Poh's Blog

38th Update - 4 Years after Surgery

2011-06-13T14:59:00.004+08:00

The fourth anniversary of my knee operation has just passed. I’m fine generally. In addition to my part-time lecturing stint at the Polytechnic, I’ve also taken up another part-time job as an advisor to a local conglomerate. This will keep me active and occupied with worthwhile things to do. I’ve also travelled to the US and UK and will be visiting my eldest daughter in Canada soon. I’ve continued to play recreation golf regularly since it has low impact on the knee and I can ride the buggy to avoid over straining the knee. Together with my wife, we have also been taking relaxing stroll in walking trails in nature parks. We’ve covered quite a numbers; West Coast Park, Labrador Park, the Southern Ridges, including Clementi Wood to Kent Ridge Park, Kent Ridge to Horti Park (Alexandra Road), Alexandra Arch to Henderson Wave, Telok Blangah Hill to Mt Faber, including the Marang Trail to Harbour Front. We’ve gone up to the Bukit Timah Hill and visited the Hindele Quarry, taken the Diary Farm Nature trail to Singapore Quarry, visited Bukit Batok Nature Park and the Little Guilin. We’ve also gone for the tree-top walk and reservoir boardwalk at MacRitchie Reservoir Park. Didn’t know Singapore has so much green space. Perhaps I’ll post some pictures the next time.

The last checkup with my doctor recently showed some wear damage on the cartilage of my left knee as well (the good leg). There were occasional episodes of pain on both knees but it wasn’t too bad. The doctor is quite happy with my recovery and said that he has successfully tried out this technique on older patients, one of whom is a fit 67 years old man. He joked that by the time my left knee requires attention, there may, hopefully be new, less invasive procedures for the cure.

37th Update - Nearly 3 Years since my Surgery

2010-04-26T23:25:00.006+08:00

It has been some time since I last posted in this blog. That is probably good news, meaning I don't really have much to complain about. I just retired at the end of Feb 2010, but have been trying to keep myself busy. The most immediate impact is the great load off the shoulder; no more heavy work responsibilities or tight dateline to keep; with much lower stress level and you can wake up at what ever time you feel like it. Currently, I'm conducting some weekly evening lecture at a Polytechnic. Guess sooner or later, I will probably still find something more substantial to do, perhaps some flexible part-time job to keep occupied. I have also went for a good holiday in Taiwan with my wife end of last month - it was quite enjoyable.

My right knee is holding up well - it is almost 3 years since my operation. Actually next month would be the 3rd anniversary. My left knee is generally also holding out well too, although there were occasional pain. Spoke to my doctor about this in Jan and he ordered another radiography check for both knees come Jul 2010. Hope the conditions don't deteriorate too soon. He advised to exercise the leg muscles regularly, preferably to swim more often rather than to jog/walk. Hope I can take his advice more diligently.

36th Update – 29 Months after Surgery

2009-10-31T15:19:00.004+08:00

I know I have not been updating this blog regularly. Apologies to my many friends who have inquired about my progress. I was thinking of updating this blog only after my appointment with my Professor doctor, but the appointment is now postponed to Jan 2010. Both my knees are holding out fairly well, although there are still pains from time to time, especially after prolonged standing or walking. What worries me most is my left knee (the good knee), as it starts to ache and climbing stairs has become painful. There is, however, no symptoms of buckling nor locking up of the knees. The pain would go away after rubbing with some glucosamine cream. Not sure whether the pain could also have been induced by stress, which I'm currently experiencing. In the meantime, I'm still swallowing glucosamine pills three times a day.

35th Update – 26 Months after Surgery

2009-07-31T21:22:00.013+08:00

My knee is holding up quite well, although from time to time, I do experience some rheumatic pain. But it is not serious and usually goes away the following day. However, one should never be too complacent. Last month, after bringing visitors around my workplace, we have to go down several flights of stairs. As usual, I held on to the railing when going down. However, I was distracted when someone asked me a question and I must have lifted my arms to gesticulate when my knee suddenly buckled and I tumbled downward. Fortunately, it was probably at the last few steps and I wasn’t injured. Except for some embarrassment, I was all right – there was no pain, but some soreness at the knee afterward. I still need to constantly remind myself to be careful.

At my last posting, I mentioned that my citrus tree is fruiting with green oranges. It grew to be larger than a normal orange as can be seen in the photo. Well, we couldn’t resist the temptation and finally harvested a few. Somewhat to our disappointment, it wasn’t oranges, but some kind of calamansi lemon-lime variety – it was quite sour. Anyway we juiced it and sweetened it with pandan leaves flavoured syrup – it makes a really refreshing drink when chilled. Cheers!

