Six Week Follow-up with Dr. Kerina

So, yesterday I had my six-week follow-up with Dr. Kerina.  Bill and I went to the Lady Lake office,  where I received very positive feed-back on my progress.  I had an x-ray taken that shows the new knee in alignment with no instability or soft tissue problems.  He told me there is no reason to work on increasing the range of motion; 130 is higher than any expectation for six week post-op,  and any additional range will come from my normal activity level, which is fairly high.  I don't need any more PT, and he reluctantly said I can hit tennis balls "as long as you don't run."  He also reluctantly said I could use the elliptical machine, but hitting tennis balls is much more fun that that!

I  had previously picked up the Operative Report from Leesburg Hospital; the knee is a "Zimmer Natural Gender (cobalt chrome cast alloy) #1 femur, #2 tibia, 9-mm ultra condylar and tibial bearing, #1 patella."  The patella parts are "ultrahigh molecular weight polyethylene."  He chose that particular knee because I am a tennis player, and the "plastic" parts because the substance is stronger than some other choices, and can better withstand the usage that comes from playing tennis.  He said it should last 20 years of normal use, but my lifestyle is not considered "normal use."  The parts that are most likely to wear are the "plastic" parts, and they can be replaced if necessary.  The other parts are glued in and "aren't going anywhere."  The soft tissue, though, takes longer to heal, hence no running yet.

As for antibiotics and dental work, absolutely I must take antibiotics before any dental work, even cleanings.  "Don't listen to your dentist."  Dr. Kerina said the antibiotics are very important; the mouth is a dirty place, and any infection will seek out the parts that are alien to your body, i.e. the new knee.

And yes, I will set off metal detectors.

Physical Therapy #8: Graduation Day

"Today is graduation day."

It's almost six weeks post-op, and Forwen was working on my knee for the last time, preparing to take the measurement to include in the final PT report to be sent to my surgeon.

Range of Motion:  -3 to 130.

I was told this was an unusually good result for only six weeks out.  He has not had another patient do as well as fast.   It's bittersweet, though, since while I love the fact that I feel as good as I do and can do as much as I can do, I am really going to miss my 3x week at PT.  I think it is partly knowing that 3 times a week, I had an appointment to do something important (sort of like playing tennis?), and now I'm going to have to be disciplined and do the stuff by myself with no one standing over me.   That's no fun!  But I knew from the onset that, whereas tennis was my "job" prior to surgery, that rehabbing was my "job" post surgery.  Of course, I'm passionate about tennis, but, unfortunately, not as passionate about rehabbing.  Oh, well.  On to the next stage in the TKR recovery process!

Pleasant Surprises

So, I drove to Skyview to attend the tennis ladies Cookie Exchange, which I was pleased to be invited to.  On my way home three hours later, I realized that I had stood on my feet for almost the entire time I was there, and was totally unaware of any discomfort.  If anything, I was conscious of how well-balanced and solid I felt.  Last year, I needed to be sitting most of the time.

It's the little realizations like this that are so significant.

Physical Therapy #5 and #6

Today is five weeks since the surgery.  I will have two more PT appointments, and then I will be done.  The physical therapy plan is that you must reach certain goals before being released from PT, including range of motion, certain knee lift/bending with 5 lb. weights, certain balancing, certain level on the bike, etc.  I'm just about there.  My range of motion is  -1 to 127.   I'm up to ten minutes at level 7 on the bike; 5 lbs. on the knee lifts, and have the balancing part nailed, I think.  That's standing on the balance board tossing and catching three balls of ascending weights (one at a time, though), at a small trampoline.

I asked about using certain machines at the fitness center, and Forwen said go ahead.  He said he knows my legs are strong because I can walk up and down stairs.  I can pretty much do what I want to do, with the exception of tennis.  I'm being patient with that, because I am well aware of the damage I can cause if I do something stupid, and playing tennis would be stupid!  Serving, however, I have been doing.  I might as well try to keep one aspect of my game honed.  But I am still shooting for January 1 to be hitting tennis balls.  I see Dr. Kerina next Thursday, and we will see what he says.

Reflections on Range of Motion

I have been aware from the onset that regaining range of motion after TKR is big. Range of Motion is drummed into you from day one.  It is stressed how important it is to the overall recovery to get the best range you can from your new knee.  The "gold standard," as Bud put it, was 0 - 120.  That is the goal to be achieved with PT, and after it is reached, from what I understand, PT is no longer needed.

While still in the hospital, I remember, even in my drugged haze, that Ingrid measured, and I was 0 (perfectly flat) from day one.  That had to be the surgeon's expertise, I think, and I reached 90 degrees before leaving the hospital.  My feeling is that your range of motion before the surgery has to have some impact on the range of motion you are able to reach after the surgery.  My upper range has since been increasing gradually, and has reached a high so far of 127.   I have achieved that because I have worked on it, and have been proactive with the PTs.  For instance, very early on, when Bud was coming every day once I was home from the hospital, I suggested a rocking chair, which we have on the porch.  It is very difficult to increase your range by pushing, but not very difficult if you sit in a rocking chair and "rock" it.  I also asked him about an exercise bicycle, and that is how I have increased it as high as it is now.  Each time I use the exercise bike, I move the seat a notch closer.  Bud showed me how to do that carefully, by going backward very slowly until you can go around, and then cycle at that setting, and the next time move the seat up closer, and repeat.  Had I not been proactive and asked the PT about these things, it would have taken me much longer to achieve some goals.  Of course, the knee had to have been co-operative enough, but in my case, it apparently was.

