What if this works?

There are always exceptions in this world, but I think you would be hard pressed to find anyone who has had articular cartilage repair and hasn't spent some time in a dark place. Many of the people who need this type of surgery are athletic and active. And I think that often goes along with being a results-oriented, independent person. Then this "cartilage catastrophe" happens and suddenly your activity level drops to zero and you aren't really in control and you actually need people. And then there's the "what if" demon who undermines your confidence in the most sinister of ways. What if this doesn't work? What if I can't ever do the things I love to do again? And from my personal favorites playlist, what if I've done some little thing to mess this up and all is lost?

True confession. I'm not a glass half-full person by nature. I'm a practical, no-nonsense Midwesterner. If you really want to irritate me, tell me to look on the bright side. Don't give me false hope. I want the straight skinny and the worst case scenario right up front so I can perseverate on how bad things could be. When given an 85% chance of success, I'll focus on the 15% chance of failure. And I have come to despise this quality in myself. Despise it enough to learn another way.

My wise big brother told me recently that when he's facing life's most difficult challenges, he plays a little trick with himself. He flips the "what if" demon on its ass. Instead of focusing on his fears, he asks himself things like, "What if this new business venture is wildly successful?" My inner negative nelly was skeptical, but you know what? There's powerful magic in that approach. I started timidly with, "What if this procedure works?" And without much conscious effort, that morphed into "Hell, this is definitely going to work! Why wouldn't it?" No kidding. I know it's going to work. And I'm going to be back to doing exactly what I love to do. Like every other human being, I've faced my share of challenges. What haven't I overcome? Nothing! When have I been defeated? Never! Think about it. You're here to tell the tale, aren't you?

My guy has long told me that there are inevitably stormy seas in life where you have to choose the life raft or the anchor. He is, as usual, absolutely right. What do you really have to lose by choosing the life raft? Now don't get me wrong...those stormy seas do a great job of disguising the life raft. But it's there. Waiting to deliver you to shore.

Progress Report: 5 Weeks

So far, so good. The thing with cartilage repair is that activity advances soooo slowly, particularly in the early weeks, that it's hard to gauge your progress. The primary goal is to protect the graft site and regain some ROM. There are some real wins here though:

1. Minimal pain. My incision feels very tender. I have a little stiffness and achiness in the morning and at night, but true pain? None. Overall, my pain has been very manageable throughout this process. 
2. Hello VMO! I'm allowed to do a few quad sets in full extension. I've heard that a lot of folks can't get their VMO to fire for months. I was doing my mini quad sets last week and lo and behold, that little bugger fired!
3. Incision. My surgeon made an awfully big incision. It's about 5 inches, but they did close it cosmetically. It's long, but it healed up great and is a very fine (albeit purple) line. It's really a blessing that I've had no complications in that arena. I've started using a scar product called Bio-corneum. Like Mederma, it's silicone based, but it contains sunscreen. It's crazy expensive. I'll let you know how it goes. 
4. Purple leg. There's this crazy thing that happens when you stop bearing weight...your leg forgets how to send blood back to your heart. Normally, your calf muscle contracts when you walk and helps pump blood back to your heart. Since you're not using your calf much, the blood pools in that leg and it turns a delightful shade of Barney. And it hurts. No fun. The good news? This means you've done a GREAT job of staying off that leg and protecting your graft! If your doctor allows, calf/ankle pumps help a lot. Massaging your foot and calf also helps. I'm told this gets better when you advance to full WB status. 
5. Partial weight-bearing. In full extension only. This is going well. I started at 2 weeks. This also really helps with the "purple leg syndrome". One more week until I advance to full WB. Woohoo!
6. Pool. Ok, this isn't fair to pretty much anyone who lives north of Miami, but it's November and I can get in the pool. Oh joy! It feels so darned good. A surgeon I spoke with in Virginia recommended gentle pool exercises. That's going great. 
7. CPM. Still doing about 6 hours of CPM/day. I reached 90 degrees a week ago and I'm not allowed to advance for another week. So I'm just getting real comfortable at 90 for now. Wondering how the next 30 degrees will feel. Stay tuned. 
8. Sleep. This is still a little tough. It's hard to get comfortable and I find myself tossing and turning a bit. Started sleeping without the brace at 4 weeks. Follow your doctor's recommendations, but I wouldn't sleep without it for at least 4 weeks. 

