Knee Infection* Revision #3 Journey

[Jamie]

I’m so happy to read your latest report. Although this is all very serious and complex, your surgeon seems to really have things under control. His path forward makes sense and sounds like it has the potential to work for you. You’re so wise to just take things in small steps and not get ahead yourself by dwelling on the “what ifs.”

I did some reading about the flap procedure you will have and, from what I could see, it is an excellent option with much hope for a positive outcome on your knee. This all will take a toll on your body as it fights the infection, so don’t be surprised that you need a lot of rest in the coming weeks. You may want to discuss the need for home assistance with your hospital social worker. They may be able to point you to a lot of resources quickly. Most counties have an office on aging that also helps with resources when needed. We’re always here to chat and help you navigate any of these challenges ahead. Don’t hesitate to post if you’re worried or running into problems.

 

[sistersinhim]

@celynda, how are you doing? Is your surgery still on for tomorrow?

 

[celynda]

You are right, @Jamie about needing help. I’ll definitely work with the social and home health folks to get what I need.

They did an ultrasound to check for blood clots ~ no clots.

Also, did a transesogegal echocardiogram (TEE) to check for endocarditis. Negative.

So waiting on flag surgery tomorrow.

 

[Layla]

Great news!
Good luck tomorrow, celynda!

 

[lovetocookandsew]

I'm so glad you have such good doctors caring for you. that all goes well tomorrow and you can quickly go home. I'm happy to hear everything is as under control as possible for your surgery and to help you as you recover.

 

[sistersinhim]

We are lifting you up with prayers! Please let us know how you are tomorrow as soon as you are able.

 

[sistersinhim]

How are you doing? I pray you are doing better. Did you have your surgery on Friday? We are all waiting to hear from you.

 

[celynda]

The surgery went well. I am WBAT ONLY for transfer to/from potty chair or chair. It took a couple of days to get the pain management correct.

CURRENT ASSESSMENT

MSSA bacteremia
Right knee septic arthritis secondary to MSSA
History of multiple revised R TKA (most recently in May 2023 with revision to DFR following failed ORIF distal femur TP fracture at HSS)
TTE negative for vegetations; TEE ordered for today
Orthopedic surgery consultation appreciated
Now status post right knee revision on 8/21/2023 and plans for flap on Friday
Continue scheduled acetaminophen 1000 mg 3 times daily
Continue lidocaine patch
Continue Robaxin 500 mg every 8 hours
Increase gabapentin dose to 300 mg 4 times daily
Add scheduled oxycodone 5 mg every 6 hours
Continue as needed oxycodone
Decrease IV morphine to 1 mg every 6 hours as needed

POSTOPERATIVE PLAN:

• Weight bearing status: WBAT right lower extremity. No knee ROM until cleared by Dr. Apel, likely 3-4 weeks.
• DVT prophylaxis: Per Dr. Adrados / Adult Reconstruction .
• Drains: Measure and record drain output. The patient will need to go home with her drains, and also measure and record drain output. Anticipate about 4 weeks of draining.
• Antibiotics: Per Dr. Adrados / Adult Reconstruction .
• Disposition: Per Dr. Adrados / Adult Reconstruction .
• Wound care: Maintain incisional VAC until Wednesday, September 6.
• Skin graft donor site per below instructions.
• Follow-up on Wednesday, September 6 with Maggie Tuck, PA-C. At that time, all of the dressings will be removed and the skin graft will be inspected. The wound will be redressed, and he will then be placed in a cylinder cast. She is allowed to weight-bear as tolerated in the cylinder cast.
• Follow-up with Dr. Apel or Maggie Tuck when the patient is about 3 weeks postop. Remove all sutures and staples at that time. At that point, she can go to knee immobilizer for 3 additional weeks.
• Maintain drains until drain output is less than 30 cc / 24 hours x 3 days. This typically takes about 4 weeks.
• Follow-up with Dr. Apel when she is 4 weeks postop.
• Maintain knee immobilizer until she is 6 weeks postop.

Case Management/Social Work will hopefully organize transfer to the 4 star SNF in my network near the hospital for follow-up appointments.

I am feeling much better and am surprised at how little opioids I need. I’ve sat in the chair every day since the surgery on Friday. The staff here is doing a good job. The response time could be better. I’m on a geriatric med/surg floor so most of the other patients have sone form of dementia and are quite demonstrative.

I feel a little more confident about the future, even though it may be several weeks before I can restart PT and months before I even think about looking for a job. Retiring now is sounding better and better so I am researching options.

ADVICE to other smarties: Don’t let pets lick incisions or pick at scabs, One or both of these caused the cellulitis which in turn got in the joint and resulted in Septic Arthritis.

