1st Update – Hygiene & Exercises

23 – 29 Jun, Sat – Fri. D23 to D31 - Maintaining hygiene & exercises

I’ve told my story over 12 episodes & 3 annexes. I’ve also added some 50 references & links to web pages & websites for further reading, in Annexes A & B. That should be it. From now on, I’ll post updates on my rehab progress and sharing of my thoughts. Time flies, I’ve already gone past the 4th week, since my operation on 30 May 07.

A hard day’s work?

Someone asked how I’ve been spending my time each day – must be very boring with not much things I could do. Others loaned me lots of DVD movies to watch. My kids suggested reading books, as we have many good books at home. Reflecting on what I’ve been doing each day, I’m actually quite ‘busy’. The trice daily CPM sessions normally take up almost 4 hrs; exercises, ambulating with crutches & getting some doses of daily sunshine - almost 2 hrs; grooming, airing & dressing of the knee twice a day – 2 hrs; reading the newspaper, watching TV & the News – 2 hrs; accessing both my home & office emails & reading up on the Internet – another 2 hrs. That’s already 12 hrs - the rest of the waking hrs is for meals and other daily routines.

My compact bedside 'Workstation' with leg-rest

and laptop PC connected to home wireless LAN

Grooming the knee

One of the tips someone advised me was to ensure good hygiene of the knee, as day & night wearing of the knee brace may give rise to irritating rashes, especially when you cannot wash the knee yet. I spent an hour each time, twice daily, ‘grooming’ the knee, airing it and putting on new dressing. Fortunately, I’m well prepared for this, giving tender loving care to my leg. I used disinfectant spray, antiseptic spray, alcohol swap, post-op dressings, anti-microbial, hypoallergenic wet wipes with Chamomile & Aloe Vera, and absorbent gauze dressing to cover the knee before strapping up the brace. I have another spare but elaborate leg brace, which I borrowed from somewhere, that I can put on temporarily, so that I can dismantle and wash my usual Ranger brace at regular intervals. Hope all these measures will keep the rashes away.

Daily Exercises

In addition to the various isometric exercises, of which I have progressed to the full raising of the right leg unaided, I’m also doing crunches and sit-ups. I’m progressing from 55, to 85 and now 105 sit-ups this morning. Now, why the numbers always end up with 5 extras? Read on. Normally, crunch & sit-up should be done with both legs in bent position, but in my case, only the left leg can bend. I’m doing it cautiously, not wanting to strain my right knee. When I was serving national service in the combat engineers, some 33 years ago, my commanders used to make us do 3 better (actually 3 extras, especially for punishment) – one extra for the Country, one for our family and one for yourself. Over the years, I’ve added another 2 more, one more for my friends and one more for the community. I think this is a very positive mindset to have, always willing to go the extra miles and knowing that you can always put in more than 100% efforts in many things that you do, with great passion and love.

I had a bad dream

Last night I dreamt that I was, as usual, keeping myself busy doing chores around the house when I suddenly realised that I was limping around without my crutches. I woke up in horror! I cannot imagine what could have happened to the implanted cells in the sutured periosteum pouch. It could've been squeezed out because I’d put full load on the knee. What a frightening thought! I’m thus determined not to let this happen. I’ve read from the Internet forums that some of the not so successful cases were probably due to falls and aggravation of the injuries on the knee during the recovery phase. While I can speed up the strengthening of the leg muscles by exercising harder, I cannot biologically hurry the remodeling, quick setting and hardening of the new cartilage cells.

Episode 12 - What's Next

21 Jun 07, Thu. D23 - What's the next stage of rehab.

Saw the Prof this morning. He was happy with the healing of the wound. He was surprised with my fever episode immediately after my discharge from hospital. He said it was unfortunate this occurred as my conditions appeared quite stabilised when still in hospital. He examined the slightly swollen knee and was satisfied that there was no abnormal redness or localised swelling. To play it safe, or be a bit "kia-su", he asked me not to push too hard for a quick recovery. He explained that the repair to my chondral ulcer was quite extensive and deep, and as such, the range of motion for the knee should continue to be capped at 0 - 30 degrees. He asked the nurse to dress up the wound to prevent any infection. He would extend my hospitalisation leaves for another 3 weeks. The zero load bearing for the right leg has to be for the full 6 weeks. He also asked me to extend the rental of the CPM machine to cover the whole of the 6 weeks, so that I could continue with my thrice daily CPM sessions. He explained what to expect for The Next Few Months. He would see me again in 3 weeks time, before my MCs expire, to review the situation.

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I spoke to him about the experience which I've had, and told him that I've been taking notes. I've also been reading up quite extensively on this subject. I told him many of my friends and colleagues have been asking about my treatment procedures and that my notes may be a source of reference for others. I intend to publish it in a blog to share it with others. He said it was an excellent idea and asked me for the blog address so that he can view it and maybe asked his students to study it too. He said he also had in mind to start a website, but was just too busy to do it. While waiting in the specialist clinic, I found the ortho wheelchair quite comfortable as it has a leg support.

Now, what's this?

