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Total Knee Replacement

This post is not about gardening, but I had to put it somewhere :)

On June 15th I went into surgery with a bum arthritic right knee, and came out with a shiny new chromium cobalt knee.  It has been quite the ride I tell you. Before I had the surgery, I searched for TKR (total knee replacement) stories, and found lots of people saying how great it was after the fact, but very few that actually described what the process was like. So I'm going to try to fill that gap here.

Pre-surgery was no picnic in terms of getting cleared for surgery. Oddly enough, the thought of having my leg sliced open, and the bones chopped through, and the knee tossed into the trash caused a spike in my blood pressure that was hard to get under control. I had to delay surgery by one month so I could get my BP low enough to get cleared for surgery. I was very frustrated by the delay, but in the end I think it was a good thing, because by the time the day of surgery actually arrived, I was very ready, and indeed could not wait.

Day 1

Surgery itself was the simplest and easiest part of the whole thing. Getting admitted, having blood drawn, getting prepped, getting the nerve block.... all of these things went smoothly, and I didn't have any escalating fear or nervousness. Martin was able to be with me until Anaesthesia came to get me for my nerve block. I wanted him to come with me, but we were headed backstage, so he went off to begin his long wait. After the block, I vaguely remember being told we were going to surgery, and I said "but my surgeon hasn't signed my leg yet!"  I heard Dr. Danziger's voice reply, "Don't worry - I signed it a while ago". So clearly, I wasn't *fully* there, but kind of.

My next memory is being in the bed, and wheeled into a different room. I wondered if this was the OR, but then my eyes fell on a clock, and almost 2 hours had passed.  Surgery was over! And I felt great! I came out of anaesthesia easily (one of my fears was having an unpleasant "wake-up" period). I sucked on ice chips and watched the other post-op patients come in and out of consciousness and say silly things.  I looked down at my wrapped-up leg with curiosity, but it just lay there -- I felt nothing at all. I had to stay in post-op an hour extra, because my bed on the joint replacement ward wasn't ready yet, but finally I was wheeled over there, and into my shared room.

My roomie was also fresh out of surgery, with a TKR of the right knee. She was a bit older (60's?), as were all of the other patients in the ward. But she was lovely. At first I was afraid she would be too chatty, but it turned out to be a nice interaction, and she and I comforted each other at times, as well as told stories.

My surgery was in the afternoon, and by the time I got to my room, there was no dinner service.  Mind you, I hadn't eaten since MIDNIGHT THE NIGHT BEFORE.  I do not like being deprived of food :)  But I wasn't as hungry as I thought I would be.  Turns out anaesthesia will depress normal hunger.  I had some crackers and juice, and got some sleep.

I also of course had to go to the bathroom that night. Just urine of course, but even that was no small feat. My roomie had a bedside commode brought in, but by the time she was done, I had decided to go into the bathroom. First they have to put on the knee immobilizer (required because of the nerve block - can't use the muscles), and the tech helps shuffle me over to the bathroom with the walker.  Maneuver the walker through the bathroom door, shuffling carefully over the threshold.  Then, to sit... yay for raised toilet seats!  I didn't have to lower myself very far. But I can tell you that cleaning up after yourself in this configuration is a bit of a challenge. 

I had been told that my nerve block would last anywhere from 12-36 hours. I was hoping for the 36, but no.... at pretty much the 12th hour (around 3:30 am), I started feeling pain in my leg. I made a mental note that I should ask the nurse for my first pain meds. By the time the nurse answered my summons, then left and came back with the meds, I was already off the deep end in pain. After an hour of this, hoping for the pills to kick in, I told my nurse that the pain was still very high -- I think I said "Assuming a 10 means I have passed out from pain, I'm at a 9".  I got a shot of morphine in my IV that did help, and knocked it down enough to relax a bit.

