available, doctors will jump at it if it gives them an edge to improve outcomes. Yet my OS used the technique he was comfortable with despite standing right beside the Mako in the OR. It made me wonder why and if I was missing out on something that might improve my outcome. Thanks for you insight that the recovery is virtually identical regardless of technique.

 

[Josephine]

Yet my OS used the technique he was comfortable with despite standing right beside the Mako in the OR. It made me wonder why and if I was missing out on something that might improve my outcome.

One good maxim to remember in this is that new doesn't always mean better! And that can apply to the surgeon just as much as the equipment.

 

[Josephine]

I've finally got around to responding to your answers!

1. Pain is highly variable. During normal rest, ice and elevation, I'll say a 2.
Sitting upright in a chair is a 3-4.
Walking when warmed up and stretched is a 3,
but walking when stiff is a 5.
Flex stretching exercises is normally a 3-4 but higher when the fibula misbehaves (6-7). Leg extensions or lifting a straight leg can easily jump to an 8 after 2-3 repetitions.

So generally 2-7?

2. I was sent home with 2 mg hydromorphone 4hourly but quickly dropped it.
Have been only taking 3000mg Tylenol (1 500mg every 4 hours) and one 200mg celebrex daily since day 4.
My primary doc has taken me off of ibuprofen and naproxin due to stomach erosion.

I'm pleased your GP has taken you off ibuprofen and naproxin. For one thing, both are NSAIDs and you should never take more than one type of NSAID at a time. Another this is that NSAIDs can do our bodies a lot of harm. In addition, you should know that Celebrex is also an NSAID.
Read these
Medications: acetaminophen (Tylenol, paracetamol) and NSAIDs, differences and dangers
NSAIDs Diclofenac. ibuprofen increase risk of heart problems: new study

Your pain medication is grossly inadequate. 500mgs of Tylenol is not sufficient. You should take 1,000mg every 6hrs as a minimum. I know that's a total of 4,000mg per 24hrs and the FDA says only 3000 but that's because of over caution in case patients were also taking other medications that included acetaminophen and unintentionally risked an overdose. Here in the UK, we still subscribe to the 4,000mg limit which is perfectly safe.

3. Swelling is moderate

Okay

4. Around 90 to 95 degrees flex and maybe 5-10 degrees extension.

Not bad for three weeks out.

5. I do about 3 sessions of 30 minutes with a Cryocuff a day. More if it's extra sore.

You accomplish little or nothing in 30 minutes. Ice for at least 40-60mins and more than 4 times a day.

6. Full elevation (knee near heart level) is done about twice a day for at least an hour each time. Partial elevation (sitting with leg up) is done 6-7 times a day for between 30 minutes to 2 hours.

You have that wrong! It's "toes above nose" which isn't quite such a steep angle! Also, elevate while you are icing.

7. Most of my activity is simply walking from one room to the next, about once per hour. I have a flight of stairs that I traverse 3-4 times day, one step at a time. I refill my own drinks, reheat leftovers, and do a quick washing of my own dishes. Folded laundry once while sitting on the floor.

Don't be too intent about about the 'every hour' routine or the stairs. You could about half what you are doing there and still be okay.


Exercises done at home (reflective of at home PT):
walking numerous time a day with one 5-10 minute walk per day - not knowing how many 'numerous times' represents, it's a little difficult for me to comment. But I do know that overall it looks too much
heel slides (not sure how often since I find myself doing them unintentionally) - then don't! Your flexion isn't that bad so you really don't need these.
lay on side, lift recovering leg, slowly flex and then extend lower leg, and relax leg (to degree tolerated) goal to do a set of 10 per day but I haven't completed a full set yet - never heard of this before but it seems excessive and unnecessary
Very short range leg extensions x2 sets of 10 - you don't need these either
ankle pumps numerous times per day - you really only needed these in the first few days when you weren't very mobile. Now that you ARE mobile, you don't need them any more
glute sets x2 sets of 10 per day - these are unnecessary too
hip abduction x3 sets of 10 per day - you've had a knee done, this is a hip exercise!

Lower back and hamstring stretches x2 day and IT band stretches x2 day - assuming that you actually have these pains (as you said you did) then these are okay

So in summary:
1. quit the Celebrex and up the Tylenol as suggested
2. increase the amount of icing and elevating
3. adjust the mode of elevating as suggested
4. slack off the amount of general activity (read the article Activity progression for TKRs)
5. stop doing the exercises I crossed out.

 

[NoShortCut]

I've finally got around to responding to your answers!

Thank you for taking the time to provide advice. I very much appreciate it!

So generally 2-7?

Probably more like 2-4 on a normal basis, 2 when resting, up to a 4 when more active. Getting up to a 7 happens when the fibula decides to move during an exercise. My PT has been creative in developing exercises that don't trigger the fibula, which is why I had some exercises that you probably weren't familiar with.

I'm pleased your GP has taken you off ibuprofen and naproxin. For one thing, both are NSAIDs and you should never take more than one type of NSAID at a time. Another this is that NSAIDs can do our bodies a lot of harm. In addition, you should know that Celebrex is also an NSAID.