(please scroll down further to see)

Altogether, I've published 12 episodes in this blog. Please scroll down to start from the beginning at Episode 1 - Introduction to this Blog or click any of the links to read any Episode and the 3 Annexes. Future posts will be added when I have any updates.

Episodes & Content

1 Introduction to this Blog
2 The Background
3 Pre-Operation thoughts
4 D day - The Operation
5 The Day After
6 The Recovery
7 The Home Coming
8 A Feverish Nightmare
9 The Fever Pattern
10 Winning the Battle
11 Start of the Rehab
12 What's Next (this page)

Annexes
Annex A - What is ACI
Annex B - The Next Few Months (including references & links)
Annex C - The Fever Chart

Take your time to read or zoom in to the sections you're interested in. Regards, Poh SH, 21 June 2007.

22 Jun 07, Fri. D24 - I have an idea.

I don't have an ortho wheelchair at home. Sitting on a normal chair is quite difficult without a small foot-stool to support the leg. Can't be carrying the small stool around whenever I move about. I began to hatch an idea to design a portable lightweight folding foot-rest, whereby I can rest my leg whenever I sit on a chair, bearing in mind that my knee cannot bend due to the brace. While going through the sketch with my son and checking on the availability of suitable materials to build the foot-rest, he suddenly remembered he has a collapsible tripod stool which he used for his outdoor archery shoot. It turned out to be ideal for this purpose. Here are the photos:

Episode 11 - Start of Rehab

18-20 Jun 07, Mon - Wed. D20 - D22, Start of Rehabilitation.

Went to the Rehabilitation Centre (Ortho Gym) at NUH on Monday. The physio attached an electronic pulsation device to the thigh just above the knee to massage the accupoints. This stimulated the contraction of the quadriceps muscles. I was asked to tighten the muscles together with the device. He also taught me more isometric exercises which I could do at home. Finally he applied cold compress (ice pack) on the knee - it was really relaxing and take the stress and pain away from the knee. He commented that there shall not be further exercises at the Ortho Gym for the time being, as the instruction from the Prof was to avoid any load bearing on the leg. The physio advised to continue with the CPM and isometric exercises at home. Next appointment would be in 2 weeks’ time.

Tuesday was Day 21 or 3 weeks after the operation. Spent the whole of Tuesday and Wednesday compiling notes and photos for this blog. Created a number of draft postings and named them by Episodes so that I could arrange the postings in some kind of chronological order. Annexes were also created for detailed reference. Target for publishing by Friday evening, hopefully.

Episode 10 - Winning the Battle

15 -17 Jun 07, Fri, Sat & Sun. D17 - D19, Fever scaling down.

Short bout of fever came at 8am on Friday and went off at 9.30am. Managed to access the office email until 4pm when I had to stop owing to the returning fever. I decided not to fight it, as I read in the Internet that fever is the body’s natural mechanism to fight against infection - I should let it runs its course unless the temperature exceeded 39.5° C. At temperature beyond 40° C, some people may become delirious and go into fits. High fever may also damage the brain - that's why we need to cool down using ice or cold pack or sponging down. I went to sleep instead, but felt very sick as the body concentrated all its energy to fight the enemy. The temperature rose to 38.6° C at 7pm but returned to normal by 9pm and I was able to sleep fairly well that night.

Waited the whole day on Saturday for the fever to return but it didn't. It's kind of strange - anticipating it, scanning with the thermometer for the symptoms which never came. The body had finally won the fever battle - hurray! Although there was no fever, I felt weak the whole day, as I was fighting the fever for almost 8 days! Sunday was Father's Day :-) No fever - this was the best Father's Day present. Celebrated by buying delicious food home for a feast. Felt strong enough to make my way downstairs to join everyone on the dining table. My appetite returned. I've lost more than 3 kg since the operation - Oh No! with the returning appetite and hardly any exercises, my weight would surely go beyond my pre-op days. I was pampered with gifts from my kids. Later, they taught me how to start a blog, how to select a quick template and how to post entries. They encouraged me to log my notes in a blog for my friends and colleagues to read, as well as to share my experience with others. I could email the blog's link to friends and colleagues who may want to find out my latest conditions. I should also allow anyone to forward this link to others who may need information about similar type of knee problems.

Episode 9 - The Fever Pattern

12 - 14 Jun 07, Tue - Thu. D14 - D16. Fever has a pattern.

Was able to sleep on Tuesday, but waked up repeatedly. There was no fever until 6am when the temperature started to go up, reaching 39.0° C at 9am. Owing to the fever, I had to miss the first physiotherapy session in the morning at NUH. The fever went off@11.00am. Fever returned at 4.30pm -nevertheless I continued to access the office email @6pm to get some distractions from the discomfort of the fever. It seemed to work and the fever left at 7.30pm. The fever pattern repeated again on Wednesday. No fever until 7am and then increasing to 38.8° C before leaving at 11am. Fever returned from 5pm - 9pm. I decided to plot a fever chart to show the pattern.

Click here to display the Fever Chart.