Physical Therapy #4

Since my last PT, I have gone to the fitness center to use the bike, and I have also tried the elliptical machine.  While the knee is okay with it, the rest of me finds it hard to do for more than a few minutes.  I think I have to work myself up to that level of exercise.  But I do practice going up and down the stairs and am excited to be able to do that!

Each time I go to physical therapy, Forwen adds a degree of difficulty to the various exercises.  Today it was bouncing a 4 lb. ball off a small trampoline while balancing on a balance board.  That's a challenge!

However, on the complaint side, none of my body parts likes this cold weather we are having, especially my new knee.

Physical Therapy #3

"You're doing scarily well."
"What do you mean?"

The danger is that you will do too much, too soon.  You can control the physical therapy, but you cannot control how long it takes for the healing to take place.  You must be careful not to overdo.  It takes a good 6 to 8 weeks for the healing to take place.

Points from Forwen well taken......yet again.

Physical Therapy #2

I had my second appointment with Forwen today, and it was very beneficial.  We were talking about range of motion, and today I am at 0 - 127.  I have added the extra by moving the seat up on the exercise bicycle at the HH fitness center.  But I hadn't really given much thought to the "0" part of the equation, figuring 0 was fine.  But Forwen suggested that -2 or -3 was even better, and the reason is that being at 0 or less allows you to lock your knee.  My question was, why does it matter if I can lock my knee or not?  Because locking your knee allows you to stand without getting tired.  If your knee is less than 0 it will not lock, and if it doesn't lock, you are using your muscles to remain standing, and that will make you tire faster.  The light bulb went off!  For a long, long time, I had not been able to stand for more than five minutes.  I could walk, or move, or play tennis for hours, but I could not stand.  So now I have both a new goal (-2 or -3) and something else to look forward to:  the ability to stand and chat with someone (like Bill does all the time) without having to go find a seat.

The Driving Force

So when I saw Dr. Kerina last Monday at my 2-wk post-op appointment, I asked him when I could drive, mentioning that I had been driving the golf cart since the first week.  He said one month, which is one week from today.  Truth be told, I cheated.  I drove myself to PT today, and to the other errands Bill and I ran afterward.  It feels good to drive, and it is not in the least bit uncomfortable, nor do I feel I am putting Bill or myself or anyone else in any danger.  I would prefer to have an automatic transmission instead of my stick shift, but oh well.  Nothing to be done about that.

Out Patient PT - 21 days post-op

Today was my first outpatient PT session.  I am going to Florida Rehabilitation Specialists in Lady Lake.  I chose this location for two reasons:  Forwen Dela Rosa was recommended to me by a friend who lives in The Villages and is a very active person, as am I.  I knew that her expectations for a PT would be very high.  She had her 2nd knee replacement 6 weeks or so ago, and told me how pleased she was with Forwen.  The second reason, is that it is very close to home.

So, I met Forwen today, and we began.  He measured the range of motion, and I am already on the high side at 2 degrees to 120 degrees, the desired ultimate range being 0 - 120.  He thinks I should be able to get to 125 or 130 before we finish, and maybe -2.  He does not think I will need PT very long, a month at most.  He worked me, and I am sore this evening for the first time. . .a good kind of sore.

I'll be going three times a week.

To Sleep or not to Sleep: 20 days post-op

I have always had a relatively good sleep pattern, and generally speaking, I sleep well at night.  But things have changed in the past three weeks as far as sleeping goes.  First of all, I found myself, especially early on after the surgery, needing naps during the day.  Generally, I am not a napper, but since the surgery, naps rule.  I have spoken about this with any number of people, including the nurse, Karyn, and Bud, the PT.  The short answer is that surgery takes a lot out of you, anesthesia can remain in your system for weeks, and therefore, you get tired easier.  Makes sense.

So I've been going with the flow, and napping as necessary.  But now, almost three weeks post surgery, I am finally feeling better during the day, and not in need of as much mid-day rest.

But the other side of that coin is sleeping at night, and that is a problem.  Common wisdom says that if you nap during the day, you might not sleep as well as night, but I don't think that is my problem.  What bothers me at night is an inability to get comfortable.    It's not so much Pain as it is discomfort.  It's best described as follows:

• I feel as if there is a sock full of sand in my knee.  It is heavy, thick, it doesn't bend the way it should. There is an alien in there. This creates a discomfort when I'm trying to get settled in bed.
• Following the surgery, there were black and blue marks from my buttocks/groin/thigh down to my ankle/foot.  These have been a minor annoyance in the overall scheme of things, but they exist nonetheless, and they make themselves known when I move around in bed.
• I have lost skin sensation in the front of my lower leg.  It is almost numb.  This adds  to the list of strange sensations.
• The staples are out, but the scabbing creates a tightness that rubs against the sheets/blankets.
• The quads are sore.

All of this adds up to a problem trying to sleep.

During the first week or so, I was taking pain meds, and this allowed me to sleep.  But once I realized the pain was minimal, I stopped the pain meds, to the detriment of a good night's sleep.  So last night at 2 am, tired of tossing and turning, I took a Percocet and slept well for 5 hours.  I chose to sleep.

