TKR Thank God I am now home.

[B0etijlc]

6 week checkup did not go well. I thought I was doing so good and my pain is getting easier to manage. My Doctor was not convinced. So, I go back to the hospital for manipulation. Not looking forward to that.

 

[Celle]

I'm sorry to hear that your 6-week visit didn't go well. What was wrong?

Also, I don't understand why you are going to have a manipulation. Most surgeons don't do it once you have got to 90 degrees.
How well can you bend your knee without the CPM?

You said that you have got your knee bending up to 120 degrees on the CPM, so it will bend. That shows that you don't have adhesions.
I don't see what a forced manipulation under anaesthetic is going to add to your recovery at all.

Studies have shown that early manipulation such as you are going to have do nothing to improve your eventual ROM. See this:
MUA: the ineffectiveness of early MUA (JBJS)
and this:
MUA (Manipulation under Anaesthetic) and Adhesions

Can you ask for a bit longer before you have a manipulation - to see what degree of bend you can achieve on your own, without the CPM? Remember that your surgeon can't do the manipulation without your consent, so you are allowed to say no.

 

[B0etijlc]

Sorry, I don't get how to place the quotes in these messages. My Doctor said at 6 weeks he would like to see between 110 and 120 degrees bend. I had 90. I gave up the CPM machine about 1 1/2 weeks ago and I was doing 120 on that. But, I was told that did not mean I had a 120 degree bend, which proved to be the case. My knee is very stiff and swollen. My Doctor also said between 6 and 8 weeks the scar tissue will get stronger and it will become impossible for him to break it with manipulation.

So - I have trusted him so far and I guess I'm going to continue to do so. I have been told and read that in some people the scar tissue develops no matter what you do because their bodies don't restore the fluid fast enough. I have Sjogrens, which is an autoimmune disease where your body attacks it's moisture producing glands, and I wonder if this is part of my problem. I forgot to ask what the Doctor thought about it.

Just hoping this will be a minimal setback and not too painful.

 

[kneeper]

I'm going to tag @Josephine about this. I'm not sure whether the Sjogrens means an MUA will inflame your tissues even worse or if it makes you more susceptible to adhesions.

 

[Josephine]

Well a girl's gotta do what a girl's gotta do!

 

[B0etijlc]

Thanks. The Doctor is putting me back on the prednisone to help with the inflammation. That helped a lot right after surgery. I still have a lot of bruising and soreness in the lower part of my leg.

 

[Celle]

110 to 120 degrees bend at 6 weeks is really very optimistic. Most doctors are happy with 90 degrees at that stage.

I'd recommend waiting longer, doing less exercise with your knee and concentrating on reducing the swelling, which I have no doubt is inhibiting your bending.

 

[Paradise06]

I'm just jumping in here on your thread for the first time, but I did read through it all. I had RTKR end of November, stayed in a rehab center (wouldn't do it again!) for three weeks following surgery, saw OP at one month post-op. I could not get to 90 degrees and I was plagued with stiffness and pain, so I understand how you are feeling. I have to add that in the rehab center, the emphasis was on building strength/muscle and NOT of ice and elevation, which clearly I needed. People have said on this site that an inflamed knee is like a hose filled with water...it won't bend, thus the swelling has to be reduced first, and it takes time. Clearly, not everyone has this problem.
I had a manipulation at 4 1/2 months. I saw the doctor at 3 months, he wasn't pleased at all with ROM, but I was then heading to the Caribbean for a three-week holiday, so manipulation was two days after return from holidays. Doctor said he got knee past 120 degrees during manipulation, but it was months later before I could achieve that on my own. Reason: swelling and liquid below the knee cap persisted. I would think long and hard about having the manipulation at this stage. Take in all the advice, read the articles sent to you, continue doing what works for you, and consider postponing the manipulation a few weeks....you're well within the range of time for doing it.

