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TKR Post Op Incision Care

Jamie

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Since the original image you took that concerned you was just after you got out of the shower, the mottled skin was most likely from the heat of the water. It looks as though you have some swelling that could easily be causing your pain. Your later photo supports this as it appears your skin is now back to normal again. Is that the case?

If you take photos like this again, it would be better for you not to crop them so closely. We can always enlarge them to see specific areas but the cropping doesn't allow us to view your leg as a whole.

Please post again if you are concerned about anything.
 
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Jewlz1

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Thanks for the input and the explanation is concrete. I did end up at the ER where a Doppler was done with an all clear on a clot and a CBC showed no sign of infection . So I'm all good. Probably would've been fine to not go to the ER. But better to be safe than sorry.
 

Jamie

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Your tissues are all rather sensitive right now as you're so new out of surgery. It's possible to see all kinds of odd reactions to things that normally wouldn't cause anything alarming. Of course, it's always good to ask if something concerns you, so don't hesitate to do that. I'm glad everything checked out well for you.
 
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Jewlz1

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Thank you, Jamie.
 
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Jewlz1

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I'm beginning to think my inability to sleep at night is due to nerve pain at the incision site. It's an unbearable burning pain and only seems to happen when I'm trying to sleep. I read that protecting the incision site from any sensation would be helpful and that using glad wrap is what works. It made sense and I had some Tegaderm Film Dressing that I used last night to cover the incision site. It did help somewhat. Instead of using glad wrap I would feel better using medical grade wrap but I'm not even sure if this would be advisable. Any suggestions? I would like to avoid starting Gabapentin again. Thank you!
 

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I find an ace bandage, wrapped comfortably, not super tight, is helpful to keep out the random, external stimuli. Saran Wrap sounds uncomfortable, like it wouldn’t breathe well and would hold in moisture. I hope this resolves soon for you.
 
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Jewlz1

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Had my 6-week check with my surgeon this past Monday, Feb 3. No more compression stockings and no more aspirin regimen (yay). My incision site looks good and all of the manipulations he completed were all good (yay). There was one area of my incision site below the knee where a stitch did not dissolve. Dr. used some elongated tweezers to try and remove the stitch. It created a small open area that he covered with a band-aid that once "sealed up" will allow whatever remains of the stitch to dissolve. We discussed using Palmer's cocoa butter to massage the incision site. I started applying the cocoa butter and massaging the area, avoiding the area with the band-aid the same night. I think I may have pressed too hard because my knee had very severe nerve pain that night. I continued to use the Palmer's Tuesday & Wednesday but with a lighter touch. The nerve pain remains, not quite as painful but it sometimes feels like the pain goes up into my thigh when I massage the scar.

This morning I had PT and could not complete my exercises. I've done pre-hab and my post op rehab with the same PT. I've always been able to do my PT and today the pain was excruciating-stinging, burning and achey. The more I tried the more I hurt, so it was not a good day and it brought me to tears from both the pain & frustration. I ended up resting for a couple of hours afterward at home and felt refreshed but the nerve pain is still there, loud as ever. I also noticed a crunchy feeling on the lateral side of my knee after waking up when getting up from the bed to a standing position. It also feels like my incision is being tugged from the inside when I flex my knee which I've had off and on since surgery and attribute that to the healing process.

So everything is good except for the nerve pain which is no fun. And now this crunchy feeling that seems to create pain is what I'm more concerned about or is that part of the TKR healing process?
 

Celle

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I'm glad your visit with your surgeon went well.
We discussed using Palmer's cocoa butter to massage the incision site. I started applying the cocoa butter and massaging the area, avoiding the area with the band-aid the same night. I think I may have pressed too hard because my knee had very severe nerve pain that night. I continued to use the Palmer's Tuesday & Wednesday but with a lighter touch. The nerve pain remains, not quite as painful but it sometimes feels like the pain goes up into my thigh when I massage the scar.
There's no need to massage your scar, and massaging it seems to be causing a problem, so please stop doing it. Your scar will heal without massaging - all the lumps and bumps will even out all by themselves.