34th Update – 2 Years after Surgery

2009-05-30T11:32:00.001+08:00

Today is the second anniversary of my knee surgery; the operation was carried out on 30 May 2007 at the National University Hospital, Singapore. To recap, the procedure is called autologous chondrocyte implantation or ACI in short. This involves harvesting stem cells from one’s own bone marrow or removing healthy tissue cells form your own knee or other joint, growing them in culture in a laboratory, and injecting them back into the knee cartilage to repair the cartilage damage. As this involves “growing” your own cartilage, there is no danger of the body rejecting a foreign object. The cartilage comprises hard outer surface of collagen fibers on the surface and a porous underlying substructure, allowing the cartilage to have a slippery, wear-resistant surface, and yet remains flexible and providing a shock-absorbing substrate. The cartilage of the knee is a living tissue but it has no blood vessels (avascular). Once degenerated through arthritis or injury, the cartilage cannot repair itself and has limited regenerative capability. Advances in tissues engineering and stem cell techniques have however, allow the body to repair itself naturally, although it is a rather slow recovery process.

I saw my Professor doctor last week; he was very pleased with my progress so far. He said there are now more than 200 patients who has undergone similar type of operations in NUH and he would really like to start a web site or blog to allow such patients to share their experiences, except that he is too busy to start one. I suggested to him that he could give it as an assignment to a group of his medical students and they could use any resources found in my blog, as I’m willing to share my experience with others. He examined my leg and determined that it can be straightened and stretched without pain, although the right knee still cannot bend fully when squatting. I would say that I have regained most the normal function of the knee, except that I wouldn’t want to test how well I can hop or jump! He continued to prescribe another 6-months supply of Glucosamine capsules. Addressing my concerns about the effect of the long-term consumption, he said that this type of products is considered a health supplement and should have no long-term ill effects, except for those allergic to seashell as they are made from it. For such people however, there are now vegetarian Glucosamine extracted from plants. Glucosamine can also be absorbed transdermally by rubbing the affected area with Glucosamine cream or ointment.

I’ve been playing golf more regularly now, 2 to 3 times or more a month and the knees have been holding up quite well. There may be some soreness and stiffness after each game, but they would go away after a day or two.

I’ve also started to spend more time tending my small garden. My dwarf apple mango tree is blooming with 80-over fruits; some of it is as heavy as a kilogram each. To avoid the use of insecticides, I’ve made covers out of netting materials to protect the ripening fruits against birds, fruit flies and other insects. I’m now able to climb the A-frame ladder cautiously to cover the higher-level fruits. I have another small tree which is fruiting with green oranges, or is it large citrus fruit from calamansi or lemon variety? I’m not sure what it is - I’ve to harvest and eat it first.

33rd Update - 22nd Month after Surgery

2009-03-31T21:34:00.003+08:00

It's already the end of Mar 2009 and good news everyone! I've already resumed playing golf. I started lightly, practiced at the driving range several times, taking it really easy before playing my first game on the golf course. I was really rusty, missing shots and hitting the balls all over the places as expected, since I've not had a game for almost 2 years. To date, I've already played 4 games, and improving my swings and shots with each game. The outdoor and lush greenery is good for me and really uplifted my spirit - if only the score can come down more quickly to enjoy the game more...... I'd to get new golf shoes, though, since all my old shoes were rotten and hardened through long disuse. There were some aches and slight cramps on both legs immediately after each game but it usually recovered the following day. This is probably muscle aches owing to lack of prolonged exercise rather than any problem with the knee itself. As a precaution, I wore knee guards for the game and make sure I take my glucosamine tablets conscientiously everyday.

Generally, the operated knee is trouble free, but I still do not feel fully recovered yet. I still experience dull pain once in a while. After prolonged sitting, I sometimes feel some pain when straightening the leg, and have to massage the knee a bit before it can support the full body weight when walking. This is probably the final stage of recovery, as warned by the doctor as full recovery can take as long as 3 years or more.

32nd Update - the 19th Month

2009-01-11T17:34:00.004+08:00

How time passes quickly - it's now 2009 and I realised that I've not updated this blog for over 2 months. Perhaps it is a good sign - no news is good news, right? It's over one and a half year since I went for my knee surgery and I'm glad to report that my knee is pretty OK now. Saw my doctor in late November 2008 and he was pleased with my recovery. Knowing that I'm still updating this blog, he suggested that perhaps we should start a special interest group of sort for the growing number of people who have undergone similar knee operation, to share experiences. I thought it is a good idea, after all, I started this blog for the same purpose. He continued to prescribe another 6 months' supply of glucosamine pills.

