Total Knee Replacement, Part 1.

Preparing for Surgery and the Rehab that Follows​

J. Casey Gershon

As the manager of rehabilitation services for 30 plus years at a major metropolitan hospital, I have seen first-hand the
many types of physical therapy (PT) treatments needed to support the thousands of knee, back and shoulder surgeries performed where I worked.  I had the good fortune to oversee and work with some highly skilled physical therapists. Several of them were the best of the best when it came to highly specialized areas like neurology, orthopedics, geriatrics, sports medicine, pediatrics and so forth.  But it's one thing to be a manager of rehabilitation it's quite another when you're the patient.  The problem started when I sustained a serious knee injury when I was 19 as an undergraduate student
at the University of Vermont.  At the time, I was taking a course in modern dance.  Part of the routine was learning how
to leap and turn with a final landing on my left leg.  The instructor cautioned us to be careful and to do the exercise only
once until such time as we learned how to build up our muscle strength.  But of course, I knew better, I was 19 and so
I practiced and repeated the same exercise multiple times in one of the common spaces of my residence hall at UVM's Living and Learning Center.  It seemed like a good idea at the time.  Unfortunately, the final landing caused my knee
to dislocate with a tearing sound I will never forget.  As it was, my college roommate was reading in the same commons

area and passed out from the sound of my knee cracking and the sight of me falling.  So, when the EMS arrived, soon

thereafter, they ran to her instead of me.  I had to feebly raise my hand to show that I was indeed the patient.  The fracture

was sufficient that it required my having to wear a full plaster cast on my leg that went from my ankle to my upper leg.
 

Getting Ready for Surgery
Over the next 40 years, my knee has imperfectly adapted to a number of different sports, including running, cross-country-skiing, bicycling and more recently pickle-ball to name only a few.  There has always been a moderate to sharp pain
when I did these sports for any length of time.  My husband Rick would tell you that I have a high tolerance for pain when
it comes to active sports.  All this changed when I turned 67 on a hiking trip in the country of Morocco.  The periodic cortisone shots no longer worked.  The pain was no longer moderate to sharp; it was now kick-you-in the knee stabbing pain awful.  With my back to the floor, Rick would help me straighten my leg as the tears were running down my cheeks.  
It was time.  There was no question that surgery needed to happen.  The good news was that I had a medical staff and set of rehab. people more than ready to help me with the upcoming surgery as well as the follow-up rehab. when the time came.  I had an excellent knee surgeon who knew me very well from our past work together.  My group from PT met with Rick and I before surgery and reviewed with me the regular set of exercises that I would need to do in the weeks following the surgery.  I went to a lending hospital equipment vendor to temporarily get a raised toilet seat as well as a walker.  
I also had an Airdyne stationary bicycle delivered to my home that took over the TV room.  An Airdyne bike uses a large
fan as its resistance mechanism. The harder you pedal, the more resistance the fan creates, providing a challenging and customizable workout.  Once you really get going, the wind flow alone could rival a 747-jet taking off.  Let's just say our
dog Dexter looked like a combination of Snoopy the dog and a fighter pilot with his ears flapping in the wind.  One thing to remember is to have all of your support equipment in place (i.e., crutches, air-bike, raised toilet seat, walker, etc.) in place

before surgery.  You (or a family member) don't want to be spending your first day after surgery trying to find equipment.

​

I had a team of my PT folks check on me prior to surgery.  Rick was with me as well before they wheeled me into the operating room.  I remember very bright lights and lots of people, on all sides of me.  I was asked if I was ready.  Without any countdown, I was out for the duration; not to be aware of anything until I awoke in post-op recovery area.  I later learned that one of the lead therapists was kind enough to bring Rick a cup of coffee in the waiting area during the time
of surgery.  The small kindnesses such as these are very important and made a lasting impression.  After awaking, 

I felt a stinging sensation in my hip.  For a moment I thought that maybe they operated on the wrong part of my body.

Apparently, I was laying on that same hip for most of the surgery.  Let’s just say there was a lot of pulling and tugging on

my leg so my hip was sore.  I was still very groggy when I awoke and had a hard time staying awake.  The nurse

proceeded to give me instructions but I didn't catch much of anything as I fell back to sleep.  I was glad that Rick was

there to actually hear the instructions.  Later, I was asked to take my first set of steps with a hospital walker.  While I didn't feel any pain, per se, I did feel a certain disconnect from my leg.  I could stand but the ability to move forward in a walking motion was a challenge.  It was as if my leg muscles did not know what to do.  Nevertheless, everyone seemed pleased with my first attempt at walking.  As for me, I was just tired and wanted to go home.  We later met with nursing, discussed my medications and left the hospital.  I don’t remember getting in the car or how we got into the house for that matter.
I do remember that I slept the first night on the main couch in the TV room since it was on the first floor.  I slept well that night.