14 days Post-op

The nurse, Karyn, came today to remove the staples.  22 staples later:

I am staple free and I can shower! Oh, and look how straight that leg is!

Pain - Eleven days post-op

Pain is very subjective.  My criteria for the level of my pain dates back six or seven years when I had severe back pain. The pain itself was in my left thigh, but it emanated from my back and that pain is the worse I have experienced since childbirth.  I spent 6 weeks flat on my back.  But I learned what a ten was on my personal scale. The pain in my leg went from a murmur to a whisper  to talking,  to an angry voice and then to YELLING.  But when that leg would SCREAM at me, it was a nine. It was unrelenting, and was hardly ever a 2 or 3 for that period of time, and that is also when I was first introduced to pain meds, and the pain meds were what allowed me a few hours a day of normal activity.  The rest of the time I was in bed or on the couch.  So I had my own personal pain scale for when the hospital staff asked me my pain level.  Today is 11 days post op, and the highest it has been is maybe a 6, and that was the second night when the femoral had worn off and I hadn't yet gotten the pain meds right, and that included PT.  Much lower than my expectations.  Of course, earlier, I had "kept ahead of the pain" with pain medications, but that's what they are for, and if taking the pain meds allowed me to put in a better effort to get better results, go for it.  Now, though, I am taking maybe two a day, one at bed time to help get a good night's sleep, and one before physical therapy.  And my pain level has been practically nil.  The most surprising to me is that I was in more pain before the knee surgery than I am now.  Yesterday, after going with the PT to the fitness center here at HH and trying out the bicycle, Bill and I went to Target, and I could walk around Target in less pain than I did prior to the surgery.  This is a result I expected to achieve eventually, but not ten days post op.  

The Cool Machine - A Tip

This little baby was one good investment.

As we were leaving my last appointment with Dr. Kerina before the surgery, he told us to go pick up an ice machine from OrthoCare, for which he gave us a prescription.  We rented it for two weeks for $50, and were told to bring it to the hospital with us.  I think the hospital can provide it, but Medicare does not pay for it, so Dr. Kerina tells his patients to rent one.  Just put ice and water in the cooler, plug it in and wrap the magic suction wrap around your knee secured with the wrap provided.  The motor then circulates the cold water through the octopus-like wrap.  The hospital staff kept it cold for me and applied it as necessary.  It works to keep the swelling down, and it is easy to use at home.  We put 8 bottles of water in the freezer, and each morning Bill puts 4 bottles of the frozen water into the cooler with water to the water line, and it is ready to go for the rest of the day.  The other 4 bottles go back in the freezer.  I find myself regularly going and elevating my leg with the wrap on it, and it is very soothing.

Dressing change - Not for the weak of stomach

The nurse came by Tuesday afternoon to change the dressing on my wound.  She cleaned it off, and before she applied the new dressing, Bill took this picture:

There are 22 staples, which will be removed next Monday.  The wound is clean and I think I looks pretty good, if not pretty.  

8 Days Post Op

The physical therapist, Bud, came this morning and we took a little walk around the neighborhood.  I am using the cane, and he was helping me get all the movements sychronized.  He is pleased with my progress.  The leg is straight, and that is a six-week goal reached.  I can bend to 95 degrees and I think the goal is 120.  It's still swollen, of course, but all in all the experience so far is not as bad as I had anticipated.  The pain is tolerable, and I'm taking fewer pain pills.

Bill and I went to Publix to do our shopping, and I was introduced to the wonderful world of battery-operated shopping carts, which I like, since without that, I would not be able to go.  And my appetite is back, at least for today, so food shopping was fun.

The nurse is coming by this afternoon for a dressing change, and then a week from today she comes back again to remove the staples.  Then, I can shower.  AAHHHHH!

So, I am slowly getting back into the normal routine of daily living, and sooner than I expected.   The house is still a mess, but I'll get to that soon enough.  Housekeeping was never my forte; dust is, after all, a protective coating.

THE HOSPITAL

Day One (Monday, November 8, 2010)

The surgery took about 1 1/2 hours.  I don't remember a thing from the time they wheeled me out of the preparation room until I awoke in my "private" room, and not much after that.  Bill was there, and my leg was in a machine that kept it moving continuously,  and my knee was in an ice wrap attached to a cooler that kept the cold water circulating.  I was in and out of awareness, more out than in.  I had a PCA, an IV, and a catheter, and when I wasn't in the machine that keep the leg moving, both feet were encased in boots that keep the blood circulating.  I wasn't going anywhere.  The hospital offered room service, so I was able to order my meals from a menu, although I had no appetite, and only ate a fraction of what I ordered.  Bill was with me, but I slept most of the time.

Day Two (Tuesday, November 9, 2010)

I slept OK; I don't remember much about the night.  The Femoral block was still blocking.  It was supposed to last 18 hours or so.  My GP came by to see me early, and Dr. Kerina also popped his head in.   The Physical Therapist came in twice:  once in the morning and once in the afternoon.  Ingrid is from Belgium and it took me awhile to stop calling her Bridget.  She massaged the quad, which wasn't too soothing.  It was very sore, but she said the surgeon had cut it; hence the pain.  Then she gave me various exercises to do, which I could manage with her help.  She measured the angles that could be reached and explained the goals.  The instructions are to take the pain meds at least 1/2 hour before she gets there, so once the PT appears on the floor, the staff sort of alerts you. The object is to "stay ahead of the pain."  But I did find a disconnect between the advice given by the PT and the actions of the nursing staff.  I found you must ask for the meds, they will not come in and tell you it is time for your pain meds.  And it is very difficult to keep track when you are out of it.  There are clearly mixed signals being sent.  The nursing staff does ask frequently about your pain level on a scale of one to ten.