The pain stayed pretty high (7 and 8) for the next 12 hours. My next nurse asked how the pain was, and I told her.  She said "Well, this is a painful recovery, so you will definitely have pain." I replied "yes, but must it be at level 8?!"  I was convinced my drugs weren't doing enough. This actually got her attention. Turns out that they have a guideline that says pain of level 5 and below should be lived with, but above that should be treated.  So she called the resident doctor, and had my meds amended -- I stayed on the Oxycontin, but also got Dilaudid every four hours, plus Celebrex (anti-inflammatory) every morning.  Ahhh, sweet relief.  From here out, things were much less horrifying.

Day 2

Bright and early day two sees me moved to a large recliner chair -- Get out of bed!!  I wasn't looking forward to it, but it was actually pretty darn comfortable. I sat there for most of the day, doing not much.  The level of pain meds really didn't allow for much -- I remember trying to do a crossword puzzle... ha!  Later in the afternoon the physical therapist arrived, and began trying to get me to move my leg. My goal is to lift the leg up off the bed/chair/whatever using my quadriceps muscles. But for some reason, my right quad would not cooperate.  I really wanted to be able to do this, mainly because that would allow me to go to the bathroom without the hated immobilizer.  But I absolutely could not fire that muscle. On the plus side, I received two beautiful bouquets of flowers - one from my good friend Rachael and her family, and one from my father and stepmother. I did enjoy looking at those flowers in my hazy state.  I also received a CPM machine today (a device that provides Continuous Passive Motion of the leg), and was put into it for the first time. That was actually pretty scary -- the idea of putting my leg into a machine that would bend it for me, when my mind was pretty convinced that bending this leg was going to hurt like hell.  But it wasn't bad at all. We started with a low degree of flexion, and I increased it until I was where Dr. Danziger wanted me to be for therapeutic stretching. I love the CPM :)

Day 3

Get up, get in the chair. Each morning, Dr. Danziger would come by and check on me. This morning he said he would like for me to go to a rehab center after release from the hospital, where I could get a lot more physical therapy than I would at home. I think this sounds like a fine idea, given my recalcitrant quad. My case coordinator heads off to get insurance to approve the move.  More PT, more hazy hours in the chair, some reading and pretend-puzzling. The right quad finally starts firing enough that the therapist says I can dispense with the immobilizer. Gah! I hated that thing. I'm still not lifting my leg, but at least she doesn't think I'm about to crumple to the ground. Today was also the day I requested a suppository to get the bowels moving again (on strong recommendation from the nurses). Success was mine. 

Day 4

Case coordinator told me this morning that insurance won't approve me going to rehab, even though both the surgeon and the physical therapist recommend it.  Truly a case of Cigna practicing medicine without a license.  This upset me greatly.  For one thing, the heavy pain meds had made me super emotional (multiple crying sessions over pain). For another thing, I had heard from the surgeon and the PT that I would do "better" if I went to rehab.  In my mind, this translated into: I would do "worse" if I didn't go!  This was (of course) unacceptable.  The nurse manager (a true sweetie) spent some time with me convincing me that this isn't how I should interpret it, and that I could have just as good an outcome without the rehab as I could with it, but I would have to do more of the work myself.  Martin was a big help too -- he really wanted me to come home, and said over and over that he would help me do what I had to do, and make sure I kept up with the PT.  I slowly became "okay" with not being able to go to rehab.

Day 5

I got an extra night in the hospital because I needed more PT to go straight home than I would have if I went to rehab. I needed to learn how to climb stairs. I needed to learn how to get into bed, and get in and out of chairs, all with a leg that still had a barely-functioning quadricep.  This last day actually was the first day that I could raise my leg up by using that muscle -- just a tiny bit, but enough to make my PT very happy.  So anyway, in the afternoon, they delivered my walker, my cane, and my raised toilet seat. Then I got my discharge papers and loads of prescriptions (pain meds, blood thinner, anti-inflammatories), and I was ready to go. I and my stuff were piled into Martin's truck (I was allowed to right up front, after a bit of maneuvering to get my non-bendy leg into the cab). We headed towards home, with a stop at the pharmacy.

NOTE TO ANYONE WHO LIVES IN A NON-PRIVILEGED ZIP CODE

Pharmacies in my neighborhood DO NOT STOCK narcotic pain killers. We tried two before Martin just turned around and headed back to the hospital. We used their pharmacy, and all was well.

