Mako Robotic Arm TKR ONE WEEK

Posted by saeternes @saeternes, Dec 3, 2019

Therapy started this morning and I was looking forward to getting an opinion about my progress from "Alex." Since the rough 3-hour ride home from the hospital, I had doubted myself in terms of whether or not the Mako robotic arm was worth going to such lengths. But now I am happy I did it, since Alex pronounced me at the top in terms of one-week progress, with only one other person having done this. I could tell he was genuinely impressed, and he also had worked at our local large orthopedic group, so he has seen plenty of knee replacements. Like me, Alex veers away from competition and from creating too much inflammation and swelling through painful exercises, instead saying push it slowly several times during the day and make steady if not linear progress. He did not want to take off the thick bandage and pad at the knee so could not get accurate measurements, but he eyeballed it from several angles. As many of you have mentioned, he also said strength training can wait a while longer.

Next week I will be able to see the scar, how long it is, and in general how things look once the stitches are removed. Although I have nothing to compare it with, the Mako right now seems to have been a good decision. I should also mention that I don't have any real pain when pushing the ROM, so maybe that is the nerve ablation kicking in?

@dixiedog : Thank you for all your remarks and information. Yes, the pre-surgery class only mentioned “a walker”, no specifics. I’m not really surprised, since in the hospital I ended up with an extra wide version – for 200 lbs + people, which was also a little hard to handle. Regarding flex: yes, 125 is probably very good, quite enough for great function. Mine officially ended at 132 at end of PT, but I can tell that it has further improved (as by how close I can get the heel to my butt while on my back). Extension seems to come easy for most people, not for me. It is at least as important as flex in order to maintain proper form when walking.
As far as PT goes, I really was lucky. I had worked with several of the therapists in that particular office before (shoulder surgeries), and they know me very well. Progress was pretty quick – mostly they showed me what exercises to do, and to do them properly, and then sent me off to work at home. Since they knew that if they said 30 repetitions, I would do all of the 30, and then report back how difficult/painful/achievable those were, and at the next visit that would be discussed and evaluated. Some exercises had to be modified because of long-standing problems with Sciatica, but we were able do work around that. One of the therapists freely admitted that they tend to give most people a fairly high # of repetitions in the assumption that they would do perhaps half of those. With me, they told me absolutely not more than what they indicated. All in all, while TKR rehab is not pleasant by any means, good support from the PT people makes a huge difference.

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@dixiedog

I am not all surprised by the walker issue- most people/professional have no clue. And in the pre-joint classes, they often just way "get a walker". There are pros/cons to all styles with the swivel ones are by far the worst due to many safety and instability issues- I would never recommend one. I ended up using crutches (for stairs) and front wheeled walker at home, and eventually a straight cane.

Regarding the ROM: 145 degrees of knee flexion- that is no where near the norm; norm values for knee flexion (while on your back)- is 130-135 degrees and the numbers depends on several factors including scar tightness, quad tightness, having a larger calf (like a very muscle bound person), or a large calf, etc. When you measure knee bending (flexion) in supine, it is often less due to tightness of the quad; in sitting- this is the easier position to cheat and have a inaccurate measurement and 145 degrees is possible to measure- but it's not due to pure knee motion (usually comes from hip motion) and often sloppy technique by the therapist.

As far as how much you need? Many patients get hung up on the number- for example, a quest to get to 125 degrees for example. For functional purposes (this is for daily activities), usually a minimum of 90 degrees is needed (like to go up steps) but around 110 bend is optimal for the minimum number. With bending, If you get more great, but having more won't necessarily change your function. In comparison, if one has a lot of scar tissue and can't bend past 80 degrees (while on their back, for example), this has a much larger impact on the ability to do functional activities.

There's a need to get full extension- which is often lacking due to tightness as well. A lot of people forget the value of having near full extension (often called zero, 0 degrees) which is needed for optimal function.

If you have other therapy questions, ask away!

