THE TERRIBLE MIDDLE

HARD INDEED, it is to find a proper name for a phase like The Terrible Middle. Whatever the right name, here I am in the Terrible Middle...perhaps The Dreadful Middle, could that be the right term?

Those of you who have been here will know what I am getting at. Back when I rode century bike rides with my mates in Portland, I came to understand the existence of this Middle. How does one ride 100 miles? Or run a marathon? Physical training is important but can be overemphasized. Psychological conditioning is most important and often this comes down to understanding The Terrible Middle. Thirty three miles to warm up, then thirty three of the The Terrible Middle, and then "Well, anyone can ride 33 miles.".

Right now, my Terrible Middle looks and feels like this: Surgery done, walking about a bit, off drugs, only need pain medication occasionally, driving the car for shopping and library, but only able to sit, stand, walk, read (long list could continue) for short periods. Little engages my interest, I read but do not take in, chocolate does not yet taste like chocolate should, I eat because it is time to eat, food is boring...how the litany flows on! Folks, let me introduce you to my my Terrible Middle.

The only good thing to say about the Terrible Middle is that it is a Middle. How far can one venture into a forest? Well, just to the Middle...after that one is on the Way Out. One of my favorite TV shows is 'Man Against Nature' (a silly title, really, since man is part of nature). The heroic adventurer is in a dense Bolivian jungle, for example, and climbs a tree to see where he is in the forest; or shows us a way of keeping going in the right direction to exit the forest. Knowing the forest from the trees seems like a very good idea. Understanding the Middle and how not to go around in circles could be one of the great secrets in life.

This is not confined to long cycle rides or recovery from surgery. Where are we in the Great Financial Crisis; what about the Great Oil Spill; and how about the ordinary business of getting older? Unfortunately, despite our expectations from our youth, Terrible Middles abound and may even pass unnoticed.

What we do in the midst of the Middles, retrospectively, can be critical. Learning to save instead of spending, engaging in kindness to others, taking a walk in the sun instead of being indoors watching Telly, talking with a neighbor, and the like. Generally, doing other than what we prefer to do or are wont to do bears on the secret of surviving the Terrible Middle.

For those in the Terrible Middle of middle age, let me recommend Barbara Strauch's book, "The Secret Life of the GROWN UP BRAIN". Not only will this book slay many myths and fears about the aging brain, but also light up the path of things to do to exploit the strengths and properties of the mature brain.

Middle Age happens not to be a problem for me. On Saturday I trip over my 73rd Birthday and thus near the final quarter of my life. I am having a lot of fun dreaming up what that will be.

On the knee front, what lies ahead is the work of rehabilitation, especially restoring a good range of motion through physical therapy, extending my walking range, and also arranging the next ordeal for the right knee. I see the surgeon next Tuesday and hope that the good progress made with the left will persuade him to press on with the work on the remaining knee.

NEW KNEE: DAY 8

TUESDAY: Just over one week since the surgery.

Yesterday the local area nurse came by to change the dressing and check progress (measuring various circumferences and the like). An opportunity to get pictures and here they are...not exactly what one might call pretty! I have 14 staples closing up the skin and they are due to come out toward the end of this week. The underlying sutures closing up the deeper layers will dissolve. As you can see, there is a deal of bruising. What you can see from the back of the leg is due to the tourniquet used to stop the flow of blood to the knee during the procedure. There are other areas of bruising related to retraction of the sides of the incision to expose the operating area ands on the shin and ankle where the jigs to do with the carpentry and assuring alignment were sited.

Seeing all this bruising has reinforced in my awareness that one serious risk of the procedure is the formation of blood clots that could cause a lot of trouble in the leg and other parts of the body (lungs, heart, brain, and so on). I have been careful to take my blood thinning medication and to do the exercises that offset this risk.

I am pleased to report that the wound is healing well and swelling seems reduced each time the leg is measured. It is good to be able to slack off and spend lots of time napping with my feet elevated. I now am able to walk with more or less respectable form without the aid of a stick but the stick still proves to be a good tutor as to the proper way to walk. Life is a not unpleasant routine of my five physical therapy workouts followed by some time lying with feet elevated listening to a recorded book, interspersed by short walks hither and yon (like out to the mail box).