 

[Celle]

Take in all the advice, read the articles sent to you, continue doing what works for you, and consider postponing the manipulation a few weeks....you're well within the range of time for doing it.

Actually, there is no time limit concerning when a MUA is done. There's no "window of opportunity"within which time it has to be done, or else all is lost.
See this:
Myth busting: the "window of opportunity" in TKR

 

[Paradise06]

I just reread the link "Myth busting.." The stats are very interesting. It does say:

Average time from surgery to MUA was 11 weeks.

My first appointment with OS was 3 1/2 weeks post surgery. That went okay, but the knee was very stiff due to inflammation and I had a lot of pain. My next FU appointment was two months later, which in retrospect was too far out. I've used the same surgeon for knee #2 and respect him a lot, but clearly I made lots of mistakes and PT during that time was not appropriate. He will see me more frequently with knee #2 OP.

I also find this comment in the article interesting to say the least:

to conclude that the procedure did not increase the ultimate range of flexion after TKR.

Questions:
1. So why do doctors continue to do it? Perhaps with the thought: "it can't hurt" (pardon the pun)
2. I would find it difficult to say to the OP surgeon "thank you very much for the suggestion, but its my knee and I don't want to have the MUA". Believe me, I'm one to think for myself and do plenty of research, but this would get sticky, meaning you're doubting the OS's advice.
3. So what alternatives are there when one chooses not to have the MUA? Go back to elevation, ice, pain meds, rest to reduce the swelling, then more PT?
4. Don't adhesions become a continuing problem?

Looking forward eagerly to some further discussion about this topic.

 

[Josephine]

The Doctor is putting me back on the prednisone to help with the inflammation.

I have never thought this to be a good idea. Not one surgeon I ever worked with would think so either. Prednisolone is not a very nice drug.

Clearly, not everyone has this problem (swelling)

Oh but they do. It's just some people won't see or admit it!

I had a manipulation at 4½ months. Doctor said he got knee past 120 degrees during manipulation, but it was months later before I could achieve that on my own. Reason: swelling and liquid below the knee cap persisted. I would think long and hard about having the manipulation at this stage.
So why do doctors continue to do it?

I quite agree with you. The fact that he got your knee past 120 when you were unconscious says a lot - principally that there was no need for the MUA in the first place. They may talk 'scar tissue' and 'adhesions' beforehand but I've been present at and helped an awful lot of MUAs over the years and those that genuinely have adhesions are tough to bend. Really tough. But I have also been present at MUAS that did bend to 120+ and the surgeon then rejoiced because he 'knew it was all in the patient's head'! Once the surgeon even tied the knee bent with bandages so the patient could see when she woke up that her knee would bend! No worries about the patient waking up screaming in pain! Oh no - he'd proved his point and that was all that was important to him! And every time I read here that a member is being coerced into having and MUA is just to prove to him/her that their knee will bend and 'it's all in their head'!

I would find it difficult to say to the OP surgeon "thank you very much for the suggestion, but its my knee and I don't want to have the MUA". Believe me, I'm one to think for myself and do plenty of research, but this would get sticky, meaning you're doubting the OS's advice.

Well, surgeons do get things wrong and invariably their ego comes into play in this too. They have a need to see their cases get a good outcome and an under-performing patient is anathema to them. Hence the rush to 'prove to the patient' that they can do better if they would but try.

So what alternatives are there when one chooses not to have the MUA? Go back to elevation, ice, pain meds, rest to reduce the swelling, then more PT?
Don't adhesions become a continuing problem?

Fact one - adhesions are very rare
Fact two - swelling is very common
Fact three - too much exercise heats up the tissues and hot tissues can create adhesions
Fact four - both can limit ROM
Fact five - one doesn't need to rush to do an MUA so time can be allowed to see if the problem truly is adhesions or is it just swelling.

