Well I guess the fact this is closer to a four-week update than a three-week one tells its own story. Lots has happened, lots going on. Now I’m back at work, week two seems an absolute AGE ago too.
Have summarised updates as follows (for quick navigation - it's a bit long, sorry!):
General progress
The biggest change over the last two weeks has been getting back to work, part-time (in theory, at least).
First day back was hard going but I finally feel like I’ve got a handle of what’s going on across our client base. I’m meant to be working mornings only but, due to the nature of the jobs that needed doing first week back, that accidentally turned into 30 hours over just over 3 days, so not quite to plan. Luckily there’s so little I can actually do physio wise at the moment that it hasn’t caused too many issues with the rehab and, at this stage, so long as I’m sat icing at the same time, I reckon I’m doing my thing. Pretty shattered but, on the plus side, night time sleeping has not been an issue and it distracts from cabin fever, if nothing else.
The swelling is definitely coming down well - I can actually see my knee cap again now - but the muscle atrophy. OMG!!!! I don’t think I’ve ever seen my quads and calf this small, even following previous surgeries. Always wanted skinny legs but still…! Slightly concerned that another 2+ weeks protected weight bearing means it’s still going to get worse so hopefully we can start doing something practical to build back the muscle and get some functionality back asap. Taking the brace off is a slightly scary concept now as it literally feels as though my leg is just hanging. Pain wise, it gets achy if I’ve been up and about or sit ‘normally’ for a while, or I get sharp pain if I lie on my right-hand side (legs on top of each other with a pillow between them) for more than 15 mins or so, but the pain aspect is seriously one that has been SO much better than it could have been so, on balance, happy days.
Physio
I had my clips out two weeks after the surgery, followed by my first physio session next day. It’s early days but I’m glad I stood my ground to see the physio recommended by my consultant. We seem to get on, she has a good grasp of what has gone on and my consultant’s approach, and has blocked time to make sure she can keep seeing me (which is good news as, chatting to another patient in the waiting room, they were getting fed up of bouncing between different physios each time). I’ve said it before but I’ve been here too many times to leave anything under my control to chance now. I’m not messing around.
In terms of actual activity, as I’m in the brace (protecting extension) and protected weight bearing, there’s very little practically I can do so the next few weeks remain ankle flexion, ankle rolls, straight leg raises (in brace), standing side and rear leg raises (to wake up glutes), and working to increase flexion (which was already 100º at that appointment so a good base to build from). I can twitch my quads but as we’re trying to encourage scar tissue (hence the brace) to reduce hyperextension, I can’t really do traditional quad sets/exercises that ask you to push your knee down so I’m hoping this won’t cause too many problems down the line.
Also found out that the knee had a good scrape out during surgery so hopefully that will help with day-to-day discomfort when this is all healed.
As for goals, I gave the physio fluffy, difficult to measure objectives such as ‘confidence’ and ‘trust’, along with a few more prosaic things like ‘kneeling down properly (bum to heels)’ and ‘surfing (not bodyboarding)’. She reckons it will be 9-12 months of physio until discharge, rehabbing the HTO and the ACL so hopefully, just hopefully, this can turn out to be a one-hit-wonder surgery.
Follow up appointment
Also had my first consultant follow up appointment earlier this week (week 3) and all seems to be going okay.
Much faffing over what to wear to a) ensure he could see my knee properly while b) not wanting to go out in public in shorts and c) still having TED stockings to navigate. Taking the brace and those off was going to be a right royal PITA. I eventually settled on summer shorts under a long skirt, leaving TED stockings off for a while and, after all that, all he did was take a quick look at the scar and then chat 😂
Anyway, he confirmed the full six weeks of partial weight bearing due to concerns about bone quality and agreed with me that there was no real point having another physio session before I was transitioning back to weight bearing, so I cancelled next week’s appointment and rearranged that for just after the six week point.
Apparently the bone tunnels of my previous ACLrs are pretty vertical. That means what’s left of the last ACL should be okay at preventing anterior translation but not so good at controlling rotational instability. I should have asked at the time if the MacIntosh procedure I had previously was controlling the latter still or not, but forgot 🤦🏻♀️ Basically, he’s now hoping that the realignment, combined with (hopefully) reducing hyperextension, will be enough to give me stability back without any further surgeries. I’ll leave my evolving views on that for the Musings section….!
In other news, I confessed to plumbing the depths of cabin fever desperation by watching the Barbie movie and was ‘gently reminded’ that I’m not really meant to be back at work yet so don’t do too much too soon. I also asked (without thinking) what reduction in slope we’d got/were aiming for. Unknown until the 8-week x-rays are in. Based on my limited understanding, I'm now hoping for a posterior tibial slope of less than 12 degrees - closer to ‘normal range’ (5-7 degrees) ideally - but not so low it increases the hyperextension problem. I don’t have any fixed goals re the varus - that one feels like the bonus ball (but possibly ultimately more important aspect longer term) at the moment.