Post-Hospital

Thus began my days on the couch. I came home on a Friday, which was nice, because that meant that Martin was with me for the next several days. Friday night I slowly stepped up the stairs and headed to the bedroom, and Martin ferried up a pitcher of water, and a bag of ice, and my bag of goodies that I kept bedside all during my hospital stay (phone, comb, lip balm, iPod, crossword puzzles, and Kindle). Saturday morning we reversed the process, ensconcing me on the couch for the day. This was to be our process for many days.

On Saturday my home health company sent a nurse to open my file and take blood. I needed to have blood draws twice a week to make sure I was maintaining therapeutic levels of blood thinner. On Monday the Physical Therapist came. On Tuesday my usual nurse arrived to draw blood. On Wednesday the occupational therapist arrived.  I only saw her once - she was satisfied with our home environment and accommodations, and gave me some good tips for how to shower.

Martin rigged up his office chair to recline over the bathtub, and washed my hair for me.  That felt soooo good, you have no idea. it had been 6 days since the surgery, and I was feeling (and looking) it.  In the hospital every day, one of the techs would give us warm disposable towels and help us wipe down our bodies as best we could, but there was nothing they could do about the hair.

Assistance

Speaking of Martin, I have to say a few words about having someone available and willing to help you.  Those first few days especially will be difficult as you arrange things the way they will work for you. Yes, I know, you're supposed to do that ahead of time, but you don't really know what you are going to need/want to get you through the day. Keep in mind you are on heavy drugs, and are physically and mentally unreliable. The drugs also made me terrifically thirsty -- how exactly are you supposed to carry around your pitcher of water while you are using a walker?!

Thankfully Martin was a wonderful caretaker, helping me with everything, often without asking, and even maintaining his good nature and making me laugh throughout the ordeal. 

ICE

I haven't said much about ice yet, but ice is HUGE.  Ice helps numb the pain, as well as reducing swelling. In the hospital, I constantly had a bag of ice on my knee, and willing techs and volunteers to give me fresh bags at any time of day or night.  At home, ice became an issue.  Our poor ice maker could not keep up.  In fact, Martin couldn't keep up.  I think it was day 3 at home when I finally got onto the internet and found the ice machine I wanted to buy.  Some of the folks in the hospital bought them while they were there, so I had seen what they used. These ice machines are basically coolers of ice water that circulate the cold water through a pad that gets strapped around your knee.  Genius.  Hours of cold, no leakage.

FYI:  YOU CAN BUY AN ICE MACHINE ON E-BAY FOR $50, instead of paying several hundred dollars for a new one.  We had ours by day 5.

CPM

I also had a CPM delivered for home use. I was allowed to keep it almost two months.  It leaves me this coming Saturday, and I will miss it. The use of CPM machines has not been proven to have therapeutic value (so they say), but I found it therapeutic for me, if only mentally. After doing my PT exercises, I could use the CPM to maintain my highest level of flexion for a much longer period than I could just working it by myself.  I also used the CPM on days when the knee just felt stiff - it warmed it up nicely and at least made me feel like I was keeping it flexible.  I understand this doesn't constitute proof that it was affecting my final outcome, but I certainly like having it.

Birthday

My 51st birthday was 15 days after surgery.  Day 13 was a Sunday, and we invited some people over for a backyard cookout, to celebrate both my new knee and my birthday, and to see some humans.  I figured - surely I will be able to shuffle out to the backyard with my walker, and sit on a bench and visit with people!  And I did, and all was fine, for the first couple of hours. And then BOOM, my body signaled exhaustion to me in the form of shaking and dizziness. Lesson learned - even just sitting up stresses the body if it is in a weakened state. I headed back to my couch after that, and ventured out a few times to say hi and bye to folks.  I loved seeing them so much, but I really wasn't ready for a multi-hour party.