Crutch Hacks 101

1) Take your time! Be patient with yourself. Everything takes longer on crutches. Allow yourself that time. Go slow. Be safe. Don't try any crazy circus stunts to reach something or to try to do something you know you shouldn't. Not worth it. Use extra caution in the bathroom and getting in and out of the car. 

2) Proper fit. I am a nurse. I've taught thousands of kids how to use crutches. When I walked into PT the first time, the PT pointed out that mine weren't adjusted correctly. Embarrassing. Have your PT look at yours the first time you go. Ignore the height measurement on the crutches. Also, you may need to adjust for shoes vs. barefoot walking. 

3) Crutch bags. You can buy these on amazon.com. Mine are from Crutcheze. Buy one for each crutch. If you do nothing else, do this. 

4) Crutch pads. You'll see these on Amazon when you search for crutch bags. Here's my thought- if your crutches fit properly, you should never need these. There should be two fingers of space between your armpit and the crutch. You bear weight with your hands, not your shoulders. 

5) Mason jar. I love this one! Get a jar with a tight-fitting, one-piece lid. Like a glass peanut butter jar, for example. You can now pour yourself a cocktail or glass of wine and stick it in your little crutch bag. You can use this for any cold beverages, cereal, cut fruit... It's great!

6) Thermal to go mug. Find one that fits in your crutch bag and doesn't leak. Coffee and tea are now possible!

7) Food. Nutrient-dense, protein-rich, minimally processed foods are what you need to optimize healing and stave off muscle and weight loss. Easier said than done with crutches. Cooking and cleaning is tough. It's a little pricy, but look for individually packaged foods. If you have some of the foods below on hand, you can throw them in a small ziploc (stock up on those) and carry them in your crutch bag or backpack. 

• Natural cheese sticks or string cheese. 
• Bananas, apples, pears, oranges, grapes or pre-cut melon and pineapple. 
• Individual containers of hummus, cottage cheese, peanut/almond butter, and yogurt. 
• Good quality canned salmon and tuna. 
• Bags of greens. Add some canned salmon, cheese, fruit, nuts, dressing- whatever you like- and eat your salad right out of the bag. 
• Celery and carrot sticks. 
• Nuts, dried fruit, or trail mix. Watch quantities here as they are calorie-dense. 
• Organic or natural beef or turkey jerky. 
• Microwave popcorn. 
• Pretzels. 
• Minimally processed granola or fruit bars. 
• 16 oz water bottles. Stay hydrated! 

8) Plastic grocery bags. Use these for garbage. Keep some closeby your CPM machine, your bed, and in the kitchen. You can easily carry them to the trash can. 

9) Backpack. Get a cheapie, lightweight backpack and carry it with the pouch in front. Use it to carry things from room to room- ice packs, an iPad, a book...the uses are endless. 

10) Pockets. Not a fan. Some people recommend pajamas or robes with pockets. My experience is that they get in the way of the crutches and increase your risk of an accident. 

11) Hand weights or exercise bands. If you're like me and exercise is an integral part of your mental health, use these to do a little upper body workout. Put them somewhere you can access them easily and safely. Mine are right under the couch.
12) Chair. Put a chair in the kitchen so you can heat up food and eat off an actual plate. You won't be able to carry a plate from room to room, so if you're by yourself, this is your best bet.
13) Paper plates and utensils. Though not environmentally friendly, I recommend temporarily using plastic/paper plates and utensils. You really need to minimize the strain on your hips and good knee when you are non or partial weight bearing. Doing dishes is just an unnecessary effort until you're a little more independent. 

Getting Ready for Knee Surgery

Oh the things they don't tell you... There are some pretty simple things you can do BEFORE surgery to make your postoperative experience smoother.  I figured out some of this before surgery and some of it after. Since sharing is caring, I'm passing it on:

1) Elevated Toilet Seat. Ok, you can make it without this one, but it sure makes life easier. I am 6'2" so it's a long way down to the toilet and a long way back up. More than anything, this reduces the strain on my good knee. These things aren't exactly made like cadillacs, so buy the best one you can.
2) Shower Chair. I got a bench without a back. It saved me. You can't bear full weight for 6 weeks or more. Get a real, medical-grade, sturdy one. Practice getting in and out of the shower before surgery to find the best position for it. Get a non-slip mat for the shower/bathtub.
3) Shower Nozzle. Consider getting a shower nozzle with a hose. This way you can sit on your shower bench and wash your hair, etc.
4) Clothes. Get yourself a bunch of loose pajama shorts or boxers and comfy t-shirts. Old Navy and I became well acquainted. Short nightgowns work too if you're into that. Anything tight or long isn't going to work. Do your laundry before surgery. I put all my "post-op" clothes in neat piles on the bed in our second bedroom so I wouldn't have to go in and out of drawers and closets. Until you're really used to crutch walking, it's best to keep things simple.
5) Toiletries. Place everything you use within arm's reach. Bed, Bath, & Beyond sells some great little shower shelves and hooks with suction cups. I have a shelf with my toiletries right next to me in the shower and a hook for my washcloth. Put away things you don't use. Make sure you stock up on things you use and like. You won't be shopping for a little bit. Buy some baby wipes. You won't shower for 3 days and these things just come in handy. Trust me.
6) Crutch Bags. You'll thank me for this one. You can order these on Amazon. The ones I bought are from "Crutcheze". Buy one for each crutch. They are INVALUABLE for carrying water bottles, keys, cell phone, snacks...these are a must.
7) Ice. Your doc will likely order a cryosleeve. There are some that are self-cooling and are typically provided by a DME company. If your insurance doesn't cover it, these can run around $150/week. There are some that require ice and must be replenished with ice several times a day. My hospital sent me home with the second type to keep. Your ice maker cannot possibly make enough ice to feed this monster. It requires a daily ice run to the store. Also, you will need someone to refill it for you. It's a major pain for the poor person helping you. It is also critical for your pain control and recovery! Nothing feels better than getting that thing cooled down. Really stay on top of it for 72 hours and continue to use it as long as you can. Stock up on ice before the surgery. Consider buying a cooler (if you don't have one) to store extra ice.
8) Pillows. I'm a fan. You can't be too rich, too thin, or have too many pillows. Period. I am partial to king-sized, down. Use them to keep that leg elevated! And they really help with getting comfortable to sleep. If you're not used to sleeping on your back, it's an adjustment made easier by copious pillows.
9) Bandages. Ask your doctor's office what bandages you may need post op. Probably you will need 4x4 gauze, rolled 4-6" gauze (Kerlix), waterproof bandages, and a couple of extra 6" ace wraps. Stock up before surgery.
10) Food. Saltines, graham crackers, ginger ale, and soup were my stand by's for a day or two. I'm going to talk more about nutrition and crutch-friendly foods in a later post, but for now, stock up on easy to digest foods. Avoid heavy or rich meals and alcohol for a couple of days. Narcotics lead to constipation, so if you like prunes, grab some of those. Either way, make sure to stay tanked up on fluids. It will help prevent constipation, promote tissue healing, and make you feel better all around.
11) Prescriptions. Ask your doc to give you your post op prescriptions before surgery so you can get them filled. If you're a puker like me, ask for a couple of days worth of nausea medication. Stock up on Tylenol and Motrin. If you take regular prescription drugs, get them refilled before surgery.
12) Clear a Path. Take any bath mats or rugs out of your bathroom. They are mortal enemies with crutches. In the same vein, think like you are already on crutches and get rid of any obstacles you can.
13) Backpack. First, you must temporarily bury your sense of style. Don't worry, a resurrection will come. In the interim, get yourself a small, light backpack that you can carry around backwards (pouch in front). I'm using a freebie, cheapo, nylon one from my employer. I won't enumerate the myriad uses for this thing. You will find your own to be sure. The boyfriend gets credit for this one. Smart guy, I have. 
14) A Person. You will need an actual living, breathing person for several days. No way around it. You will need help getting to and from the bathroom for a couple of days while you're on narcotics and learning your way around crutches. You will need help changing your bandage. You will need help showering the first couple of times. You simply need a second set of hands and feet. And for your mental health, you need a little company from someone who cares about you. It's truly a tremendous amount of work for the person helping you. Parent, spouse, child, sibling, friend...find yourself a "person". I'm now going to take a moment to recognize that my guy has been a prince through all of this. He's taken care of me in the most tender and loving ways. Heaven sent, really. I wish you this blessing! 