The fever came a bit later on Thursday morning at 8am @38.7° C, and went off quickly at 10.30am. Fever returned in the afternoon at the usual time. Temperature reached 38.7° C. The fever remained high when I had to visit the neighbourhood clinic @8.00pm to remove the stitches. Took the opportunity to show the doctor the fever chart which I’d been compiling. He said it was not unusual to have this kind of pattern. However, he advised to continue with Ibuprofen and take note of the A&E doctor’s instruction. When he pulled out the 2 stitches, there were sharp pains. I started sweating and felt the fever disappeared suddenly! This was how the knee looked after the removal of stitches.

Episode 8 - A Feverish Nightmare

9 - 11 Jun 07, Sat, Sun & Mon. D11 - D13, A Feverish Nightmare.

Fever continued unabated since Friday evening. Unable to sleep - needed cold packs and sponging throughout the night & day. Took 2 Panadol, but couldn’t take more as the limit is 4000mg per day. The Panadiene tablets prescribed by the hospital 3 times daily, already contained 3000mg of paracetamol. The fever showed no sign of subsiding. Had to keep track of the temperature readings regularly. Temperature ranged from 38.1 ~ 39.0°C.

Fever continued into Sunday, reaching a high of 39.1°C@2am. I started to have nightmares. My family members began to get worried. My wife called NUH first thing in the morning, but as it was a Sunday, could only managed to reach the staff nurse of my previous ward. She told us my case history had already been returned to the central registry and advised us to go to A&E, as the doctor would be able to retrieve my case history. Went to NUH A&E at 11am, as advised. Doctor examined me but said there were no other apparent causes of the fever – there were no rashes, so it wasn't dengue, it was probably due to inflammation as the knee healed. He prescribed Ibuprofen, an anti-inflammatory drug, which can be taken concurrently with Panadiene. He instructed to return to A & E should the fever reach 40°C or showed no sign of subsiding after 5 days. On Monday morning, fever reached the highest point, 39.5°C @3.30am. Fever stayed above 39° C for a few hours, finally dropping to 37.5°C@10am. Fever returned in the afternoon, from 5.30 - 9pm and then subsided.

Episode 7 - The Home Coming

8 Jun 07, Fri. D10, Day of Discharge - The Home Coming.

Woke up a several times, but avoided the isometric exercises on the bed. Dr Jeffrey came in to brief me about the post-op care at home and the medications needed. I asked for another 'strong' painkiller to be taken only when the excruciating pain returned. He informed that the Prof would review my case in 2 weeks’ time. The pharmacist came in with a big bag of drugs and briefed me on the dosage of the various medications. I was subsequently discharged from hospital at 2.30pm. I would like to take this opportunity to thank all doctors, nurses and staff of Ward 88 (29 May - 1 Jun) and Ward 78 (1 - 8 Jun) for taking such good care of me while I was hospitalised there. I knew some of them by names, but it wouldn't be fair to name only some of them, as in my drowsy state, I could not remember many others who were very helpful too.

After settling down at home, I decided to access my office email @5pm to inform my colleagues of the duration of my Medical Leaves (28 days in total from date of admission) and to tell them that I was discharged from hospital and now recuperating at home. Home Sweet Home. The delivery man brought up the portable CPM machine into my bedroom and taught us how to use it. He reminded us of the rental rate of S$15 a day and asked for 2 cheques - one for the deposit of S$300 and another for the minimum rental period of 2 weeks, i.e. S$210. Actual charge will be recomputed later when the treatment period is over.

4 hours after discharge from hospital, from 7.00pm onward, I developed a persistent fever @38.8° C, which kept me from sleeping. I'm now back - bedridden again, sigh! Had to rely on others for almost all my daily needs again. I used an ear-scan thermometer for quick check of temperature and counter-checked the readings against a normal digital thermometer. To make life a little easier, I rounded up a collection of some bedside gadgets and items: TV and air con remote controllers, a small writing pad to jot down notes, ear infra-scan and digital thermometers, handphone, illuminous digital alarm clock, bottle of water, medicated oil, eye drop, LED torchlight and a remote wireless door chime to call for assistance whenever I needed help. What were not shown are lots of tissue-paper packs, wet wipes, a plastic urinal pot, medications, post-op dressings, supplements, anti-septic spray, gel coldpacks, wet towers packed with ice in plastic bags and a bottle of cooling spray to sponge down the temperature. I also had a foldable chair to sit, a commode for toileting and bathing, a small stool to support the leg when sitting on the chair, trashbag, plastic bag and masking tapes to cover the braced leg when bathing.

Episode 6 - The Recovery

2 - 3 Jun 07, Sat & Sun . D4& D5, The Recovery - Learning to walk.

