Surgery #3

In the week leading up to my most recent surgery this past Wednesday, I was very optimistic and spent most of my time being relatively comfortable. Surgery #2, which placed the first plate in my leg, had relieved one of the major sources of pain that I had been feeling. I went into #3 thinking that things were just gonna get better.

Not exactly. This was the biggest operation yet in terms of time, complexity, and work to be done. Even the surgeons really didn't know precisely how bad things were until they came in from this angle. They knew what they were going in to do, add a second plate, but they didn't know what other issues they might find with the joint or how much groundwork they'd have to build so that the plate could be secured. Turns out things were pretty messed up in there.

Both the cartlidge of the knee and the meniscus of the knee had essentially flopped open and out. They called in a sports medicine surgeon for a consult during the surgery and were able to get those pieces pushed and trimmed back to what they described as almost good as new. They had to do a significant amount or bone grafting. Since grafting from the pelvis brings about all sorts of complications, they use artificial bone. They take pieces of sea coral which has a porosity nearly identical to human bone. On to the coral they paint and blot a calcium sulfate compound and thus create artificial bone. Within five minutes the stuff is strong enough to sink a screw into. Eventually, my bone will grow around, absorb, and replace the artificial stuff. They had to use a lot of it.

The plate they put in has a dozen screws that run at various angles all the way from one side of the bone to the other. I've got a great xray picture of the setup and if I ever make it back to my own house, I'll get it up here. Essentially, the six inches immediately below my knee are a lot more metal than bone nowadays. The first plate had, if I recall, five screws coming in from the other direction.

I woke up without the external fixator - those rods and pins that had been sticking out of my leg. That means that my leg is now floppy again and that if I lift the top part of my leg, the bottom part swings at the knee. It also means the knee can move laterally which is a most scary and extremely painful occurrence. The last thing they did to me while I was under for surgery was to gather up all of the muscle in the room and force my knee to bend. Keep in mind that I had been locked in place with no movement at all for two weeks. The doctor said that it was very difficult but that they were able to crank it down to an angle of 120 degrees, which is apparently very good.

During the surgery, in addition to the general anesthetic, they also used a femoral and sciatic nerve block. Basically what they do in a nerve block is to find the high point of the nerve in your leg, and then insert a catheter that drips mordacaine sporadically onto the nerve. That then prevents any of the lower pain from traveling any further up than the block: your brain never gets the message that there's a whole ton of pain lower down.

I was scheduled to be sent home around 7 AM on Thursday morning, but around 5 AM the nerve blocks started to wear off. By 7, I was writhing in pain. The pain was a heavy, intense pressure inside of my leg where the plate had gone in, plus the shearing pain in my knee from having it bent so dramatically during surgery, plus the fire from the long incision and related sutures and staples along the cut line. On top of that, my wound drain had clotted off and wasn't working. They had to yank the drain out and resort to catching the blood with pads and gauze and letting it run back into my body for absorption. This required unwrapping and re-wrapping my leg and every little touch, twist, and manipulation added to the fire. I was miserable.

The surgery was at the surgery center instead of the hospital this time. They don't always have people stay overnight. The first night, I was the sole patient. They had no one scheduled to work Thursday evening. There was much back and forth as to whether I should be sent to a hospital - where they would be able to give me a PCA pump (patient controlled analgesic - morphine!), whether they could get me stabilized enough to go home, or whether they would be able to scramble and get the two staff - one nurse and one aide - that they would need to keep me over night. While that debate raged, so did the pain. They pumped me full of more drugs that day than I might have expected to be possible. But despite the femoral block, the front-side sciatic block, blocks on the nerves at the surgery site, oxycontin, percocet, fenterol, verced, and demerol, I still couldn't get caught up to the pain.

It was the demerol that eventually won the day. The first shot made me really loopy. The second one about knocked me flat. By then the decision had been made that I would stay at the center another night. I got my regularly scheduled oxycontin and then percocets every four hours. With each dose of percocet I was able to sleep for two or three hours. I woke up the next morning feeling like I was finally out in front of the pain.

So they set about to getting me out of there at about 7:30 AM. Unfortunately, I still had to deal with a pair of nurses who seemed bound and determined to make my physical departure as difficult as possible. Over the previous two weeks with lots of good help and instruction from the physical and occupational therapists, I had gotten quite good at getting in and out of beds, chairs, wheelchairs, and cars. Suddenly these two were completely changing everything I had been taught. Getting from my bed to the wheelchair was a painful nightmare as they lifted and twisted and pushed and pulled at me in ways that just didn't make any sense. It was infuriating. At least by the time we got out to the car I had the sense to tell them to just back off and let me do it my way. Still, I went from ahead of the game to behind in 20 short minutes.

Arriving home, my given goal was to instantly begin physical therapy. On Wednesday night, while all of the blocks and pain killers were still working, I had been introduced to the CPM: continuous passive motion machine. This is a sling like device that I lay my bad leg in and it moves up and down ever so slowly. Under the nerve blocks, I rode the thing for two and a half hours all the way to a sixty degree bend. Thursday was such a bad day that I didn't use the machine at all. Yesterday, I could only manage a bit more than two, one-hour sessions and only up to about 40 degrees. Actually, it turns out that so far the upper limits aren't where I feel the pain. It's when my leg gets down to flat, 0 to 10 degrees, that it really pulls and hurts the most. My goal is to spend four hours a day in the thing eventually working it up to 120 degrees over about the next three weeks. Soon, I'll get more of a physical therapy regimen and this will just be part of it.

So far today, I have managed two, one-hour sessions on the CPM. The first went fairly smoothly, but the latter was much more challenging especially in the last 20 minutes. The next two sessions are going to be a bear. I've moved out into the living room for a little bit this afternoon. Last week I was zooming back and forth from the bedroom to the living room. Now that my leg is not as stabilized, it's a much trickier proposition as every waggle of my knee hurts intensely.

I kind of feel like I was blindsided coming out of the last surgery. I really thought I was well on my way to a quick recovery. I realize now though that I have a long, painful road still ahead. I don't mind a bit of hard work, but the pain really sucks. The doc told me to expect to have to rely on narcotic pain killers for at least another month. At least the surgeries are done.

Jonathan 8/26/2006 08:33:00 AM