 

[celynda]

Admins,

Please add the following to my signature

Right 3rd Revision and Washout - August 14
Right knee medial gastrocnemius muscle flap - august 25
Right knee, split thickness skin grafting to right knee wound, 5 cm x 8 cm - August 25

Not sure how you want to include the Aug 25 items as they were required to cover the open wounds lost to infection. They moved muscle from calf to knee to help with flexion and a skin graft to cover the jknee

 

[sistersinhim]

I am feeling much better and am surprised at how little opioids I need. I’ve sat in the chair every day since the surgery on Friday. The staff here is doing a good job. The response time could be better. I’m on a geriatric med/surg floor so most of the other patients have sone form of dementia and are quite demonstrative.

Feeling much better and low pain is great news! Being disturbed is not. Can you be moved to a quieter room?

Please add the following to my signature

I took care of it. The way you have it listed is fine.

Be sure to keep us updated! Have a blessed day!

 

[Jamie]

Hope you are continuing to do well today…..just thinking of you and wanted you to know.

 

[sistersinhim]

You have people all over the world, even some not on BoneSmart, praying for your recovery!

 

[Pumpkin]

Glad you are doing well and your pain is controlled. Wishing you well in your recovery, hope it is uneventful.

 

[mendogal]

Looking forward to more positive updates!

 

[celynda]

Got an update from Ortho…

Success of flap surgery is very good, 90%.
Limb salvage is dependent on eradicating/controlling infection. There’s less than a 50% chance of eradicating the infection, so controlling is the goal.

Follow-up, 9/6, will provide first opportunity for doc to see wounds and confirm progress. No ROM work or bending the knee until at least end of September. While I am WBAT, it’s limited to a few steps or transition to potty chair or recliner.

Nurse Practitioner said it to eat high protein, fruits, vegetables, etc. said to limit sugars. I think I can do this as long I dont have to give up chocolate.

 

[sistersinhim]

I think I can do this as long I dont have to give up chocolate.

I am right there with you on that! After my tkr, all I could tolerate was dark chocolate kisses and mixed nuts. This went on for about 2 weeks. I am cut way back on the nuts, but still have a few kisses every day. What is life without chocolate!?

That is great news about your flap success. We will still be praying that the infection goes away completely! Who knows, good things happen every day!

 

[Jamie]

This all still sounds positive. I’m sure the doctor is giving you the worst case scenario just in case. I’m with sistersinhim, that it still is possible that the infection will be gone at some point. That’s what I’m praying for, anyway!

 

[celynda]

In addition to five days of IV iron, medicine ordered a unit of blood today. Count dropped to 6.9 overnight.

Haven’t seen social work yet today, hoping Insurance and the facility are on the same page today so discharge could be today or tomorrow. A friend is bringing some clothes for me as I came to the hospital in a hospital gown.

Drain sites are the most painful so I am very careful not to move much. Pain management regime works mostly. Supplemented by Oxy and Morphine prn. I don’t think the SNF will do IV morphine so need to check with Medicine to see how the PRN meds change.

 

[mendogal]

I hope the SNF transfer goes smoothly. With friends and family I have seen medication orders either botched in the transition or capriciously rewritten by the SNF doctor without reviewing the history or talking to the patient. So be prepared to smile and self advocate!!!!
Holding you in my heart.

 

[celynda]

@mendogal, thanks for the reminder. I am being discharged today to a 4 star SNF/Rehab in Roanoke. Friendship South has private rooms and showers and was recommended by case management and a couple of the nurses. A friend brought me a suitcase with clothes and toiletries. I chose to stay near the hospital as the facility will arrange transportation to/from doctor follow—up appointments which I have between 9/6 and end of September. I hope insurance

The medical doctor just stopped by to let me know of changes made to meds for the SNF. In the hospital, most of the meds were scheduled. In the SNF, most will be PRN so I need a plan to make sure the blood levels are maintained and pain is well managed. This is my going in plan. @Jamie and others, all thoughts and suggestions appreciated.

• Gabapentin 300, scheduled q6 hours
• Robaxin 500, PRN, q8 hours; will request 2 hours after Gabapentin
• Oxycodone, 10, PRN q4 hours, will request 2 hours after Robaxin
• Tylenol, 500, PRN q6 hours, will request with Oxy

I’m still on two antibiotics: Ansef (IV) and an oral one.
I still have a wound vac (from the revision) and 2 drains from the skin flap surgery. This is in addition to the PICC line for the IV antibiotic and any blood draws.

The facility is sub-acute which is ~1 hour of therapy split between OT and PT.

1:32 PLOT TWIST

1) facility wants me to prepay because they’ve been burned on COBRA before. I am going to fight it but will pay if needed.
2) facility wants me of IV Morphine for a couple of days. This is my go to when nothing else is working or I’ve over-done it. At least this gives me a couple of days to fight on the Prepay

So not going anywhere today. GRRR