Drugs

I stayed on my narcotics for probably a bit longer than I needed to.  I was able to stop taking the Dilaudid every four hours, eventually cutting it back to just nighttime, then none at all. But I was afraid to stop the long-acting Oxycontin. After I decided I needed to go back to work (which ended up happening on July 15, 30 days post-surgery), I realized that I'd have to stop taking it.  I spent a week on one a day (down from every twelve hours), then finally (on July 19) stopped the nighttime.  Two things immediately started after that:  (a) ridiculous night-time muscle spasms in my surgical leg, and (b) freaked-out bowels.  Narcotics really depress your bowel functions. As soon as my body was clear of the drugs, my bowels went into overdrive. Thankfully this just lasted a few days. The muscle spasms are still occurring, though with less intensity than they were at first. I don't know if their appearance was causally related to stopping the Oxy, but I'm sure it's possible.

Sleeping

Ask for ear plugs in the hospital!  There are so many noises there, even when they turn the lights down. We were provided with eye masks as well. Sleeping is very important for healing, so do whatever you have to. In hospital they woke us up every few hours for blood pressure/temperature, giving meds (either my meds or my roomie's meds), the 5:00 am blood draw, etc.  Surgeons come by EARLY, and if you are lucky, you can sleep some more after they go. Sleeping in the recliner happened more than a few times as well :)

Just a note about sleeping positions -- you can sleep however you like, so long as (a) it's not on your stomach, and (b) you can handle the pain. In the hospital, I slept on my back for the entire 4 nights. That was only possible because of the high-tech hospital bed that kept subtly redistributing my weight so I never got uncomfortable. As soon as I got home, and found myself tossing and turning, I had to get creative. Best position for me is on my left side, with my surgical leg on top, and a thin pillow between my knees.  I can do the right side, but I can't stay there as long. The back works for a while too. So that's three perfectly decent sleeping positions.  Eventually you could sleep on your stomach, if that's what you like, but I don't think you could do it in the beginning.

Flexion

I've been in outpatient PT 3 days a week since July 13.  My home PT got me to about a 90 degree bend in the knee, and probably 3-5 degree extension (a slight bend).  In outpatient, I've been progressing well.  I now have 113 degree flexion (using a strap), and 0 degree extension.  It's hard work in the sense that it just keeps going. I try to do exercises and stretches every day.  PT days are hard, because I end up with inflammation, and then stiffness the next day. Part of my mind says "You deserve a break now", but the other part says "push on through". I've listened to both sides. I admit to having some days here and there where I do no strength exercises. The stretches make me feel better, so I'm good about those. But I'm only human - and sometimes I'm just sick and tired of it.  Despite this, I am making good progress. So take heart :)

Let's see... what else?  Photos!  Knee progression shots:

Eight days post-surgery. I should have exposed my left knee so you could see the difference in size. This is the same brown bandage that I received in the OR -- it stayed on until the staples were removed two weeks after surgery. The little white bandage covers the hole left by the drainage device (which was removed the day after surgery).

 

Fourteen days post surgery. I took this in the doctor's office, during my first post-op visit. They removed the bandage, and the staples, and put on a bunch of steristrips that would come off "by themselves". Ha. 

Twenty days post surgery.  My PT told me to get the steristrips off within a week after they were applied, so that we could start massaging the scar.  I ended up just ripping them off. No pain no gain. The swelling is pretty evident here. 

Thirty-five days post surgery. There's still some swelling, but much less. 

 

So there you have it. My knee replacement story, as told 38 days later. I'm sure I've left out some salient details that somebody might be interested in, but this is it for now.

 

Quick Vinca Update

Before I had my knee replacement, I decided we needed to do *something* about the vinca ASAP, because if I was going to be out of gardening commission, I wanted the vinca to be in the process of dying while I sat by.

So, here's what we did -- Martin weed-whacked the heck out of the vinca patch.  Then we layered broken down cardboard boxes on top of the spot. Then we moved our secondary compost pile (sounds so official -- really just a giant pile of sticks and weeds that formed because I was too lazy to dispose of them in the right places) on top of the cardboard.  Voila - it will sit like this for months and months, probably until next spring.  Hopefully total vinca death will result.  Or at least a lot of vinca death. 