Your pain medication is grossly inadequate. 500mgs of Tylenol is not sufficient. You should take 1,000mg every 6hrs as a minimum. I know that's a total of 4,000mg per 24hrs and the FDA says only 3000 but that's because of over caution in case patients were also taking other medications that included acetaminophen and unintentionally risked an overdose. Here in the UK, we still subscribe to the 4,000mg limit which is perfectly safe.

Just to be clear, I'm taking 500mg every 4 hours for 3000mg daily. As I understand, you suggest increasing this to 4000mg daily and dropping the celebrex. I'm no expert on these medicines and forgive me if I'm confused, but the doctors and nurses involved in my TKR have been adamant about me not exceeding 3000mg daily of Tylenol because of potential liver damage. When I was taken off of ibuprofen, my GP told me that celebrex was easier on the stomach, although there is some similar risk of heart attack. I'm open to making the change you suggest, but just to be safe, I think I'm going to pass this by my GP. I'd like her to know what I'm doing and see has any opinion.

You accomplish little or nothing in 30 minutes. Ice for at least 40-60mins and more than 4 times a day.
You have that wrong! It's "toes above nose" which isn't quite such a steep angle! Also, elevate while you are icing.

Nobody really told me how much or how often, so your advice is very helpful. I am modifying my routine accordingly.

Exercises done at home (reflective of at home PT):

I sat down with my PT to discuss what I should be doing and what I don't need to be doing. The list of activities has now been trimmed down, either because they are not needed or no longer appropriate. I was still doing exercises on a printed list given to me by the hospital, including abductions and glutes that my PT didn't know why they were ever assigned (like you).

Again, thank you for your insights and advice!!!

 

[Josephine]

but the doctors and nurses involved in my TKR have been adamant about me not exceeding 3000mg daily of Tylenol because of potential liver damage.

I did explain that. But so long as you are not using any other medication with acetaminophen in it, then 4k is perfectly safe. Only the US believes differently!

When I was taken off of ibuprofen, my GP told me that celebrex was easier on the stomach, although there is some similar risk of heart attack.

'easier on the stomach' is not safe for the stomach. I wouldn't ever take any form of NSAIDs at all! To risky for my tastes but if you chose to, that's entirely up to you.

 

[NoShortCut]

I did explain that. But so long as you are not using any other medication with acetaminophen in it, then 4k is perfectly safe. Only the US believes differently!
'easier on the stomach' is not safe for the stomach. I wouldn't ever take any form of NSAIDs at all! To risky for my tastes but if you chose to, that's entirely up to you.

Thank you again Josephine! I discussed this with my GP and I made the change you suggested today. I'll probably need a few days before I know how it works out. It's frustrating as a patient dealing with varying instructions from the different doctors and nurses along the way. Probably very few have been through any of this on their own. The first nurse tending to me right after surgery told me I should not elevate my leg so I could keep it straight. I now know that is terrible advice, but as you go through the experience, sorting out fact from fiction isn't easy. I did a lot of reading before the procedure, but you still feel like you don't know everything when it actually happens. I also encountered one PA about a week after surgery that didn't seem to listen to anything I said and came across as very mechanical and uninterested. By then I was better armed with the ability to deal with him. I say this, but I recognize that the vast majority of the medical providers that have been helping me have been wonderful, caring and when they weren't sure of something, asked somebody that would know. But still, approaches, instructions and knowledge can differ when the shift changes. Just me venting a little bit.

Again, thank you for you input and to everyone involved in developing and supporting this forum. It has really helped me learn a lot.

 

[sistersinhim]

It would be is all of our health care providers were on the same page. But, that just isn't so. That's why the best thing to do is the listen to your knee and your body. That's the right way for you!

 

[NoShortCut]

I crossed the 4 week threshold today and I can't believe how far I have come. It started off being overwhelming and then it because painful and daunting. And then day over day, it seemed as if nothing got any better, but looking back over 4 weeks, I think I'm feeling pretty proud of how far I have come. No, I'm not running around, dancing, hiking, biking or anything all that active, but I am walking without much pain and the limp is softening. I can stand a little longer and I can finally do leg extensions, even though it's got a little pain to it. Flex is about 110 degrees and extension is lagging a bit a 10-13 degrees. Advice from this forum has helped me in many ways and I think focusing on reducing swelling versus pushing range of motion is very good advice. As my swelling went down, my flexion improved tremendously. My instinct was to push it along, but this surgery recovery can't be rushed that way. It needs time to heal before it can be pushed.

I seem to still have a lot of scar adhesions that pull when I bend the knee. Does anyone have any advice on how to work those loose? My PT says to just rub it, but I figure that somebody might have a technique that works well.

 

[NavyGunns]

@NoShortCut, I remember when I had a lot of knotted areas along my incision causing it to be raised up. My PT also recommended firm massage across the scar with gentle pressure that got firmer as I went. One day I felt a popping, similar to popping bubble wrap. No pain, just popping noise. Next thing I noticed is my scar was laying flat. I also noticed that the pulling I usually felt when bending my knee was greatly diminished. Today (7 months), you can barely see my scar.