Got fairly good sleep on Saturday. Woke up to find someone visiting with freshly made roti-prata, smelled really good, except that I had no appetite. In the late morning, a young doctor tried to remove the wound dressing alone, but caused another severe cramp of the leg. Finally, with the help of nurses, he removed both the bandages and the drain line and pot. Removal of the dressing revealed a shrunken leg and a swollen knee. Another physio came in and with her support, I could ambulate around the room slowly with crutches. In the late morning, I was wheeled into the Rehab Centre, also known as Ortho Gym, to try stair climbing - but couldn't as I was too weak. On Sunday, I felt much better. Have been exercising on the CPM for 2 to 3 times a day. In the evening a doctor came in to remove the infusion needle & plug on my left hand as it was no longer required. It was much more comfortable without a needle sticking into your hand.

4 - 5 Jun 07, Mon & Tue. D6 & D7, Feeling Good.

Have been on semi-liquid diet for the past 6 days as I have no appetite and I had not moved the bowel yet. Doctor prescribed stool softener and laxative. Later nurse inserted suppository into the rectum and finally all accumulated wastes were flushed out with great relief! Also took the first shower in days. Went to Ortho Gym in the afternoon and was able to climb several steps of the staircase, but needed great efforts and someone’s support. On Tuesday, I started eating solid food after 7 days of soft food such as porridge, soups, 'mee-sua' mee-hoon soup, etc. Tried a variety of Chinese, Muslim and Western foods, but all were not too tasty. Exercised on the CPM machine 3 times. For the first time today, could feel the quadriceps muscle strengthening – was able to lift the leg slightly. Did some walking on crutches. Someone brought dumplings, it was something different and nice.

6 - 7 Jun 07, Wed - Thu. D8 - D9, Isometric Exercises.

Woke up at 5 am, got adventurous and did all kinds of isometric exercises. I could now turn in prone position and lifting the leg backyard. The Prof came in and check on my conditions and said that I could be discharged on Friday. He instructed that the range of motion on my brace should be locked at no more than 30° for 6 weeks. Was very happy to hear that I could go home soon. Redoubled my isometric exercises the whole day. However, I had to shorten the 10pm CPM session owing to pain in the knee. Silly of me to have overdone the exercises. The pain worsened by midnight and I had to call in the staff nurse at 1am as the pain had become unbearable. She gave me a painkiller jab which reduced the pain within 30 min and I went back to sleep. Woke up on Thursday morning feeling much better, but skipped the morning CPM. Physio came in with a pamphlet - The Prof had instructed to rent a CPM machine for home use for 3 to 4 weeks. I have to arrange with the supplier to deliver on Fri evening in order not miss the exercise session after discharging from hospital. The rental rate was S$15 a day.

Episode 5 - The Day After

31 May 07, Thu. D2, the day after (the operation ).

Pain continued throughout the night and day. Informed the nurse that the pain level had gone up to 8. Today, I can wriggle the toes and flex the ankle slightly, but there was no relief to the pain. Started to get a fever @8pm, 37.9deg, BP shot up to 149 (my normal BP is 110 and below). A Dr Jeffrey came in to check and instructed to start sponging. He said he would give me a painkiller injection later.

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1 Jun 07, Fri. D3, Introducing the CPM Machine

Called the nurse as I couldn’t sleep and the pain was unbearable. She finally came and gave a painkilling jab at 1.40am, which reduced the pain level by half to 4. Fever also subsided and I finally managed to get some sleep. Prof came in the morning and said I could start on the CPM machine (Continuous Passive Motion). He explained that flexing the knee regularly stimulates the growth of the cells, as well as prevents the stiffening of the knee muscles. He also ordered a 'Ranger' brace for my knee and instructed that it be set at 0 to 30°. Brace cost S$210 which had to pay in cash to the supplier. The physiotherapist, or physio in short, came in later and the nurse removed the bottom cast to get ready for the first session on the CPM machine. The machine is designed to flex the knee very slowly up and down to a preset angle. This was set from 0 to 30°, identical range of motion as the brace. The CPM session wasn’t painful, although the machine did looked like a torture machine at first sight. The drip was finally removed as I could now eat and drink normally. As a Class A1 room was finally available, I was shifted to Ward 78 Bed17 @5pm. The physio came in @6pm and tried teaching me to get out of bed on crutches – my leg cramped up several times with intense pain. She finally strapped up the brace. By then, I almost fainted when I stood up with the crutches for the first time since the operation. Lots of blood and pus could be seen draining off through the tubes into the drain pot.

Click below to see how the CPM machine works

Episode 4 - D day - The Operation

30 May 07, Wed. D day, D1, The Day of the Operation.

Woke up early in the morning and tried exercising - couldn't move much with the drip and tube hanging on top of my left hand. Waited for what seemed like an eternality to be wheeled into the Operating Theatre. Finally, 2 operating nurses came @11.20am – they assured me that what needed to be done would be done – very reassuring indeed! At the Operating Theatre, the anaesthetist announced that the operation could commence. It was very quick, he told me he would be administering GA, and before I can say anything – blackout! I woke up @5pm, totally disoriented, with severe headache and throbbing pain on my right knee. The nurse asked me to describe the pain level on a scale of 10 – told her it was at pain level (PL) 7. My operated leg was immobilized in cast, had no feeling and cannot move at all. There was also a drain tube sticking into the knee to drain off any bleeding, accumulated fluids and puss into a drain pot. The Prof came in with a large group of doctors later. Showed me the digital photo of the ulcer on a camera and said it was larger and deeper than he expected. He joked that ladies would be happy with the scars on the knee, however, as he was able to make only small cuts. Despite being prescribed with 2 types of ‘strong’ painkiller drugs, the pain was really unbearable. Didn’t get to sleep at all.