  
 

 

As a bonus, the super fertile ground under the erstwhile compost pile is a great new garden for shade plants!  So far I've just tossed some herbs in there that we don't want to have bolt too fast. Gotta come up with a plan for the planting.

In other garden news, this spring/early summer gave us a WHOLE LOTTA rain, lower temperatures, and lots of sun.  My natives garden has grown wildly. I swear the ironweed plan is 8-9 feet tall. It's a true jungle in there.  After my surgery, when I felt decent enough to get out and about a little, Martin and I went out there and pulled out probably 20-30 pounds of weeds. I need to post a photo.

Native groundcovers in DC?

Continuing in my search for native groundcovers that will work for me here in DC.

I'm particularly looking for some that will work under trees (to replace that big mat of vinca), and also some for partly-shaded spots around some showier plants.

This is what I have found so far:

Full Shade:

  • Pachysandra procumbens (Allegheny spurge). Gets a little taller than I would like, but might look great under trees!  6-10 inches tall. "Allegheny pachysandra performs well in a variety of soils from moist to dry and a range of soil pH as long as it is growing in partial to full shade."
  • Packera aurea (Golden groundsel or golden ragwort). 12 inches tall, but again, could be great under trees. Says it works in shade, moist to dry woodlands.

Partial Shade:

  • Chrysogonum virginianum (Green and Gold / Goldenstar). Grows in partial to dappled shade or in full sun in northern regions. Chrysogonum prefers moist soils, but will tolerate dryer conditions with protection from the sun. 8" tall.
  • Meehania cordata (Meehan's mint or creeping mint). Apparently does best in moist shade, but is reported to do well in partial shade and average soil. Height: 1-2", spreads by runners.

 

I thought the Barren Straweberry (Waldsteinia Fragarioides) might be a good option, but the description says "Does not tolerate heat & humidity", which is the very essence of summer in DC!

So I'm thinking about what to get, and when to clear out that vinca. I'm probably scheduling a surgery for sometime soon, and may be unable to dig, plant, or even weed for a month coming up soon.  So I'm afraid that clearing out the vinca and replanting that space won't happen until I recover from that. I suppose I could spend the summer after recovery just killing the vinca!  Covering it with heavy cardboard and waiting for it to die a slow death....

BUT, I think I have time to order a flat of the mint or the green and gold (or both?) for the partial shade areas, and get those in the ground.  Off to Google to find online vendors....  'K - just order 4 1-qt pots of Meehan's Mint from Sunlight Gardens.  Pricey  at $10 each, but cheaper than the others.  We'll see how it goes.

Fall Garden

Oh my, fall is a big time for the garden.  First, I actually spotted some monarchs.  The first I have seen in a very long time, probably several years.  It made me so happy, to think that my "butterfly garden"  might actually be doing what I wanted it to do.

I'm trying to refrain from cleaning up -- I have brown, dried up leaves and seed pods, but I'm leaving them where they lay unless they are right up front near the sidewalk.   I even added a stick pile. My husband came out with me and said "hey, what's with that stick pile?"  My answer was "It's a stick pile."  "Oh, it's an intentional stick pile. Okay!".

Yesterday I hit up a local fall native plant sale -- this is what I purchased:

  • 1 - Monarda didyma 'Jacob Cline' (Bee Balm)
  • 2 - Heuchera villosa 'Purpurea' (Coral Bells)
  • 1 - Aquilegia canadensis(Columbine)
  • 2 - Liatris microcephala (Dwarf blazing star)
  • 1 - Liatris spicata (spike gayfeather)
  • 2 - Antennaria neglecta (field pussytoes)
  • 1 - Packera aurea (golden ragwort)
  • 1 - Ageratina altissima (white snakeroot)
  • 1 - Anemone virginiana (tall thimbleweed)

Some of these are new species in the garden, and I only bought one of each because I'm not sure yet how they will do. If I bought multiple, it's because I already have some and know they will do well.