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@dixiedog I was actually to my orthopedic surgeon this week. My flex is @117. I was told they can improve that if it’s a problem for me but I think it’s functional enough. The improvement would involve a minor outpatient procedure. I have always had full extension.
My problem now is severe, recurrent bursitis. That is causing a limp which is affecting both knees. It is worse this time than ever before.
JK

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@contentandwell I'm responding to the news of your bursitis! I have it below and toward the inside of my surgery knee. It's so tender, driving me crazy. Am taking anti-inflammatories and icing the area. Hope you feel better!

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@babette

@contentandwell I'm responding to the news of your bursitis! I have it below and toward the inside of my surgery knee. It's so tender, driving me crazy. Am taking anti-inflammatories and icing the area. Hope you feel better!

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Thanks, @babette I have had persistent bursitis in my L hip for at least 8 years. Often cortisone injections help but I had one two months ago and it’s really hurting again, worse than ever. Last night I woke up in the middle of the night to use the bathroom and it was bothering me so much I couldn’t get back to sleep – I was awake for 2 hours. If when you say anti-inflammatories you are referring to OTC drugs like ibuprofen, I can’t take them, I can only take a limited amount of acetaminophen due to my immunosuppressants.
I have a small, trial-sized tube of CBD cream that I bought at Whole Foods so I put some of that on. It seemed to help. Could have been a placebo effect, or simply that after being awake for two hours I finally fell back to sleep. I always mean to ice but rarely remember to.
I have an appointment with the trauma orthopedic doctor to make sure that it is not related to the fracture that should be healed by now. I doubt it is related, but want to make sure. The fracture has had a huge negative effect on my life, and when I think that if the osteoporosis had been diagnosed more timely it infuriates me.
JK

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@ellerbracke @contentandwell @dixiedog @babette thanks so much for the comments, they do help flesh out the context and make me see that there are many differences in body type, muscularity, etc that will alter one's own experience of recovery. I had therapy yesterday and Alex added and changed a few of my exercises. He has now started the leg raise, which I am able to do, about 4" is all I can manage. I am doing toe raises holding onto the wall, and squats by the bed where I try to touch my butt to the top of the bed without sitting down. Then of course the bends and extensions; extensions are relatively easy for me but bends of course take effort and teeth-gritting. And finally lymphatic massage with leg elevated, starting with ankle pumps and then gentle massage at back of knee, then at the groin area where the leg connects to the torso. Needless to say, this is my favorite (no pain involved).

Alex also transitioned me to a cane which was not difficult. It is good for stairs and I went up and down a few times. However it doesn't stand up on its own so when doing things in the kitchen is less convenient, it dangles from my wrist or I have to put it down. I will go back and forth as needed.

Today I started weaning from the narcotics onto pure Tylenol. I made it through the first set of exercises. I suspect I will have to take a med at night and then can slowly get off the things.

@babette I had bursitis before the surgery so I sure hope it has gone away.

@dixiedog you are so right, form is everything and slight changes in form can produce very different numbers. So I think the best thing is to only use numbers in a relative way. I can also see that in the weight room, where people change the position of their bodies and suddenly can lift more, or use their backs when they are supposed to use only their arms, and so on. Being a PT yourself (what is a PTA?) must give you a different perspective.

Thanks all and I'll post about my progress (or backsliding) with meds!

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@saeternes

@ellerbracke @contentandwell @dixiedog @babette thanks so much for the comments, they do help flesh out the context and make me see that there are many differences in body type, muscularity, etc that will alter one's own experience of recovery. I had therapy yesterday and Alex added and changed a few of my exercises. He has now started the leg raise, which I am able to do, about 4" is all I can manage. I am doing toe raises holding onto the wall, and squats by the bed where I try to touch my butt to the top of the bed without sitting down. Then of course the bends and extensions; extensions are relatively easy for me but bends of course take effort and teeth-gritting. And finally lymphatic massage with leg elevated, starting with ankle pumps and then gentle massage at back of knee, then at the groin area where the leg connects to the torso. Needless to say, this is my favorite (no pain involved).

Alex also transitioned me to a cane which was not difficult. It is good for stairs and I went up and down a few times. However it doesn't stand up on its own so when doing things in the kitchen is less convenient, it dangles from my wrist or I have to put it down. I will go back and forth as needed.