Bill arrived early afternoon, but I was not very good company.  I'm sure he enjoyed watching me doze off.  But I enjoyed knowing he was there.  And Val and Dixie stopped in to see me late in the afternoon.

Another dinner from room service.

Day Three (Wednesday, November 10, 2010)

First thing this morning both the catheter and the PCA are disconnected.  So begins the transition to oral pain meds and getting out of bed and into the bathroom.  I took my first walk with the walker, but didn't go far. I was nauseous and feeling very weak.  I hadn't been able to eat much, and I was continuously sick to my stomach, though I didn't throw up.  My morning blood work (which they draw at 4 am) indicated that I needed a transfusion.  (7.9; and normal is 12 or so?).  So they worked that in around my PT.  The first unit would go in after the morning PT and the 2nd unit after the afternoon PT.  It was a slow process, followed by Lasix injected into the IV.  I was told its purpose is to rid the body of the elements of the blood transfusion that are not needed, so it makes you urinate frequently for 4 or 5 hours.  Tomorrow I go home, so it's important to have the blood level where it should be, or I'll be another day in my private room.    I was feeling even sicker after the transfusion, but I did take a few walks down the hallway to try out my new knee.  I was told on Tuesday that the goal was to walk to the nurse's station and back in order to be discharged, so I had acheived that goal.  Now, I just had to be sure the blood is ok tomorrow.  Bill came in the afternoon and I think I was a little more fun to be around, but not much.  I cherry picked from the veggie and side menu for dinner.  No wine though the apple pie wasn't bad.

Day Four (Thursday, November 11, 2010)
 HAPPY ANNIVERSARY!

What a great anniversary present:  to go home!

Today I go home.  I was told I needed to wait for Dr. Kerina to come by to release me so the plan was I would call Bill once I got the go ahead.  The blood (again, drawn at 4 a.m.) came in fine, so all signs were good  I got the word around ten that I could go home, and  I called bill to come fetch me.  So I was wheeled out of my private suite around noon, and happy to be headed home.

Bill's Omelet

Every day is a new adventure.  As I become better at feeling better, as I did this morning, I'll be able to post more about my experiences.  But first things first.  This morning I was feeling much better than I had felt in quite awhile.  Friday morning I felt great; both the PT and the nurse came by, and the PT was pleased with my progress so far and gave me some assignments for the weekend.  Come Monday, we could get down to business (see:  chills running down my spine).  Anyway, an upset stomach and swelling of the leg was keeping the discomfort level high all afternoon and last night, so my appetite was poor.  But this morning, I awoke hungry!

Voila!  Bill cooked me an omelet to order, and it's the first morsel I have eaten in the past five days that I really enjoyed!

The Hospital Experience, or, What I remember of the Hospital Experience

La La Land is a nice place to visit but I wouldn't want to live there.

But I felt as if I have spent a lot of time there for the past three days. (Just ask Bill).  We arrived at the hospital at 7 am, hurry up and wait.We did the due diligence, made the decisions about anesthesia (general) and femoral block (yes) and off we went.  By one o'clock I was in my room (private).  A private room in this case means there are two TVs, ergo two remotes and two phones, but only one bed.  The remotes control the TVs, the lights, and the nurses' call button.  When the phone rings, though, you have to find it, and the first one you find, might be the wrong one. Now, the lights are a different problem, because the aide may give you one nearby, but it does not mean that that one controls the lights that are on or off, which, of course, you don't find out until you need to, and then it's too late.  And let's not forget about your cell phone.  So much to keep track of with only 1/2 a brain functioning.

I awoke in a device that moves your leg into positions you are not sure it wants to go in yet, but drugs are a wonderful thing!  Who knew.  And now at least it's moving.

Arden's Gong

Happy Anniversary

As fate, or choice, would have it, I will be in the hospital on our anniversary.  Bill and I were married on November 11, 1993, admittedly an easy date to remember, since it is Veterans' Day.  We chose that date partially because I worked for lawyers and always had the day off (when the court house is closed, the office is closed.)  So our early celebration today consisted of some time on the tennis court followed by a good lunch at Glenview.  

The rest of the day, though, was full of shopping and preparations so that the house would be stocked with the necessary vittles and such.  

And while my knee is throbbing, Bill has gone outside to do some work in the yard.  The man is incredible!  I call him an anomaly; his so-called friends, though, call him a freak of nature.  He's almost 82, he is constantly in motion, and nothing hurts.  What's that all about?

  

Expecting the Unexpected

It's Friday night.  Surgery is Monday afternoon.  The phone rings at 8 pm.  Be at the hospital Monday morning at 7 a.m.  The doctor has moved your surgery up to #2 in the queue.

Rats!

TKR minus 4

Yesterday afternoon, Bill and I went to my final pre-op appointment with the surgeon.  After waiting the obligatory hour, we visited with Dr. Kerina.  He went over all the things that can go wrong, including, but not limited to, death. Most of the other possible, but not likely, outcomes were not so dire.  Not being a pessimist, however, I'm expecting it to go fine, while still expecting the unexpected.  He said the surgery itself (his part) should be 35 minutes or so, but 1 1/2 or 1 3/4 hours all-told.