This morning I had PT and could not complete my exercises. I've done pre-hab and my post op rehab with the same PT. I've always been able to do my PT and today the pain was excruciating-stinging, burning and achey. The more I tried the more I hurt, so it was not a good day and it brought me to tears from both the pain & frustration.
We do advise this - it was in the Recovery Guidelines posted for you:
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.​

So, I suggest you stop trying to do PT and exercises for at least a week, to allow your poor knee to settle down again. Instead, spend more time resting, icing and elevating your knee.
If you keep on trying to do PT, your knee won't get a chance to calm down again.

It's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your knee has the potential to achieve good ROM right from the start, but it's prevented from doing so at the moment by swelling and pain.
 

Jockette

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and all of the manipulations he completed
This is most likely the cause of your new pain. What exactly did he do?

And, as Celle said, massaging your scar is just adding to your discomfort.
 
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Jewlz1

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Celle-your response is confirming two decisions I've made-no more massaging the scar AND no PT for a bit. I will take a week of rest and see how I feel then. I'm not concerned with my ROM and swelling is minimal. My pain seems to be exclusively nerve regeneration or lack thereof. That's what is so frustrating. Anyway a week off from exercising should tell alot. Thank you!!

Jockette- the manipulations he completed were to check for fit of the prosthesis, I agree his exam could've created new pain.

I've been awake for almost 2 hours now because of the nerve pain. I was trying to isolate the location by gently touching my knee area and felt a rounded cord like thing that goes from the knee out to the lateral side of my leg and it ends at the bend of the knee which is where I started experiencing the crunchy feeling I mentioned. I'm trying to remain positive but this new episode has gotten me worn down.

Thanks again for your replies and guidance.
 

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You’re on my mind @Jewlz1. Is there an easy way to let your surgeon know about the cord you feel? The practice I go to is part of a big healthcare system and we can leave messages on a patient care site. We get answers within a day, during the week. This helps me when I’m worried, and twice they were able to help with something that actually wasn’t the normal course of healing.
 
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Jewlz1

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Hello Helizabug-I thought I had replied to your message but it may have gotten lost during the site's down time. My doctor doesn't have a patient portal like you mentioned for communication. Once I read that I thought it odd that the orthopedic group didn't have one. The cord thing is a vein. My knee area was so swollen I couldn't see the vein, just felt it. Thanks for your thoughts it means a lot.
 
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Jewlz1

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An update on the status of my knee. I did end up going to the PT on Feb 7. The therapist did a light massage, had me on the bike and did some step ups, side to sides, balancing one foot in front of the other and a couple more exercises. I shouldn't have gone. That was too much work for the amount of discomfort I was dealing with. The weird thing is once I start exercising, the pain or discomfort goes away but returns afterward. I've done nothing but ice and rest today. My knee does feel stiff and I did do some very gentle heel slides supporting my leg with my arm and some kickouts- again slowly and not very many. I'm literally afraid that my knee will lock up on me or drastically lose ROM if I don't move it or that I've done some type of irreparable damage through too much exercising. My concern: I started leg presses during my 2nd week of post-op PT starting with 40lbs and increased to 60lbs in a weeks time and then to 80lbs during my 4th week which was to have been my final week of PT. My doctor wrote an order for another 4 weeks of PT at my request during my 6 week postop visit. I think between massaging my scar too deeply and leg pressing 80lbs have contributed to my current quandry and I'm not going to continue with PT. I can do exercises at home and have a stationary bike. There's so much subjectivity with TKR. Different doctors have their unique protocol and each patient is different too. But it just seems there should be some universality in PT protocols. Trying to remain positive through this, but definitely feel like I've had a minor setback. One day at a time.
 

Celle

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@Jewlz1 - I'm so glad you've decided not to go to PT any more.

There is no universality in knee replacement recovery, because every knee is different and all surgeons have their own opinion, based on their training and experience.