Today I started weaning from the narcotics onto pure Tylenol. I made it through the first set of exercises. I suspect I will have to take a med at night and then can slowly get off the things.

@babette I had bursitis before the surgery so I sure hope it has gone away.

@dixiedog you are so right, form is everything and slight changes in form can produce very different numbers. So I think the best thing is to only use numbers in a relative way. I can also see that in the weight room, where people change the position of their bodies and suddenly can lift more, or use their backs when they are supposed to use only their arms, and so on. Being a PT yourself (what is a PTA?) must give you a different perspective.

Thanks all and I'll post about my progress (or backsliding) with meds!

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@saeternes I cannot take ibuprofen but if you can they say it is almost as effective as the narcotic drugs. I can only take acetaminophen due to my immunosuppressant medications.
It sounds as if you are making great progress though, keep it up. It's great to hear positive results so please keep reporting.
JK

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@contentandwell

@dixiedog I was actually to my orthopedic surgeon this week. My flex is @117. I was told they can improve that if it’s a problem for me but I think it’s functional enough. The improvement would involve a minor outpatient procedure. I have always had full extension.
My problem now is severe, recurrent bursitis. That is causing a limp which is affecting both knees. It is worse this time than ever before.
JK

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117 degrees is great motion and if you’re able to do activities with minimal limitations, all the better! Sorry to hear about the bursitis. Are you able to get into a pool? Sometimes water therapy does wonders for bursitis but I don’t know your circumstances or the state of your knee incision. Are you using an assistive device? As if not, you may need to as to unload your hips (is that where the bursitis is?) so that can calm down.

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@saeternes

@ellerbracke @contentandwell @dixiedog @babette thanks so much for the comments, they do help flesh out the context and make me see that there are many differences in body type, muscularity, etc that will alter one's own experience of recovery. I had therapy yesterday and Alex added and changed a few of my exercises. He has now started the leg raise, which I am able to do, about 4" is all I can manage. I am doing toe raises holding onto the wall, and squats by the bed where I try to touch my butt to the top of the bed without sitting down. Then of course the bends and extensions; extensions are relatively easy for me but bends of course take effort and teeth-gritting. And finally lymphatic massage with leg elevated, starting with ankle pumps and then gentle massage at back of knee, then at the groin area where the leg connects to the torso. Needless to say, this is my favorite (no pain involved).

Alex also transitioned me to a cane which was not difficult. It is good for stairs and I went up and down a few times. However it doesn't stand up on its own so when doing things in the kitchen is less convenient, it dangles from my wrist or I have to put it down. I will go back and forth as needed.

Today I started weaning from the narcotics onto pure Tylenol. I made it through the first set of exercises. I suspect I will have to take a med at night and then can slowly get off the things.

@babette I had bursitis before the surgery so I sure hope it has gone away.

@dixiedog you are so right, form is everything and slight changes in form can produce very different numbers. So I think the best thing is to only use numbers in a relative way. I can also see that in the weight room, where people change the position of their bodies and suddenly can lift more, or use their backs when they are supposed to use only their arms, and so on. Being a PT yourself (what is a PTA?) must give you a different perspective.

Thanks all and I'll post about my progress (or backsliding) with meds!

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You need to check this out and it’s a wonderful accessory for a straight cane- Drive quad support cane tip
There are other names and they are under $10 and can be found as many places that sell canes or online. You remove the current cane tip (You will have to pry it off) and replace it with this one. The size of straight canes are pretty standard. It has 4 little extensions (thus the “quad” word) and gives you a bit more stability due to a larger base but also it stands without falling over. I learned about this from a patient and recommend it all the time.

If you are in snowy or icy weather, there are also attachments that works like a hiking shoe ice crampon to keep your cane from sliding out.

PTA is a physical therapist assistant- they are a graduate of a two year program in physical therapy. They are licensed and work under the direction of the physical therapist to provide therapy.