We are to be at the hospital at 11 a.m.  Surgery is to be at 1 p.m.

Joint Registries

I found the below information posted on a bulletin board.  I learned in the seminars I went to that Sweden and Australia require a registry of every knee operation done by every doctor including the brand and type of device that was implanted and the results, including revisions.  This post includes the links to the two registries.  While I have looked through these, this is the kind of research that takes a lot of time, and since I have already chosen my doctor, and by virtue of that choice, his preferences, or contractual agreements or whatever arrangement exists between physician and implant manufacturer, my new knee is already determined.  So, I have not sorted through this.  But, I am a firm believer that this country should have a registry as well.  What better way to track the success or lack thereof, of these various devices and implants, not to mention the ability of the physicians?

This is a quote:


"I posted this on the total knee board, but as the registries also include unicompartmental results, I thought I would duplicate it in here. Some of the prosthesis in these countries are not sold here, and vice versa.
Following a previous post, a number of people have asked me to post the links to the Swedish and Australian Joint Registries. Hopefully the mods will make this a sticky. 
In Sweden and Australia, it is a legal requirement that every operation and knee is recorded. The UK also has a registry, but suppying information is voluntary (20% of cases go unreported, you can make your own mind up why some might not be reported)

Every company likes to tout figures on their success, normally studies by surgeons who are friendly to them, however, the registries include every single surgeon using the device, good, bad, or indifferent. They include tens of thousands of operations so will help nullify unusual events.
Its incredible to see that some knees that are commonly used in the UK have more than double the failure rate of others, must cost thousands in recovery costs.
Anyway the reports are below, 

The Swedish Joint Registry 
  http://www.knee.nko.se/english/online/uploadedFiles/113_SVK2009ENGL1.0.pdf
Gives results to 10 years, total knees are page 30-33 (or 34- 37 in acrobat). There are also some easy to understand graphs
Uni knees are page 34 (38 in acrobat)

Australian Joint registry
http://www.dmac.adelaide.edu.au/aoanjrr/documents/aoanjrrreport_2009.pdf
Total Knee results to 8 years are on page 145 (161 in acrobat)
They have a list of knees to avoid on page151 (167)
Uni Knees are on page 123 (139 in acrobat)"


Australian Orthopedic Registry

The Swedish Knee Arthroplasty Register

Pain is Your Body Telling you Not To Do Something

This is a saying I have always sort of believed in.   I considered twinges of pain, or more severe pain, as a sign to stop doing what I was doing.  It would seem that philosophy is being summarily thrown out the window.

Nurse Cindy said yesterday that the good news is that this pain is "operational" pain as opposed to arthritic pain, difference being that arthritic pain is continuous, while operative pain gets better every day, so you have that daily improvement to look forward too......except for the occasional step backward.

I hate the exceptions.

Orientation

Today I had an appointment at the hospital for an orientation.  As it happens, I was the only person present for the seminar, which was given by Cindy, an RN.  She originally had 3 patients scheduled, but two had their surgeries cancelled/rescheduled.  There was also a PT student observing.  We met in a classroom, and she went through the entire hospital stay from the time you walk into the door to the time you go home.  I was able to ask questions as we went along, and the experience was very enlightening.   For instance:

A femoral drip is an option.  It is a one-time injection that lasts from 24 - 48 hours and numbs the operated leg, which sounds pretty good to me.  The alternative to the Femoral is not to have it.  It works in conjunction the the PCA (patient controlled analgesic), which is a narcotic.  With the femoral, they have found that patients require less of the PCA pain reliever than would a patient who chose not to have the femoral.  The only down side is that it may make the muscle lazy so that it will not hold you up when you stand or walk.  The PT tests for this, and provides a supportive brace if it is necessary.  This is something I will consider and will discuss with the surgeon on Thursday.

General anesthesia or nerve block?  I always thought I would prefer not being put to sleep with a tube down my throat, that a nerve block and medication to put me in la la land would be adequate.  But, when I asked why one vs. the other, she said the operation is loud (read:  electric saws and drills!) and some patients would prefer not to hear those noises.   I'll have to give this some more thought.

Foley catheter:  apparently this is normally done, but this is a subject I will discuss with the surgeon during Thursday's appointment.  It is inserted into the bladder once you are under the anesthesia, and remains in place until the 2nd day after surgery.

The surgery is 1 1/2 to 2 hours, longer than I thought.

I was provided with "THE BOOK" during my first appointment, and I have found it very helpful.  I have been doing the pre-op exercises, and the book offers other useful information to help in the planning process.

Then, a Physical Therapist came in and filled me in on exactly what to expect from the PTs after surgery.  I'm not sure they will be my favorite people; they are very demanding, but it's the PT that will make or break this surgery, so bring it on!

Being a visual person, I asked Cindy if I could see the Ortho Ward, so we took a field trip through the hospital, where I saw the intake area, waiting room, and then up to the ortho floor.   There are some private rooms available (one of which I have requested), and I walked through one.  They have converted semi-private to private, so they are fairly good size.