Episode 3 - Pre-Operation thoughts

I've done quite a bit of literature searches on the Internet, but some of the forums which I read were rather negative. Some of the depressing comments includes: "don't jump into it", "seriously should reconsider", "success rate has been hyped up", "think twice", "the results are not positive", "the recovery is extremely slow", "don't be a guinea pig", etc. But someone posted that most of the people who have successfully undergone the procedures would have carried on with their lives and only a small group of unhappy individuals would bother to post in forums. One colleague did introduce someone who had a similar knee problem. I managed to talk to him a few times and felt much more reassured and positive about the operation, which he successfully underwent 3 years ago. He has improved so much that he has resumed his soccer games, took part in vertical run and even running the marathon , albeit slower! I really need to thank him - Mr Lau WC, for willingly sharing his experience with me and giving me much needed tips from his experience.




28 May 07, Mon. D-2, two days before the operation.

Had a slight stuffy nose, sore throat and frequent sneezing since Sunday. Hope the cold will not delay the operation. Cleared up outstanding works in the office, handed over important items to my deputy and activated the out-of-office notification in the email system. Programmed telephone voicemail to inform callers of my absence and to redirect all my calls to my deputy. Gave last minute instructions to staff and confided to some friends and colleagues that though mentally prepared, I still have butterflies in the stomach. Despite putting up a brave front, I’m actually quite scared. I hardly fall sick and except for some eye problems previously, I’ve never had any major operation before. I’ve been exercising both legs and taking supplements such as Vitamin C (1000mg), multi-vitamins and minerals, iron, zinc, ginseng, gingko, chicken essence, etc, to fortify the body prior to the actual operation. These supplements probably won't strengthen the body, but at least it should ensure that there would not be any deficiencies.

29 May 07, Tue. D-1, day before the operation, admission to NUH.

Packed my belonging, anticipating a short stay in the hospital. Continued my workout session before going to NUH, accompanied by my wife. Waited a very long time for admission as there was no suitable vacant Class A room yet. Patient Service Officer gave us some “Kopi Tiam” vouchers and asked us to have our tea break first, thought it was a nice gesture - had a big bowl of banana split ice-cream. Finally, was admitted to a temporary ward, Ward 88 Bed 14 (single room but considered Class B as it had no facilities). I don't really mind as I thought my stay would be short and I would be bedridden to be able to enjoy any facilities anyway. My Prof came in to check on me and commented how bare the room looked. He took a permanent marker pen and marked the affected leg with an arrow and a smiley – “to be absolutely sure the right leg is opened up”, he grinned. He illustrated how the incisions would be made on my knee. Later, went through routine examinations, such as, chest x-ray, ECG, temperature/BP measurements, etc. A young doctor came in late at night to draw out some blood for tests and to put on the sodium chloride NaCl drip. My earlier sniffly and sneezy nose finally cleared up @night.

Episode 2 - The Background

The Background and History of the knee Problem.

I experienced knee buckling on my right knee some 18 months ago. It was a strange feeling as there was no pain and I was unable to simulate such loss of muscular control. Later, I felt pain whenever I jogged or played a round of golf. Usually, rubbing medicated oil and putting on a knee guard would keep the pain in check. I also started taking glucosamine and chondroitin sulphate supplements and also applied transdermal glucosamine cream to the knee. They helped to relief the pain somewhat, but these products are really costly. I decided to seek medical treatments when the knee started to lock up briefly in the bent position occasionally. Trying to straighten the leg to stand up would cause intense pain at the knee. Massaging the knee and relaxing the muscles would eventually ease up the locked knee. Again, I was unable to simulate the knee locking, no matter how hard I tried - it was as if nothing had happened and there was no pain afterward.

I was referred to a specialist consultant in NUH, an Assoc Professor, who specialised in orthopaedic, tissue engineering and stem cells. He examined my leg and told me that, based on the symptoms, it is likely to be knee osteoarthritis - the wearing out of or damage to the knee cartilage. Subsequent MRI and X-ray confirmed localised damage of the cartilage known as chondral ulcer. Cartilages are normally meant to last one's lifetime. However, diseases, trauma to the joints, high intensity & high impact activities and even obesity can aggravate the cartilage wear.