Pain management has been excellent; I must admit that I was prepared to experience considerable discomfort and it has be a welcome surprise to have very little pain. Discomfort seems to unravel or become apparent in 'layers'. By the middle of last week, this had resolved into deep muscle pain. Toward the end of the week and over the weekend, it was related to the bruising of the outer tissues. Just recently, it has to do more with the actual incision and I will be pleased to see those 14 staples on their way! Pain puts a limit on how much the knee can be flexed but flexion happens to be the name of the game. Small advances are acceptable and achievable. Really, I am very happy to report, pain has been no 'big deal'.

I discovered one aspect of healing that I could have anticipated from my reading around depression. Healing of serious injuries results in a process around the wound site that eventually sends messages to the rest of the body to slow down (via substances called 'cytokines') so that energy can be conserved toward the healing process. This have a side effect of depressed mood. I had forgotten this until I noticed that I was not enjoying the taste of food and was finding it hard to focus when reading. I ordered up some baking chocolate (very dark) and made sure I spent some time out the sun, as well seeking the company of my neighbors when outdoors. At first the chocolate did not quite taste like chocolate but the pleasure of its taste, I am glad to say, has returned.

I did get a little 'cabin crazy' yesterday. I found, however, that I could get in an out of the car without too much difficulty, so took my self off down to the local coffee shop for good coffee, my favorite cinnamon roll, and conversation.

It turns out that getting over the insult to one's body that surgery happens to be is quite complicated and, no matter how impressive the surgery itself may be, it does require quite a bit of personal effort and dedication in the recovery phases.

From now on, I promise, only occasional reports; it may be that there are more interesting things to write about. If you have a question, put it in the comments section and I will answer it the best I can.

DAY SIX: RECOVERY CONTINUES

APOLOGIES that I am not able so far to present a picture of my 11 cm or so incision. You will have to wait for the next post for that.

So...here I am on the morning of Day Six (Saturday); and glad to report that I am doing quite well. On Day three, you may well recall, I was still using crutches. Feeling and control was returning to the upper leg. By the end of the day I was making only limited use of the crutches and thinking that I might well do without them. However, I had no walking stick and did not feel sufficiently venturesome to just do without them.

On Thursday, I found that I was confident to do away with the crutches some of the time, using only on and, from time to time, just walking short distances without them. Still on pain reducing tablets of various sorts. However, Wednesday night was the last time I used Oxycontin and I ceased Oxycodone on this day. This was also the day Doug, the the Physical Therapist, visited. He gave me a stick, three sets of exercises to do five times each day, and coaching on recovering a normal walk and going up and down stairs. He promises to be quite the tyrant so I am working to meet his criteria in time for his next visit on Monday. This was also the day that I ventured out to pick up the mail from the cluster of mail boxes across the road (slow progress and several snails rudely hooted at me as they passed me by).

Yesterday, Friday, was consumed with rituals to do with physical therapy, ice treatment, walking about and discovering how truly boring Friday TV can be. The longing to get some work done began but frustration at not being able to just sit for more than 10 minutes also set in. I find I can now redo my pressure bandage. Last night, I slept without it. Also, just on Tylenol every six hours now.

Now that I can view the knee, what do I notice? Quite a bit of bruising from the tourniquet application above the knee (the operative area has to be virtually blood free), as well as some bruising of the shin where the alignment tool was fixed. Swelling is greatly reduced but quite present still.

I thought I might be worried about putting weight on the leg (despite that I know the glue used sets in 5 minutes or so). In fact, the procedure results in the knee being considerably restricted in motion due to swelling and associated pain. This is mainly due to the incision itself (lots of stitches) and the trauma to the soft tissues being pulled and pushed about. The nerve block obscured this over the first two days and the magic 'Oxy's' take over after that.

The main problem is to minimize and then reduce the swelling and the ice treatment (a cuff placed around the knee that has ice water pumped through it from a Kooler-like tank)i s really good for this and I am sure the pressure bandage helps a lot too.

It helps to remind oneself that the pain originates from the soft tissue and not from the bone and that the various bits of the prosthesis are securely set in the joint. With a partial knee replacement, no muscles are cut and all the natural ligaments holding the joint together are left in place. The actual experience of pain is far less than I had anticipated and it really is very encouraging to discover that one can move about so soon after the procedure.

As there is a good chance that some of you will have this procedure, or one like it, over the next ten to 20 years, I hope that my little saga will be helpful if you recall it when considering what best to do. It is helpful to a lot of research beforehand.

In the meantime, this saga continues...watch this space!