So anyway, yesterday was a busy day with the plant shopping, deciding where to put them, digging holes, and relocating some existing plants.  I think the garden is ready for winter. At least, it will be after I'm able to collect fallen leaves and mulch everything.

This morning I headed back outside to check on the new plants, and see if I need to add more soil around them.  At one point I was looking at the Asclepias tuberosa, when I suddenly focused in on a large caterpillar.... is that?? Yes it is!  A monarch caterpillar!  In fact, there are six of them, on my five measly butterfly weeds.  I am so excited!  They are decimating those five plants, and I only hope the caterpillars have enough food to pupate.

     
     

Interestingly, the Asclepias incarnata plants right next to the caterpillars are completely untouched.  Absolutely no interest in them. Maybe it's just the timing - the tuberosa is still blooming and green, and the incarnata is browning and the seed pods have opened and spread.

I'm going to try to keep observing and taking pictures -- would love to see the final product, of course!

Cat Care - Urinary Tract Problems

Cats these days often experience urinary tract problems, which include Cystitis, Urethral Obstruction, and Urinary Tract Infection.  

My male cat Archie had an obstruction last year, and it was so distressing for both of us -- I can't imagine not being able to pee! The doctor recommended that he go on a urinary health diet for the rest of his life.  In veterinarian terms, this means Purina UR, Royal Canin SO or Hill's c/d special urinary tract formulas, dry or wet (Hill's s/d is too extreme an acidifier for long-term use).  They are usually available by prescription only, which means buying them at the vet's office or sending a prescription to an online seller.

These brands are expensive, and they are not necessarily known for being of the highest quality ingredients. They contain lots of carbohydrates and other fillers. Plus, after his days of unhappiness, Archie was only interested in Fancy Feast.  He would actively turn away from the expensive prescription food.

What to do? I decided to do some research.

The site Catinfo.org has some great information and links on the subject. It spells out that, for cats with urinary tract issues, the two main considerations are WATER and PHOSPHORUS -- you want high water content, and low phosphorus content, to maximize flushing and minimize crystal formation.  So theoretically, if I could find a high quality, high protein cat food that met these two requirements, we would be golden.

The author says "Generally speaking, the basic diet recommendation for the average cat with urinary tract issues is a high protein/low carbohydrate canned food with added water. Taking it one step further, look for one that is low in phosphorus - either below ~1.0-1.2% dry matter (not 'as fed'), or below ~250-300 mg/100 kcal."  They also provide a link to a chart listing phosphorus content for some brands of canned food.

This site also has a big list of canned foods and their phosphorus content: Canned Food Data

I was trying to straddle the line between having reasonable affordable cat food, that could be ordered in quantity on-line, and that was low in phosphorus *and* in carbs. Not an easy thing to do. I ordered a variety of samples and cases, trying to stumble across food that my now Fancy-Feast-addicted pair would eat.  I ended up with Newman's Own Organics Grain Free Turkey & Liver.  Not a bad mix -- definitely low in carbs, high in protein, but not so great on the phosphorus front:

Title Phosphorus Protein Sodium Fat Carbs Cal/oz Date
Newman's Own Organics Grain Free Turkey & Liver 1.61% 44% 0.64% 44% 3.95% 37 29-Apr-14

Well, I've been feeding this food to my cats for over a year now.  PetFoodDirect sends it to me on an autoship order every two weeks, so I don't even have to carry it home from the store!  Both cats are healthy and happy, with lovely shiny coats and bright eyes. Squeaker had good health and good labs before we started on this food, and there has bee no change.  Archie's labs are back in the normal range. No recurrence of the urethral obstruction.  

I may try switching them down to an even lower phosphorus level.  Can't decide if it's worth the trouble.  If I do I will go with either Newman's Own Organics Turkey (not the Grain Free), which is 1.17%, OR go back to my old standby, Life's Abundance Instinctive Choice cans, which responded to my inquiry with some good numbers:

Title Phosphorus Protein Sodium Fat Carbs Cal/oz Date
Instinctive Choice 1.20% 51.24%   37.20% 2.58%  37.66 16-Sep-14

The things I do for these two muppets!