​

​Total Knee Bootcamp
The next day marked the start of what Rick and I called Total Knee Boot Camp, starting at 8AM.  The name, coincidentally, came from the fact that I felt like I was wearing some type of pressure cuff around my leg; hence the term "boot."  
I felt no sensation in my knee and the boot felt like a clamp.  The first day (and the days thereafter), started with stretching and several PT exercises.  This was followed by my bicycling on the Airdyne bike.  During the first two days, I had trouble actually getting on the Airdyne bike and my pedaling motion was limited to a front and back rocking movement.  By the
third day, I was able to do a full rotation.  But once accomplished, I began to increase the number of rotations each day
as well as the length of time on the bike.  This was followed by a brief rest period of 20-30 minutes.  Rick would set 
a timer and get me every two hours for our walk.  

​

The goal in the beginning was to do three short walks each day.  The actual distance was the length of the driveway,
part of our front sidewalk and back. In the beginning, as we would walk, it was hard to tell where my foot was on the pavement, so I was quite fearful of wet surfaces and changes in terrain.  I think it's fair to say that each person is
different in terms of one's pain level.  I felt a slight to moderate amount of pain the first day which steadily progressed to mild-moderate during the first two weeks.  It so happens that because I was used to my Nordic walking poles, I was able
to dispense with the hospital walker after a day and a half.  The poles proved to be invaluable by providing full support for my walking.  I would not suggest Nordic walking poles to start if you have never used them.  And given that I have been Nordic walking for about 15 years, they were my natural go-to-approach in providing both support for my walking as well
as balance.  I used them both in the house as well as outside for our regularly planned walks.  

​

On Day two, I realized that my step was more of a drag than a step.  At issue, was that I could not fully lift my knee.  
This, in turn, limited the motion and speed of my walking.  My stepping forward was more of a short shuffle than a walk.  
So my husband Rick suggested I sit in a chair.  We took our dog Dexter's stuffed padded donut toy and placed it beneath my foot.  The goal was to lift my leg – with the donut beneath.  After the first couple of tries, I couldn't lift my leg.
But I remembered the very wise words from the nurse practitioner, “If you find you can’t do an exercise do it anyways in your mind.  Go through all the steps as if you were doing it.”  So I sat there staring at my leg not moving.  During the next
try, my front foot moved ever so slightly. During the next hour, the muscles in my knee started to fire which enabled me
to lift my leg ever so slightly.  It took a few days but I was finally able to lift my knee fully off the ground with and without
the donut.

 

While the Nordic walking portion came easy to me, I still had balance and endurance issues.  This is where having a partner makes a real difference.  Rick and I would walk together and at the turnaround point, he would help me stretch – making sure that I had enough endurance for the return part of our walk.  Each day, Rick would set a timer and come and get me every two hours for our walk.  I remember one day when the combination of exercises and bicycling was taking longer than usual and I was falling behind and off scheduled.  I had just finished the Airdyne bike, and was really looking forward to my “break”, when Rick came downstairs saying, “It is time for your walk.”  I seemed to remember that I had a few choice words for him at that moment.  We steadily increased the distance each day thereafter.  The combination of stretching and PT exercises, the Airdyne Bike and my planned Nordic Walking became my daily regimen each day for the next month.  I spent between 5-8 hours each day following this regimen.  By the 5th week, I was able to walk about 3 miles.

 

The Larger Question
After I had my total knee replacement friends would ask, “So how did it go?  I'm never quite sure how to answer that question.  The question is simple enough. Was the surgery successful?  Yes.  Was the rehab part frustrating at times?  

Yes.  Does the repaired knee sometimes still hurt?  Yes.  Would you do it again, absolutely.  To undergo a total knee replacement, or shoulder repair/replacement requires a shift in thinking.  There are no free rides when it comes to PT, rehab and recovery.  There are no short cuts.  There is no magic pill that will make you feel better right away.  At issue,

for some, is that we still see ourselves the way we were in college or high school.  We were young 
and strong and could do anything.  The challenge, of course, is our ability to reimagine the present and a willingness to work hard and set new goals.  The process of PT, rehab and recovery is more than just healing the body — it's also about building resilience, learning to adapt and overcoming setbacks along the way. It takes hard work and commitment to be successful.  Recovery is rarely a straight path, and setbacks and the sometimes unexpected are a natural part of the process.  So, in answer to the question: Would you do it again?  The word absolutely takes on a whole new meaning.