What we've learned here on BoneSmart, though is that doing too much exercise, too early, almost always has a detrimental effect on recovery. The best approach is to listen to your knee and judge your activity by how happy your knee is. If it hurts or gets stiff, at the time or later, you are doing more than you knee is ready for at that stage of recovery. So, ease off that activity for a while and maybe try it again a week or two later.

You did overdo it with the leg press and weights. We recommend not starting strength training until at least 3 months post op. Heal first, strengthen later. After all, if you had broken your leg, you wouldn't be trying to lift 80 pounds with it 4 weeks later, would you? I sure hope not!

Never mind. If you ease off all that exercise and, instead, spend more time resting, icing and elevating your leg, your poor knee should settle down again. You won't lose all the ROM you've gained, and what you can do at home will be plenty of exercise.
 

Jockette

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This article is in the Recovery Guidelines you received when you started your recovery thread:
 

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Sounds like you’ve made a good decision to stop the PT. Let your knee heal from the demolition and renovation that it went through.
 

Roy Gardiner

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I've done some type of irreparable damage through too much exercising
You can only damage soft tissue, not the joint, and soft tissue can heal.
I started leg presses during my 2nd week of post-op PT starting with 40lbs and increased to 60lbs in a weeks time and then to 80lbs
Dear Lord please stop.

All you need is to help retain mobility (not fitness or strength) until healing is complete. This is done with gentle stretching exercises, without pain. You can do training when healing is complete.
I can do exercises at home and have a stationary bike.
Using a bike to gain ROM is pretty simple:
  • Set the bike to zero resistance
  • Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
  • Gently turn the pedals, through discomfort but without pain.
  • Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
  • Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
  • Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
  • And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't
Here is a bit more chat and some pix and how 'healing' and 'training' are different
 
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I agree. 80 lb leg presses! That seems too much. I could barely do that pre TKR and I like gym work. Indeed everyones progress is different. I got a slightly late start on PT not doing much the first weeks as I could not sleep. That mattered little, once I started PT it progressed well but not rushed!

I did not dare do any gym-level weight bearing (supervised by my PT per our agreement) stuff until my fifth week, limited pounds - very few reps. And I'd used weights pre TKR. Don't over do it! It is about gentle efforts to movement. Then weight bearing (your own body weight in activities first).

My incision does not like much fussing. Once the scabbing dropped off I found less is more. The more I touch it the more it hurts. If I just leave it alone it hurts less -- needs more maturing I suppose.
 
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Jamie

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It's no mystery why your leg feels better when you do these exercises. The movement of your muscles during the exercise forces any swelling (fluid) you have around your knee out of the area temporarily. But because your knee is inflamed and and not happy about being overworked too soon, the swelling comes back as your body uses the fluid to fight inflammation wherever it is in your body. This is why we tell people to pay attention to any pain during an exercise and up to 48 hours afterwards. The body is very good about giving you clues as to what you should and shouldn't be doing. I'm glad you're listening to what YOUR body is saying. Good for you! There is plenty of time to gradually increase your activity and exercise once the inflammation level is lower. Getting swelling down is your first priority.
 
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Jewlz1

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You all are the best! Not sure what stretching exercises I should use at home other than the stationary bike. Can someone point me in the right direction on that?

The nerve inflammation increase I guess is due in part to the extreme PT? I know it's not unusual to have nerve pain postop. But mine is horrible. I may be repeating myself, but I've been dealing with little sleep because of it for the past 3 weeks. Early this morning I came to the conclusion I need some help in calming those nerve endings and know that Gabapentin is indicated for that. I took 100mg @ HS for the 30 days post op. If anyone can share their experience with the success of this drug I would be grateful. Some drug interaction concerns in taking Gabapentin is I also take duloxetine and lamotrigine. Drug interaction checker online indicates moderate interaction with an increase in usual side effects of my maintenance drugs. I still think it will be worthwhile to start the gaba to calm down the nerve endings. Thanks again for all of the support! ♥
 

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