As for the walker, cane, etc., these items are ordered before you leave the hospital, along with the in-home PT and nurse.  The doctor recommends a provider for these services, but you don't necessarily have to use the one he recommends.  I am on Medicare and have a United Healthcare supplement.  It is my understanding that all of these services are covered, but the hospital has an account/insurance person available if I have any questions.  I will be assigned a Case Manager on intake, and that person will follow my progress.

I had decided early on that I wanted the surgery early in the week.  I would prefer not to be in the hospital (any hospital) on a weekend when 1) my doctor may not be there; and 2) when the hospital my be shorter staffed than during a weekday; hence operation Monday, go home Thursday.....if all goes according to plan.

Preparations (1)

I was told that the hospital experience includes providing you with the necessary "implements" to make it through the recovery period.  However, who pays for that goes through my mind, so I paid a visit to the local charity resale store and picked up a walker for $2.  I was looking for a toilet seat "booster" or whatever you want to call it, but didn't find one of them.  Now, if I could just find a reacher......

"When it Comes to Severe Pain, Doctors Still Have Much to Learn."

Jane Brody, who writes for the New York Times, has a column that runs on Tuesdays in the Science Times section. In 2005, at 63 years of age, she had both her knees replaced, and subsequently wrote about her experiences dealing with the pain, and the lack of pain medication provided by her doctors. I remember reading these articles at the time, and wondering how anyone as well-prepared, knowledgeable, and well connected as she must be within both the medical field and the newspaper/publishing industry, could have had the experience she did. How could she NOT have been able to find the relief she needed, and if someone in her position can't do it, how can any old (or young) ordinary person? Of course, that was 2005, and the entire process has come a long way since then, including pain relief.....I hope. All conversations and indications I have from the various doctors/seminars I have attended have indicated that the medical field now understands that the only way for a patient to be able to get the best outcome, is to be able to tolerate the pain during rehab, and the only way for that to happen is with the proper medications. At least, I hope this is the case. Here are the articles; they are worth reading.

A New Set of Knees Comes at a Price

When it Comes to Severe Pain, Doctors Still Have Much to Learn

Three Years Later: Knees Made for Dancing

Thirteen days and counting.......

I play tennis on a 4.0 women's team that plays out of Ft. King in Ocala. Three of us live here at Harbor Hills and drive together to the matches. It is a great bunch of ladies, and we have a good time together. As the newbie on the team, they have made me feel very much a part of things.

We started the season with a full roster, but we've been dropping like flies, and now I'm on my last two matches before my surgery. As the surgery gets closer, I am more aware of how life is going to change, and how much I will miss the tennis and all of the activities that revolve around tennis, both with Bill and me, since we play tennis together a lot, as well as with my tennis teams.

Although I am hesitant to play on this knee competitively, the brace is still keeping me on the court, and a live body, even a gimpy one, is better than none. So we travelled together today to Gainesville to play our match. I left the house at 7:10 this morning (yuk!). I am a morning person in that I have an internal alarm that wakes me up early.....I'm just not ready to be good company then. But, off we went. We played our five doubles positions, and won three of them, so we won the day, and my partner and I won as well. It's always good to have a partner who can run, and it is also gratifying to win when you are not at your best, and to have a partner who supports you even when you don't get to that drop shot......again. Then, the celebratory team luncheon at a local Gainesville pub, where some of us have been known to have a beer with lunch, and on to the long drive home. It's a full day.

I find, though, that the tennis takes its toll on the knee, and the rest of the afternoon is spent in less than productive fashion. (Nap, anyone?)

I was looking at the Florida Health Finder site that compares hospitals, and I decided to compare three hospitals: Jupiter Medical Center, which is in Palm Beach county where we lived for many years; Leesburg Regional Medical Center, where I am going in 2 weeks; and Largo Medical Center, where several tennis friends have gone for partial knees and/or arthroscopic surgery. The results were interesting.

The category was Full or Partial Knee Replacement; The age group was Seniors (65+); the time period was calendar year, 2009.

Hosp. # procedures $ Low $High length of stay

JMC 200 63,029 75,477 4.1 days

Largo       936 34,095 53,951 2.5

Leesbg 353 36,339 42,471 3.3

A couple of things pop out at you. One, the cost for the surgery in Palm Beach County vs. the cost in Leesburg and Largo, but no surprise there, really, since PBC is an expensive place to live. Add to that the longer stay, which puzzles me, and that also helps explain the higher costs.

Two, the number of procedures in Largo far exceeds the others (and is the highest of all the hospitals in Florida, also). The length of stay is also considerably shorter.

I have been to two of the seminars by the Largo group, and was put off by the degree of the marketing they do, including referring to the knee replacements as "resurfacing," and the selling of the amenities at the facility. In addition, at the end of the seminars the presenters walk around the room with cell phones dialed into the appointment desk so that participants can make an appointment on the spot. This was a bit of a hard sell, I thought. In addition, they provided pages and pages of references to call. The interesting thing to me was that 90% of the references had partials, not full, which probably accounts for the lower length of stay.

I did not see a doctor at Largo; the conclusions I have drawn come from the seminars and the statistics.

I also looked at the numbers for all ages, not just seniors. An additional category was added: 15 day readmission. Largo's, at 1.77%, was the lowest of the 3 by far. Jupiter was highest with 3.12%, and Leesburg next with 2.76%. My only thought on this is that the rate for Largo is low because PKR are a lesser procedure in the first place.