The Prof said that at my age, I was neither here nor there - too young for knee replacement and too old for tissue engineering, such as using stem cells or cultured cells. Normal age range for cells replacement is from 13 - 55 years old and knee replacement is usually for those above 65, as artificial knee can only last 10 - 15 years, shorter if the person is active in sports. Obviously, I'm outside these age ranges. Later, however, he asked if I'm prepared to try stem cells for the repair. There are special stem cells called mesenchymal stem cells (MSCs) which can be extracted from one's bone marrow, usually taken from the hipbone. The very small number of stem cells are cultured in the lab, multiplied into millions in number and then implanted back to the knee. The stem cells will eventually transform into new cartilage cells in the knee. I agreed without hesitation. He suggested monitoring my conditions for a short period. In the meantime, however, the episodes of knee locking happened more and more often and the locking up sometimes lasted 30 minutes or more. The Prof said that it was caused by broken fragments of cartilage in the knee and these would have to be removed under a key-hole surgery called Arthroscopy. In April 2007, I underwent arthroscopy and the Prof removed 3 pieces of somewhat rounded fragments, which he called 'meteorites' floating in the knee cavity. The fragments were probably damaged a long time ago, ground until somewhat rounded over many years. He told me later that he took the opportunity to harvest some chondrocyte (cartilage) cells to grow in the lab. He asked me to be prepared for ACI, Autologous Chondrocyte Implantation in 4 weeks' time. (Please see my post on 'What is ACI'). The surgery date was eventually fixed 5 weeks later, on 30 May 2007, provided of course, my harvested cells survived and had thrived in the bioreactor.

Click the links below from Arlington Orthopedic Associates to watch 3-D video animations of Knee Arthroscopy and Knee ACI.

Acknowledgements:

National University Hospital, Singapore. (http://www.nuh.com.sg/index/index.htm)
Stem cells. (http://www.nuh.com.sg/nuh_ortho/ortho/sports/stemcell.html)
Arthroscopy. (http://www.nuh.com.sg/nuh_ortho/ortho/sports/arthroscopy.html)

Arlington Orthopedic Associates. 3-D Video animations

Knee Arthroscopy. http://arlingtonortho.com/ka/

Knee ACI. http://arlingtonortho.com/aci/

Episode 1 - Introduction to this Blog

I created this blog to share my recent experience on the operation of my right knee. Many friends and colleagues have also been enquiring about my well-being and how I'm coping with the rehabilitation, and wishing me a speedy recovery. I really wish to express my heartfelt thanks to everyone for their concerns and wishes. Being a novice at blogging, I initially thought of setting this blog up as a private blog only for family, friends and colleagues to view, but my kids suggested that I should open it to anyone who might be interested in this medical procedure - that's what sharing is all about, isn't it?

I underwent an operation called knee ACI, Autologous Chondrocyte Implantation - this basically means taking out some healthy cartilage cells from your own knee, grow it in a lab, implant it back to repair the damaged portion of the knee cartilage, something like Cut, Grow & Paste. I shall post the background of my knee problem, what is ACI, pre-operation thoughts, the post op experience, both in hospital and at home and finally what to expect in the next few months, including some 50 references & links for further reading.

Episodes

1. Introduction to this Blog (this page)
2. The Background
3. Pre-Operation thoughts
4. D day - The Operation
5. The Day After
6. The Recovery
7. The Home Coming
8. A Feverish Nightmare
9. The Fever Pattern
10. Winning the Battle
11. Start of the Rehab
12. What's Next

Annexes

• Annex A - What is ACI
• Annex B - The Next Few Months (including references & links)
• Annex C - The Fever Chart

Annex C - The Fever Chart

Click any spot on the diagram to enlarge the chart.

Annex B - The Next Few Months

What to expect for the next few months.

After implanting the cultured cells into the knee, the knee would be protected by a post-operative knee brace. This special brace is reinforced on both sides with hinged steel bars. The range of motion can be set on the hinge from 0 to 90° and free range. In my case it was set to 0 to 30° for now. The angle could be gradually increased over time, until free range is achieved. The brace may need to be used for up to 3 months to prevent the knee from buckling.

Since the implanted cultured cells may not be fully modeled into semi-solid form till the 6th week, crutches would have to be used. The operated leg must not bear any weight at all for the first few weeks and light pressure can be partially exerted until 12 weeks. The crutches can then be gradually weaned off by increasingly putting pressure on the foot until walking slowly indoor is possible. Up to the 6th week, the cells continued to proliferate and would still be in semi-liquid form. From then on they will form into matrixes with the surrounding tissues and start to remodel and consolidate into semi-solid, toothpaste-like consistencies and gradually hardening during the next 6 to 18 months. Rehabilitation exercise programme will have to start slowly, provided the range of motion has reached 90 or more degrees. Initially, hydro-therapy and wading in water may help, if the facilities are available. Other exercise equipment that is suitable include using machine that have adjustable loading, such as a stationary magnetic exercise bike, starting from almost zero force to 9 levels of resistance. Later, a more rigorous physiotherapy programme will help to rebuild the atrophied muscles. Full strength recovery may take up to 2 years for the knee to regain almost the original flexibility and strength needed for most sports activities. I know of people who could resume soccer and participated in vertical run and even full marathon 2 to 3 years after the ACI operation.