 

[B0etijlc]

I had my manipulation this morning at 7:00 am. The Doctor was able to increase my range of motion from 78 degrees to 100 degrees. I began working on my CPM again this afternoon and will begin physical therapy tomorrow. I could tell a big difference in the discomfort I was having in my knee immediately - it is much better even though it is sore. Not much more than it was already though. I can now bend my knee when walking and it feels more normal. I was very stiff legged before and it felt like I had a very tight band wrapped around my knee. The band is gone now.

I also started my Medrol dose pack. I have an autoimmune problem and my body does not handle inflammation so well and my Rheumatologist puts me on prednisone occasionally. I also have diabetes and other problems that interfere with healing. I'm used to these problems and I've always had to deal with them. This is not the first time I've had to have repeat procedures to fix problems.

I read all the information provided on this site and the information provided by each of you. I thank you and sincerely appreciate the time and effort it took to write these comments. However, everyone is different and I know my body and how it feels and reacts to illness and injury, I use the internet and other sources to research prior to making decisions. In this case, I agreed with my Doctor that I had a problem that needed to be corrected as quickly as possible. I could feel it getting worse and I chose not to wait until more drastic measures had to be taken to correct it. I made the right decision for me and that is evident by how much better I feel already. Now, I will get to work to keep this knee bending further. Again, thanks to everyone.
Jackie

 

[kneeper]

So long as you were part of the decision and didn't feel bullied by the doctor, that's the important thing. Keep following the plan of ice, elevation and exercise with constant listening to the knee. Ok to challenge it a bit but if it gets you know to back off a little.

 

[B0etijlc]

Physical therapy was easier than I expected it to be today. Not good or pain free but I made it. The therapist measured me at 95. I have lots of homework and this is going to take a lot of work but I'm motivated. Ready to move on through this recovery and get back to being physical.

 

[Celle]

I have lots of homework and this is going to take a lot of work

Having an MUA causes some re-injury to your knee. You should take it easy for a few days and allow your knee to recover from that.

You don't have to work hard to recover. This is one operation where "less is more". In fact, doing too much can really slow down your progress. You cannot make your knee recover by working hard at it.
Many people recover by doing a minimum amount of exercise and some never go to PT at all.

Read this:
TKR: work “smarter” and not “harder”

This is the only exercise you really need to do:
Heel slides and how to do them

 

[Jamie]

I hope the MUA does the trick for you. One caution, though, since you say you still have pain. Be sure you are back on something to take care of the pain. You should be taking your meds on a regular 4 or 6 hour schedule again for a few weeks until things settle down. That pain will cause inflammation and swelling if it's not treated.

 

[B0etijlc]

Thanks Jamie. Yes I am still taking my Tramadol and Hydrocodone and prednisone. I'm feeling very good today. I have been working on my knee and it is causing no additional pain. Settles down nicely. My exercises consist of lying on my stomach and bending my knee behind me, lying on my back and sliding my knee down and up the wall, sitting up and pulling my knee towards me to bend it, lying on my back and bending my knee, and stretching my knee and quad while standing up and leaning into it. I do 3 sets of these a day and I use my CPM twice a day. I also have a portable bike that I rock my knee back and forth on. I do feel a lot better overall.

 

[B0etijlc]

Measured 106 degrees in PT today - up from 95 measured last Friday. Thank you Jesus. I was also able to push the bike pedal all the way around instead of just rocking back and forth. I'm so happy with myself. You go girl. Now to just keep it up. We did new exercises so I'm sure I'll be sore in new places too. That's what the pain meds are for.

 

[kneeper]

Awesome job on the bike! How's it been going this past week @B0etijlc ?

 

[B0etijlc]

Last Wednesday I was able to bend 110 degrees by myself. The therapist helped a little and we got 114. I was very proud. The Doctor wanted me to have at least 110 by the time I go see him on Dec 4th. I am working hard to keep it. I have been moving around more and the pain is much less now. Sleeping all night with no pain meds. Hopefully, the worst part is over and I can just get better and better.