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@saeternes

Also I wanted to correct something I had said before: it IS painful to work on bending. I just completed the 10 min bend (two 5 min segments, pulling back with strap while on chair) and it hurt like heck. So the ablation is not wiping out that pain!

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In this limited instance, I’m reassured that you had to suffer like the rest of us. With no Mako. And no ablation. Some things just simply hurt. A lot. But they’ll pass.

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@contentandwell

@saeternes I cannot take ibuprofen but if you can they say it is almost as effective as the narcotic drugs. I can only take acetaminophen due to my immunosuppressant medications.
It sounds as if you are making great progress though, keep it up. It's great to hear positive results so please keep reporting.
JK

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@contentandwell : briefly: You and perhaps someone else mentioned that ibuprofen is as effective as opioids for pain control. This is an urban legend, let me assure you. Ibuprofen, as well as any strength tylenol, or aspirin, merely put useless chemicals in my system. Aleve (used to use Celebrex on occasion) works to some extent, almost to the same extent that Oxycodone does. I just sort of found out by other people on this post that I probably never started out with the proper high dose of 10 mg, so I was semi-content with 5 mg, and gave up on it way to soon. Will remember this for my next (yeah, right, not happening) TKR.

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@ellerbracke I'm not posting on Mako and nerve ablation (which itself was very painful) to gain bragging rights on doing something faster or better or with less pain, so I am surprised that you proclaim yourself reassured that I had to suffer like everyone else. Knee replacement surgery is evolving and hopefully that evolution will mean less pain for all of us, as well as better and longer-lasting results. It seems that individual differences in pain perception and also uncontrollable things such as surgeon skill are as important as anything. My goal is to keep a record that is public and can be viewed by anyone who will be undergoing this process, so they can evaluate and make good decisions on their own. Instead of going to my local orthopedic center, which swears by Zimmer knees (no robotic arm), I decided to try Mako to see if it would help the ardous recovery process. I will have no way of knowing how different it would have been to go the traditional route, but as @debbraw has posted, she did one knee the traditional way and one with Mako, finding clear better results with Mako.

@dixiedog I have seen those canes, thanks for reminding me! If I need a cane for a long time I'll check them out.

@contentandwell I have some gastro issues and cannot take Ibuprofen or Aleve (naproxen, which like Ibuprofen is also a NSAID). But thanks for the advice.

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@saeternes

@ellerbracke I'm not posting on Mako and nerve ablation (which itself was very painful) to gain bragging rights on doing something faster or better or with less pain, so I am surprised that you proclaim yourself reassured that I had to suffer like everyone else. Knee replacement surgery is evolving and hopefully that evolution will mean less pain for all of us, as well as better and longer-lasting results. It seems that individual differences in pain perception and also uncontrollable things such as surgeon skill are as important as anything. My goal is to keep a record that is public and can be viewed by anyone who will be undergoing this process, so they can evaluate and make good decisions on their own. Instead of going to my local orthopedic center, which swears by Zimmer knees (no robotic arm), I decided to try Mako to see if it would help the ardous recovery process. I will have no way of knowing how different it would have been to go the traditional route, but as @debbraw has posted, she did one knee the traditional way and one with Mako, finding clear better results with Mako.

@dixiedog I have seen those canes, thanks for reminding me! If I need a cane for a long time I'll check them out.

@contentandwell I have some gastro issues and cannot take Ibuprofen or Aleve (naproxen, which like Ibuprofen is also a NSAID). But thanks for the advice.

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@saeternes I guess you and I are both stuck with acetaminophen, unfortunately it’s not much help.

I agree with you 100% that the advances have been able to improve TKRs which is why I would only go with a custom made knee. I may have considered Mako too if I had known about them. Also, foremost, as you say, is having the most skilled surgeon you can find. I settled when I had my first TKR because I was in so much pain 24/7 but thankfully that knee is very good, just not quite as good as my second TKR. The first does have better flex though.

I think it’s great that you are keeping a record, recording everything. I wish I had done that both for my transplant and for my TKRs. I have read that the biggest lie we tell ourselves is that we will remember something. I know it is for me.
JK

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