Navigating CPM

WHO/WHAT/WHEN/WHERE/WHY/HOW:

How many hours per day? How many weeks? How much flexion? How fast do I advance? How hard should I push myself? Is this good pain or bad pain? Why the heck am I even doing this?

It turns out that CPM does a few nifty and important things. It helps mold those growing baby cartilage cells so that they conform to the articulation of your own knee joint. It bathes the graft site in synovial fluid to foster growth. It also prevents scar tissue and adhesions and helps you regain your range of motion.

I've gotten my hands on half a dozen different Denovo NT rehab protocols. Most of them prescribe CPM for at least 6 weeks, anywhere from 6-12 hours/day. And most say you should be at 90 degrees by 6 weeks and 120 degrees by 8 weeks. I reached 90 at 4 weeks and I'm holding steady. According to my surgeon, my defect doesn't engage until 90 degrees. 

Most days I do between 6 and 8 hours, a little less on days I have PT. The mornings are tough. It takes a bit to get my range of motion back. I throw a cold pack on my knee when I first start and that helps. I've also noticed that the nights are tough when I've done 8 hours. I seem to have more pain and swelling and warmth at the incision site.

CPM LIFE HACKS:

I highly recommend keeping a journal of your CPM use. Record the hours you use it, how it feels, and the degree of flexion. This becomes important when you feel you aren't making progress. You can look back and see how far you've come!

Get an iPad, find a good book, watch a series on Netflix you haven't seen, learn a new language, start a blog ;). It's a lot of idle hours and you know what they say about idle time. If you have a tendency toward depression (more on that in a future post), it will take some conscious effort to keep your spirits up and your mind on track. Break up the day. Do an hour or two and then go outside for half an hour. Or pick up some light weights and do some upper body exercises. Ask your friends and family to play a game or eat a meal with you while you're CPMing. It makes the time pass.

Set your CPM up in a spare bedroom if you have one. The couch would work too. It needs to be a comfy spot. Put a beach towel under the machine to protect the bed/couch.

Be prepared to fight your DME provider and/or insurance company to pay for the machine past 21 days. You may need for your physician to file an appeal. It runs about $175/week out of pocket. 

The Injury and The Decision

On October 8, 2013, I became acutely (if unwillingly) aware of the value of articular cartilage. I sustained an injury to my left knee while walking across a dance floor. A stranger kneed me in the side of my knee and I fell to the floor (in fact passed out) in pain. Yes, really. A freak accident, to be sure.

Doctors appointments and imaging studies quickly followed and showed a 2 cm x 2 cm "chondral defect" (in other words, a big old HOLE) on the back of my patella. Essentially, the very tough cartilage on the back of my kneecap was chipped off down to the bone. The pieces of cartilage were floating around my knee. Naively, I thought, "They'll just take those pieces out and it will right up heal up!" No such luck. If you're over about 13, your cartilage does not regenerate. And it turns out that this cartilage on the back of your patella is pretty darned important. It protects the other surfaces in your knee. Without it, you're fairly quickly a candidate for a knee replacement. Thus began my odyssey into the tricky world of articular cartilage injuries. 

When the MRI results came back, the doctors used words like "tough injury", "not too many options", and "no guarantees". In fact, when I asked some direct questions about outcomes and prognosis, my surgeon actually shrugged his shoulders. But then he brought up....an option... 

Denovo NT is a relatively new option for cartilage repair. It consists of juvenile cartilage cells that are glued into the cartilage defect with fibrin glue. These cells are harvested from cadavers of children under 13. Macabre, yet a beautiful gift to be given if you happen to need them. The idea is that these young cells will regenerate and incorporate with your own remaining cartilage to ultimately fill the defect.

As this was really the only option presented, I elected to proceed, but not without caution. I am a healthy, active, young woman and a former athlete. I am also a nurse. I had a lot of questions. I kicked into high gear and sought out information from every available source. I spoke with the rep from Zimmer. I spoke with a surgeon in Virginia who has done many of these cases. I scoured the internet for data and reassurance. At the end of the day, I agree this was my best option. 

I had surgery on 10/21/2013 and am now a little more than 4 weeks post op. It is my intention to document my experience, my progress, and share any of my lessons learned in the hope of helping someone else in the same situation.