Research

Over the past few weeks, I've come across some websites that are very useful, and some not so. Want to watch a live TKR? Truth be told, I didn't make it through it all. I always thought one's imagination to be worse than reality, but I'm not so sure about that anymore. However, watching a simulation is easier on the eyes and stomach.

Want to see if your doctor has operated on the wrong leg? Click here.

The Florida Department of Health website has licensing information.

I tried to find information on infection rates at hospitals. Florida Healthfinder has information on all Florida hospitals, but not on infection rates. The information it does offer is useful, though. I did find some infection information on the Consumer's Union/Health link. I paid $4.95 to access the information for one month, only to find Leesburg Hospital has not yet been rated, but the information for those hospitals that have been rated is pretty good.

TKR minus 17 days

Rather than jumping off the deep end as I did after my first doctor's appointment, I waited three days for it all to sink in, while both Bill and I continued to talk to people about their experiences with doctors. It's amazing the things you can find out from networking; doors are opened that you didn't even know existed, and the list of questions to ask becomes longer, just by drawing from other people's experiences.

For instance, Bill went to the Driver's License Office to renew his license (an interesting procedure when you are 81, but that's another story.) While he was there he mentioned to the lady helping him that his wife was having a knee operation. As it happens, she managed a PT facility in The Villages for ten years, and has brought her mother and her sister to the doctor we have decided to use, Dr. Kerina, for several surgeries. She has known him through her job for many years and thinks highly of him as a person and as a physician/surgeon.

So, the surgery is November 8, 2010 at Leesburg Regional Medical Center, and Dr. Jeffrey Kerina will perform the operation. He is the first surgeon we visited, but I feel better having taken the step back and visited at least one other doctor. We feel good about this decision, and now that the decision is made, I'm anxious to get it done.

Doctor Visit #2

The past 3 years, prior to the move to Harbor Hills, we lived in Homosassa. I had an orthopedist there to whom I went periodically for cortisone shots. Like the orthopedist before him in Palm Beach County, he recognized that I needed a knee replacement eventually, and when I was ready, I would come back. In the meantime, though, he kept me on the court with cortisone shots, and then THE BRACE.

So Bill and I paid Dr. Petrella a visit. He has done the knee replacements on several people we know, including a tennis friend whose husband is an orthopedist in Citrus County who also does knee replacements. Any doctor who a doctor respects enough to send his wife to must be good at what he does. Dr. Petrella also did both knees of my tennis partner's husband four or five years ago, and he is playing tennis well.

He took a look; I'm not a candidate for a partial; I need a TKR and one ligament has to be released, which is what Dr. Kerina also had said. Bill and I both felt comfortable with him. He operates out of a hospital in Crystal River, Seven Rivers (see story). So now I have two doctors who we both feel good about. Now what?

Doctor Visit #1

So Bill and I drove down to Leesburg to an appointment with Dr. Kerina. He was recommended by an Orthopaedic doctor who lives in our community, Dr. Claudia Thomas, who is also a partner in the practice. Between the time I made the appointment and the appointment itself, we ran into another resident in our community who had had two surgeries by him and was very pleased. In addition, through my tennis friends, I talked to another person who lives in The Villages who had both knees replaced by him, and who is now back on the tennis court playing at his prior level or better. So far, so good.

So, the consultation went well. Both Bill and I liked him, and felt a high degree of comfort level with him, which is important when someone is going to cut you open. He looked at the xray, and at the knee, and knew immediately what he thought had to be done, which turned out to be more than I thought. The degree of the angle in the knee (severly knock-knee) means that the ACL is probably gone, but the implant itself satisfies that lack. The PCL may need to be replaced, and one ligament has to be released or replaced, and the other ligament is a question mark. On a scale of 1 - 10, it's a 7. Of course the livelihood of any surgeon is surging, but I really knew going in that a TKR was inevitable; I'd been told that for any number of years, but I was still a little shell shocked. We scheduled the surgery for 43 days out.

Now, that is a little fast for me, and for Bill. We are both people who do not make spontaneous decisions. So, once over my shell shock (two days later), I postponed the surgery in order to see one or two more doctors. Of course I also got some input from some knowledgeable people who helped me recognize the value of taking my time in making this major decision.

Decisions, Decisions

My Ad:

Ok, so I've been talking to people, and going to seminars. Bill and I have both been asking people about their experiences. Bill is really good at that, since he can talk to anyone. I, on the other hand, am not so chatty. Anyway, during this process, we listen for what name keeps popping up most frequently. One, in particular, did. I had talked to several people who have had procedures by this doctor, including a tennis player who had both knees replaced by him, and a neighbor who had a hip and shoulder replaced. They speak very highly of him. In addition, our general practitioner recommended him, as well. He is one of 3 appointments I have with surgeons in the next two weeks, but he also happened to be first.

My Serve; Love-all

In late winter 1974, when I was a 30 year-old mother of two living in Chicago (4800 West, 5600 North) and pregnant with my 3^rd child, a friend from Skokie asked me if I would be a 4^th in their weekly indoor tennis game. I hadn't picked up a racket since high school gym tennis at Howard Park in West Palm Beach, Fl back in the 50s, but I was game (though I didn't have game at that time), and I joined the foursome. I can remember playing with the same can of pink balls for 3 or 4 weeks in a row. Who knew? I had no idea what that inauspicious beginning would lead to.