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Acknowledgements – References & Further Readings

National University of Singapore - Mesenchymal Stem Cells in Musculoskeletal Tissue Engineering: A Review of Recent Advances
http://annals.edu.sg/pdf/34Vol200501/V34N2p206.pdf

National University of Singapore - Stem Cells and Cloning, The 8 Essential Steps to Achieving A Kick Like Beckham By - Prof Lee Eng Hin & Dr James Hui
http://www.sma.org.sg/sma_news/3506/stemcells_leh&jh.pdf

Singapore Biopolis: CSI Award - Repairing Cartilage Defects through New Therapies – A Prof James Hui
http://www.biomed-singapore.com/bms/sg/en_uk/index/research_resources/research_highlights/year_2006/csi_award_-_repairing.html

Orthopaedic Sports Medicine, Mt Elizabeth Hospital – Knee injuries and cartilage problem
http://www.sportsmedicine.com.sg/patedu.html

The Center for Orthopaedics & Sports Medicine - ACI Rehabilitation Protocols
http://www.arthroscopy.com/sp08027.htm

Oscell - Tissue Engineering in Orthopaedics
http://www.oscell.enta.net/technique.htm

Allen Comer - (ACI): A Patient's Perspective
http://users.erols.com/equinox/aci_rehab.html

Chester Knee Clinic - Patient and General Practitioner Information
http://www.kneeclinic.info/download/CKC_ACI_Information.pdf
Rehabilitation - http://www.kneeclinic.info/knee_rehabilitation.php

About.com ACI - Autologous Chondrocyte Implantation
http://orthopedics.about.com/od/hipknee/a/aci.htm

Orthopaedic Technology Review - Updating Autologous Chondrocyte Implantation Knee Rehabilitation
http://www.orthopedictechreview.com/issues/julaug03/pg30.htm

The Knee Guru - Osteoarthritis of the knee
http://www.kneeguru.co.uk/

John Hopkins University - Repairing Knee Joints by Growing New Cartilage
http://www.birchbob.com/MarketingPieces/jhu/indexJE.htm

Uconn Health Center, Sports Medicine - Autologous Chondrocyte Implantation (ACI), Femoral Condyle Rehabilitation Protocol
http://uconnsportsmed.uchc.edu/patientinfo/postop/knee/re_kneacifemchond.html

Sports Medicine Institute, University of Minnesota Orthopaedics - Autogenous cartilage implantation
http://www.sportsdoc.umn.edu/Patients_Folder/Knee/aciimplantpat/aciimplant2.htm

Southern California Orthopedic Institute - Cartilage Repair
http://www.scoi.com/carticel.htm

The Harvard Orthopaedic Journal - Autologous Chondrocyte Implantation for Chondral Defects of the Knee
http://www.orthojournalhms.org/volume2/html/articles6.htm

Royal National Orthopaedic Hospital Trust, Stanmore - Autologous Cartilage Implantation (ACI and MACI)
http://www.timspalding.com/PDF%20files/ACI%20Cartilage%20repair%20info.pdf

The University of Western Australia - Perioperative rehabilitation for autologous chondrocyte implantation: A review of two case studies
http://www.ausport.gov.au/fulltext/2001/acsms/papers/ROBE1.pdf

Knee1 - Dr. Kenneth Zaslav: Applying New Techniques to Repair Cartilage
http://www.knee1.com/hero/hero.cfm/20
Forums: http://www.knee1.com/forum/index.cfm?forumid=2

Genzyme Corporation – Carticel (Autologous cultured chondrocytes)
http://www.carticel.com/home.asp

Wikipedia - Knee cartilage replacement therapy
http://en.wikipedia.org/wiki/Knee_Cartilage_Replacement_Therapy

National Institute for Health and Clinical Excellence (NICE) - Autologous chondrocyte implantation (ACI) - Review
http://guidance.nice.org.uk/TA89

University of Liverpool - A prospective, randomised comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee
http://findarticles.com/p/articles/mi_qa3767/is_200303/ai_n9167232

Tri-Valley Orthopedic Specialists, Inc. - Constructive Surgery of the Knee
http://www.trivalleyorthopedics.com/article_kneesurgery.html

HIP Health Plan of New York - Autologous cultured chondrocyte implantation (ACI) with Carticel®
https://www.hipusa.com/providers/ny/guidelines/pdf/surgical/MG_Autologou_Chondrocyte_Implantation_C.pdf

Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois - Chondral Injuries Of the Knee
http://www.cartilagedoc.org/downloads/sek/g4368.pdf

UniCare Medical Policy - Treatment of Osteochondral Defects of the Knee and Ankle
http://medpolicy.unicare.com/policies/SURG/chondral_defects.html

The TRIP Database - Listings of articles on knee cartilage defects
http://www.tripdatabase.com/SearchResults.html?s=1&gk=knee+aci&itemId=250053

Verigen UK - autologous Biotherapy® in orthopaedic surgery
http://www.sovereign-publications.com/verigen.htm

Answers.com - Knee cartilage replacement therapy
http://www.answers.com/topic/knee-cartilage-replacement-therapy

Medscape Today - Articular Cartilage: The Search for the Holy Grail
http://www.google.com.sg/search?hl=en&q=%22Articular+Cartilage%3A+The+Search+for+the+Holy+Grail%22&btnG=Search&meta=