Got a couple of photos of the in-op x-rays for my daughter to have a nose at when I got home. Her response? Awesome, that’s amazing, can I have a closer look?! Can I see what it feels like? If nothing else, she can consider all this faff part of her early training 😊
Next appointment is week 8, when we’ll have x-rays to see how the bone is healing. Fingers crossed for good news then.
OCN Jail Break Week
After a week back working as well as recuperating, I have definitely been getting very sick of the same four walls. Having time to do my own thing would be great if I could actually do anything I wanted to beyond reading (haven't really got the concentration yet to process anything too dense and rewarding). I realised last Sunday that I hadn’t been out of the house for over a week so managed to persuade my other half that we should really go out for Sunday lunch that day (bonus as that meant he didn’t have to cook either).
A random conversation with a friend along similar lines following my consultant appointment led to the birth of OCN Phase 2 - also known as ‘Jail Break Week’.
In an attempt to make sure I don’t work more than half days but to also stop myself going completely loopy (I’m fully up to date with Married at First Sight UK, for heaven’s sake), I’ve managed to plan different activities every afternoon to get me out of the house, even if just for half an hour or so. So with thanks to my rides each day, week four has consisted of; Monday - Next Cafe and consultant appointment; Tuesday - daughter’s tennis lesson; Wednesday - M&S to collect the youngest’s clothes order, then onto the eldest’s hockey tournament for half an hour; Thursday - lunch out and a gossip with a friend; Friday - school Harvest Festival 🙏🏻
Oh my days, I feel SO much better. Still tired in the evenings and my leg gets sore when I’m sat ‘normally’ for a while. It’s probably the worst it has been all week this evening as I type, but that figures and icing is helping. The only truly scary moment was when the crutches kept sliding on the paving slabs outside the changing rooms at the hockey tournament but slow, concerted effort got me back to the car safely. It felt so good to be out in the FRESH AIR!!!!! I will be careful, I promise, but just wow - outside world - inhale, exhale!
General musings…
After all that lot, I’ve had a bit of time to process what actually happened in the surgery itself and piece together some of the info I’ve picked up along the way, all of which, inevitably, leads to more questions than it answers in my ever-whirring mind… This is pretty much a brain dump of thoughts awaiting further reading and then distillation into a more logical chain of thought but, for now:
Top of the pile is this issue of bone quality: What does that actually mean? How is it assessed? What are the implications for likely surgery outcomes - this time and in future? Is my bone basically like the walls of our new-build house in that you can stick I something in the plasterboard (with the right fittings) once, but the whole thing is likely to simply disintegrate if you attempt to put anything different in there again (with associated implications for future surgeries)? At what point does the protected weight bearing (due to concerns over bone quality) actually hinder healing when you need to weight bear to stimulate bone renewal? Surely bone grafting the previous ACL bone tunnels would ultimately improve bone quality? What happens to the the screws from the HTO? Or the holes they make if the hardware is ultimately removed? Is my upper tibia basically more hole than bone now? Do those holes heal (following the same principle of bone growth bridging the gap of an opening wedge HTO)? If not, why not?
Next is the decision to leave the stretched and vertical ACL graft in there: Is it better to have something rather than nothing there to provide protection while the bone is healing, just in case? If the bone tunnels are not ideal, can I really rely on the realignment being sufficient to stop it giving way again, particularly if rotational instability could still be an issue? If the tunnels are too vertical, rotational stability is questionable, and we don’t manage to reduce the hyperextension, isn’t it still pretty vulnerable to blowing out? If the hyperextension remains, does that basically make it pointless attempting another ACLr anyway? Is the whole approach basically cautious to see what result we get on the slope/hyperextension front first, before assessing next best steps should it prove to remain unstable?
I’m totally aware that my response to this is hugely coloured by the fact that, after the last 10 years, I simply don’t trust it not to give way again. I’d like to believe the realignment alone is going to fix everything - even with a suboptimal graft left - but experience has taught me that optimism and hard work isn’t enough. On the one hand, this is meant to be the fix that finally sorts this out once and for all (or is part of a planned process that does); on the other I can’t help feeling I’m going through it all just to be back in ‘let’s wait and see’ territory all over again, which is not really where I wanted to be.
Hoping (based on informed judgement) something works could well be the smart move longer term but it doesn’t really help my confidence in the here, now and medium term. Plus, of course, if it does give out again and another reconstruction is needed (and viable), we’re back into two-stage territory when we could have been one step down that road already.
I don’t know… the consultant assured me it felt secure at the end of the surgery. On an intellectual level, I trust his judgement on this and am reassured he’s assessed what he saw in surgery and made the decisions based on that, rather than protocols and scans. Experience has taught me that ‘wait and see’, 'hope' and 'thinking you’re doing the right thing' don’t necessarily result in the the outcome you need though. I guess only time is going to tell…
Next... wk5: Keeping the groundhog at bay
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