NEW LEFT KNEE: DAY 3

WEDNESDAY: DAY THREE

RECAPPING (couldn't resist the joke!). It was early rising on Monday to get to the Outpatient Surgery Center of Strong Memorial Hospital...a modern and imposing building on the southeastern side of Rochester, commissioned last August. I half expected to have a valet parking service, so like a plush hotel is this center, but no, unassisted, I hobbled inside to join the few first arrivals.

A few formalities and I was soon called to go down to the cubicle where all the medical preliminaries were to take place...blood pressure and all the other vitals; getting to meet the first of the long line of staff who were to look after me, everybody warm and cheery. Musing a little on those nice premeds, I began to think that this was going to be quite the party. I do admit to being somewhat apprehensive but the brisk pace and the friendliness of staff greatly diminished this feeling...rather like finding oneself on a pleasant conveyor belt. The nursing staff took lots of trouble to ensure that it really was me and that it really was my left knee that was to have the procedure, drawing all sorts of hieroglyphs on my left leg. Then two anesthetic teams (one for the regional block and the other for the general anesthesia) and finally Dr. Drinkwater to discuss the surgery once more and to leave his initials on the target knee. That day, the surgical unit had 28 procedures to do and have done up to one hundred on some days...quite a production line. I hope you like the picture of me (courtesy of Uma) holding up the saline drip! Next blog posting, expect a picture of the incision; I have to wait for the district nurse to change my dressing to get a shot of the knee.

With the aid of ultrasound, the regional block team laid a slug of something like long acting Novocaine alongside my left femoral nerve (done very, very carefully), the other anesthetic team shot in the premeds and, right on time, I was transported down the corridor (all those ceiling lights flashing by) through the double set of double doors to the OR. This I observed to be spacious, filled all sorts of shiny equipment on the one side of the waiting operating table, and also rather like an office with a desk on the right hand side. Once on the table I seemed to be surrounded by a host, two of which gave me a friendly invitation to take deep breaths from the plastic mask and...the next thing I knew it was 10:30 and I was in my recovery cubicle.

The nerve block ensures that I had no feeling and no pain. It really was long lasting but also paralyzes the quadriceps so I was quite unable to move the lower leg upward all of Tuesday...a little disconcerting. However, I had two follow up calls from the anesthetic team and the surgery team and these reassured me that it may be up to 36 hours before feeling and motor control would come back to the leg. These resulted in a third call from Dr. Drinkwater's medical secretary warning me to keep up with the pain medication as feeling, once it began to return, would do so very quickly. This it did overnight. Nicely cushioned by magic Oxy-s (-contin and -codone) I slept the night through and found my leg was beginning to work this morning.

So I am getting around of crutches and gradually able to place more weight when walking with my left leg. The nurse returns tomorrow to redo the dressing and the physical therapist makes the first call for rehab on Friday.

Time for some more ice therapy and my exercises to keep blood moving around my lower leg. Thanks for all your good wishes and more later.

ON THE EVE OF THE NEW KNEE

TOMORROW is the day of of the new left knee. The procedure will be at 7:45 AM on 10th May. I confess to being more than a little awed by the prospect, plus feeling what I suppose is the normal anxiety.

I have had various troubles with this knee since 1992 when it was arthroscoped; I recall the surgeon prophesying then that I would develop osteoarthritis eventually. I reckon I have had a good run from it since then. Doing some final work around the garden yesterday, it seemed that it really had worn out.

I have collected together all the bits and pieces (crutches, drugs of various sorts, ice treatment equipment, and so on) and will soon be off to Rochester this evening. The last few days, I have been washing the area of the operation with chlorhexadine to make sure I am not carrying any bad bugs in with me and working out in the gym with special attention to ensuring good muscle tone, so I think I have done my part.

The procedure is for the Oxford Partial Knee Replacement and has been almost 30 years in development. It will be done at a Surgical Outpatient Unit of the University of Rochester and will involve resurfacing of the femur on the inside of the knee, using a curved stainless steel prosthesis. The top end of the tibia will have a stainless steel tray cemented into a L-shaped cut. When it is all properly spaced and aligned, a special low wear polyethylene insert is placed in the tibial tray and the wound closed up. This will be able to move about in the tray and provide a natural motion to the knee as it flexes. All this takes about an hour. I will be expected to stand on the leg once I recover to a reasonable level of consciousness.

When I am up to it, I will tell you all about the aftermath. When I have rehabilitated this knee I will line up for the same procedure on the right knee. Watch this space, as the saying goes.

I am sure you have found this most interesting (said somewhat tongue in cheek); after all, it is just another of my adventures