Institute for Arthroscopy & Sports Medicine, San Francisco - Cartilage Transplantation (Autologous Chondrocyte Implantation, ACI)
http://iasm.com/ccc.html

Biomedical Engineering Department, University of Wisconsin at Madison - Comparison of Four Treatments for Patients with Severe Knee Cartilage Damage
http://tc.engr.wisc.edu/UER/uer01/author1/content.html

Colorado Orthopedic Consultants - Cartilage Transplantation: Applying New Techniques to Repair Cartilage
http://www.cocortho.com/index.php~practiceId=10041&dir=article&lib=Article&articleId=2260.html

Orthopaedic Surgery and Sports Medicine at the University of Washington - Surgical options for early arthritis
http://www.orthop.washington.edu/uw/microfracture/tabID__3351/ItemID__288/PageID__3/Articles/Default.aspx

Joint Preservation Center, Texas – About ACI
http://www.jointpreservationcenter.com/about_aci.html

BBC News – Growing a new knee
http://news.bbc.co.uk/1/hi/health/1556883.stm

Action Medical Research – Growing your own knee cartilage!
http://www.action.org.uk/touching_lives/2003/09/knee_cartilage_repair/

eOrthopod - A Patient's Guide to Articular Cartilage Problems of the Knee
http://www.eorthopod.com/public/patient_education/6509/articular_cartilage_problems_of_the_knee.html

University of Pittsburgh Medical Center - Articular Cartilage Regeneration
http://www.orthopedictechreview.com/issues/janfeb02/case.htm

Arlington Orthopedic Associates - Surgery & Rehabilitation
http://arlingtonortho.com/

Annex A - What is ACI ?

What is knee ACI – it’s the acronym for Autologous Chondrocyte Implantation. It is now considered a fairly established medical procedure to repair damaged or partially worn knee cartilages, although not many people have heard of it. Knee cartilages are avascular, meaning they have no blood vessels and they are, therefore not able to be regenerated by the body. Autologous means using one’s own cells; chondrocytes are specialised type of cells that form the cartilage; and implantation means to patch new cultivated cells back into the knee. This is a two-stage surgery process, where healthy cells are first scraped off from non-weight bearing area of cartilage surface using a technique called arthroscopy. Two keyholes are opened up, one to insert a fibrescope lightsource & camera and the other to insert the tool for the biopsy where about 300mg or some 10,000 cells are harvested. While examining the interior of the knee compartment, any broken fragments of cartilage are removed. The damaged area, known as chondral ulcer, is cleaned up and the jagged edges are trimmed (debrided), to prepare the area for the next stage.

The harvested cells are then taken to a lab, together with a substantial amount of the patient’s blood (about 70 ml) to grow in a special nutrient rich bioreactor. Normally, within 3 to 4 weeks, the 10,000 cells would have multiplied to some 10 to 12 millions cells and ready for implantation. NUH is currently the only medical facility in this region with a cells culture lab, Therapaeutic Tissue Engineering Laboratory (TTEL), to grow these cells. Previously, they are sent to US, UK, Sweden, Japan or Australia for the culture. In my case, owing to the surgeon’s fully booked schedule, my operation was some 5 weeks later. My ulcer was found to be larger and deeper than originally estimated and I probably needed those additional millions of cells.

During the second stage of the surgery, which is an open knee surgery, 2 incisions are made. The major incision is for the main surgery – about 100mm to 150 mm long over the kneecap, to expose the damaged ulcer. In my case, it is at the end of the thighbone, a femoral chondral ulcer. The surgeon then measured and made a template in the exact shape of the ulcer. He then opened a second incision on the shinbone (tibia); about 50 to 70 mm long, to expose the periosteum, the membrane or skin that covers the bone. Using the template created earlier, he cut out a slightly larger layer of the periosteum and immediately sutured this on the ulcer. Bone glue made from one’s own blood was used to cement over the sutured area to seal the overlap. To ensure that the newly created pouch is fully watertight, pressurized sterile saline water was injected into the pouch to test for leak (something like hydrostatic test used in industries). Once no leak was detected, the saline water is drained and the prepared cultured cell is implanted into this pouch using a syringe. The pouch acts as the formwork where the cells continued to grow and eventually hardened to form the newly created cartilage. Both the pouch and the incisions are then sutured or stitched up. The photos below showed the ulcer before the repair and the fully regrown cartilage.

Acknowledgements:

National University Hospital, Singapore, Dept of Orthopaedic Surgery. (http://www.nuh.com.sg/nuh_ortho/ortho/sports/cartilage.html)

The Center for Orthopaedics and Sports Medicine, Atlanta, Georgia, USA. (http://www.arthroscopy.com/sp08001.htm)

Brown University, Rhode Island, USA. (http://biomed.brown.edu/Courses/BI108/BI108_1999_Groups/Cartilage_Team/christine/HowitWorks.html)

Arlington Orthopedic Associates. 3-D Video animations
Knee Arthroscopy. http://arlingtonortho.com/ka/
Knee ACI. http://arlingtonortho.com/aci/