15 love

Fast forward to fall of 1975. By then, Angela was born and we had moved to Englewood Cliffs, NJ. I quickly found myself some tennis games, and the real games began. I spent the next ten years playing tennis on hard courts most of the year, and often two or three times a day (or night). Tennis eventually became my vocation as well as my avocation. (I had to pay for all this indoor court time some way). I managed an indoor tennis facility in Englewood, and ran tennis leagues and tournaments. I also became a regionally ranked (top ten in singles and doubles in the 35s and 40s Eastern Region). I was winning singles, doubles and mixed titles at Oritani, Tenafly Tennis Club, and any other place there was a tournament to enter, and was one of a select few women “permitted” to play at Ah-deek, a small all men's facility nearby. I went to the Nationals at the 5.0 level during the fledgling years of the NTRP tennis system, when it was sponsored by Michelob and Volvo. But at a cost. My knees took a beating. And the extra weight I carried didn't help.

15 all

In 1991, after having moved back to Florida, I was playing singles on a hard court at Juno Beach with my friend (later to become my husband), Bill, when I made a jig when I should have jagged, and tore the meniscus in my right leg. I tried PT and strengthening, but the knee was insecure and I couldn't trust it to move. It would lock up, so I ended up having it scoped. And then the pain started. And it didn't quit for a year, until the doctor scoped it again in 1992 and this time “bled the bone,” so when I woke up, I discovered I was on crutches for SIX WEEKS! Who knew? Not me. So, there I was on crutches for my son's graduation from Stetson. Talk about rude awakenings.

30-15

Life went on. I had to go back to work, so tennis took a back seat, and I was down to playing 2 – 4 times a week. Good for the knees, but not my sanity. I divorced my husband, married Bill (who I met on a tennis court and who is a very good tennis player in his own right),and my knee was holding its own, though I never got full mobility back after the second surgery. And it got progressively worse. I have been on Mobic (after trying Celebrex (rash), Vioxx (upset stomach)) and went through many temporary fixes, including Synvisc, Euflexa, cortisone shots.....but the damage had been done, and it continued on its downward path. I had been told repeatedly along the line that TKR was inevitable, but I, of course, was putting it off as long as I could, rationalizing that the process and procedures and bionic parts would only keep improving.

30 all

Retirement came and went. I retired, was bored, since I had the time to do stuff, but not the money, went back to work part-time, and ultimately retired for good, all the time continuing the tennis as frequently as I could. We moved from Palm Beach County, a beautiful place once, but now too glitzy and ritzy, to Homosassa, FL, the polar opposite of Palm Beach County. It took us nine months to sell our house in Palm Beach Gardens, and the weekend of the 11^th hour we had set for ourselves, we got two offers. Since both our lives revolve around tennis, we will only go where we can find it. The first criteria no matter where we live, is tennis; anything else is secondary. Homosassa, for a variety of reasons, did not work for us, so three years later, after having the house on the market for 7 months, we moved to Harbor Hills, a beautiful golf and tennis facility just outside of the Villages in Lady Lake, FL.

30-40

But first came The Brace. Before the movers came to move us out of Homosassa, I asked my orthopedist for a brace. He wrote out the criteria and sent me down the road for measurements, and five days later, the fitting. It was big, black and intimidating. How can anyone run around on a tennis court with that thing wrapped around their leg? But I had some tennis friends who managed to do it, so, what the hell. I got to try it once before the movers came, (it sorta helps, actually) and then it sat for a week or so during the transition.

But, it wasn't long before I was hooked. It reached the point where I could no longer walk onto the tennis court without it. And subsequently, I found it was even more difficult to stand and/or walk for great distances, a problem I had been having for a loonnngg time. I haven't been able to go up or down steps for any number of years except by the very slow “one step up, drag bad leg” method. So while as recently as a few months ago, I was able to play tennis and still do whatever needed to be done in the afternoon, i.e. shopping, chores, etc., of late the knee is too painful, and I'm hobbling around. Quality of life has declined. Now, it is no longer just about tennis. Even if I gave up tennis, I would still be unable to do everyday stuff. I'm leaving tomorrow for Boston to spend time with my daughter, Alyssa, and we will be limited as to the walking we can do, which is very frustrating. One of the charms of Boston, is walking around the city. What's a trip to Boston without a walk along Newbury Street? And we are going to the MFA. The thought of being on my feet for that length of time is daunting. Quality of life is declining. It's time to act!

Duece The Seminars

So, I've begun the task of attending knee seminars. The first one was held in The Villages, and it was presented by an orthopedic surgeon out of Tavares, Dr. Donald J. Perry. Presentation was well done; surgeon had knowledge and personality, uses minimally invasive technique with less down time. May make an appointment with him. (and the food was good and good for you: fruit and cheese, wraps....not a lot of junk).

Next, was the Largo group. Lots of marketing by this outfit. I went to one of their seminars 3 years ago. Same woman presented this time. A nurse who has been with the hospital/doctors for 26 years. Excellent presenter. The patients stay in a suite at their facility, 3^rd and 4^th floor devoted to hip/knee replacements, so no sick people are present. Minimally invasive, with little down time. (Florida Knee and Orthopedic Pavilion, Largo Medical Center, Largo, FL) One of my tennis friends is scheduled to have her knee done there on October 13, 2010.