A View Down the Line

I am now at 4 weeks after the surgery.  The journey of healing is really amazing.  Its not a straight, linear experience.  There are quite a few ups and downs- during the ups, everything feels great and during the downs even I, as a surgeon, was getting worried.  The ups and down are either in function, motion, general vitality, and pain.  Those seem to be the major categories.  Let me start with how I am at 4 weeks.

  • I am walking well with no pain.
  • I can walk up steps in a normal manner barely the need for using the railing
  • Walking down steps is still difficult and I use the railing and hold my hand on a wall on the other side.  Sometimes I walk down steps one at a time
  • I walked around my neighborhood- over 1/4 mile walk.  I have not needed a cane since the end of week 1.
  • My leg is fully straight and I bend to 121° (according to my physical therapist
  • I starting driving this week without problems

Here is my protocol:

  • Since I came home from Seattle to New York 8 days after surgery I went to physical therapy 3 times a week- I stay for about 90 minutes.
    • Moist heat
    • Manual massage
    • Quad sets- a number of different exercises
    • Stretching to extension and flexion
    • Stationary bicycle
    • Hamstring stretches
    • Compressive cooling device

When I am home I go on the stationary bicycle I have and continue exercises I learned in both preop and postop physical therapy.  I heat up the knee a couple of times a day and ice it down about 3 times a day.

I start my day with one 325 mg aspirin, 660 mg Aleve, and 650 mg Tylenol.  I take no more Tylenol or Aleve the rest of the day.  The aspirin is for anticoagulation so I take another one at night.

As previously mentioned in the post “Thinking About Pain,” I have not taken any opioids since the second and third day of surgery and even then only 3 separate 10 mg doses of oxycodone.  This really surprised me and definitely will be changing my patient protocols moving forward.

I think the keys to opioid reduction are:

  • Preoperative patient education (this is Number 1!).  Really getting the patient to know what to expect, pain wise, is critical
  • Preoperative caregiver education- almost as important as Number 1
  • Multimodal Pain techniques- specifically
    • IV Tylenol (Ofirmev)
    • Injections during surgery that include liposomal bupivacaine (Exparel) that extends the pain relief 2-3 days
    • NSAIDS (I used Aleve, some people use Celebrex- depends on whether your stomach can tolerate these)
    • Tylenol 650 mg every 4 hours
  • Surgical techniques that protect excess tissue damage
  • Early activity and range of motion
  • Frequent ice packs/cooling

I will be returning to work the first week in October.  Since I cam the Chairman of the Department my entire staff is pleased mainly because I am spending too much time while I am home emailing all of them!


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