I have totally weaned off the walking stick and am now walking quite normally, even going up and down staircases. At the last physiotherapy session in early December last year, the physio checked on me walking/jogging over 2.1 km on the rubberised track and certified that I've recovered sufficiently to be discharged from the rehabilitation centre. He advised that I should continue to exercise regularly on my own, without over-stressing the knee. The recovery came at just the right time as I was kept very busy running around the whole time, preparing for my daughter's wedding on Boxing Day. My leg held up quite well, especially on the big day itself, when I was practically on my feet for some 15 hours!

I've not resumed my golf game yet - it should be quite soon, I hope. Thought I should get some light practice sessions first as I'm worried about the twisting motion of swinging the gold clubs. Just 3 days ago, I had my first session of bowling - although only for 2 games. My legs weren't that steady and it was uncomfortable bending my knees, but I did OK - none of my balls went into the drain! The knee was a little sore afterwards, but rubbing some glucosamine cream relieved the aches.

My wishes for the New Year? Good health is top. Hope I can have good games of golf, that I can go jogging regularly, perhaps even cross-country running and playing social games of badminton and table-tennis (I've given up tennis and squash as it would be too demanding on my knees). Perhaps it may be too early to tell, my doctor says that eventually, I could even try snow boarding or skiing when on overseas vacation in future (but definitely no bungee jumping!).

31st Update – 17th month

2008-10-30T23:17:00.002+08:00

74 weeks after Knee ACI

The knee is generally stable although I still have slight occasional pain. I’ve continued to take the prescribed glucosamine 3 times a day and exercise conscientiously during the fortnightly physiotherapy session. Last week I was able to brisk walk about 600m to warm up and slow jog about 1.5 km on the rubberised track at the Ortho Gym. Someone recommended that I should jog on the beach – may be I’ll try it the next time. Nowadays, I don’t need the walking stick indoor, but I still use it outdoor, as a precaution. I intend to wean off this since I have not encountered any knee buckling recently. I’ll be seeing my doctor next month and hopefully, can resume most of my outdoor activities and perhaps play a round of golf.

30th Update – the 16th Month

2008-09-30T22:19:00.003+08:00

70 weeks after Knee ACI

Today is the 70^th week since my knee operation. Someone whom I’ve not met for some time was surprised that I have still not recovered fully and commented that I should perhaps change doctor and seek alternative treatment. He said others recovered from knee surgery in much shorter time. I told him that for ACI cases, it might take 2 or even 3 years to fully recover. For my case, I’m making steady progress, but it is still early, being only 1 year and 4 months since the operation. I told him that I’ve read up a lot on this subject, including alternative treatment methods. Even Tiger Wood would probably need to rest his knee for more than a year before attempting to play golf again. His final comment that having too much information is also not good left me quite puzzled…

I told the physio that when ‘cold’, the knee was sometimes quite stiff, especially after sitting for a prolonged period of time. It would take some flexing to warm up the knee. He suggested some leg stretching exercises while sitting before getting up. In addition to all the exercises at the Otho Gym, I’ve also started brisk walking and slow jogging on the 150m soft rubberised track next to the Gym. Wearing my new ‘max cushion’ jogging shoes, my knee seemed to hold out quite well over 10 laps, about 1.5 km. I’m proceeding cautiously, as I do not want to stress up the knee. There was no pain and no knee buckling, although I felt a little soreness, afterward.

29th Update – the 15th month

2008-08-31T23:02:00.001+08:00

65 weeks after Knee ACI

I just realised that I’d already attended the 40^th physiotherapy session this week. Although one of the physio has been attending to me most of the time, I’ve also seen 4 others, each with a slightly different approach and emphasis on the rehabilitation programme. I think this is all right, as I’ve learnt quite a variety of exercise techniques from them. My knee is growing stronger and it is more stable this month. Adjacent to, but outside the NUH Otho Gym, there is a winding 150m soft rubberised track that I’ve started practicing brisk-walking. I’ve even attempted a slow trot over several laps. Although the physio observed that I’m still limping and putting most of the weight on the good leg, I hope that I can progressively start my long awaited jogging session, a milestone in my recovery progress.

I didn’t use the Nintendo Wii Fit balance board for some times owing to the Beijing Olympics, as the TV was fully occupied for the live and delayed telecasts of the various events on the numerous cable channels. I should have resumed my Yoga sessions, but felt a little lethargic after 2 weeks of watching the Olympics.

28th Update – the 14th Month

2008-07-31T18:25:00.002+08:00

61 weeks after Knee ACI

The knee is still not as strong as I wish it could be and I’ve still not gone for any jogging yet. At the 38th physiotherapy session, I was still trying to improve the strength and stability of the leg. Did more exercises with one leg, trying to balance without using the big toe. Walking-wise I can now walk quite briskly without tripping, although I still carry the walking stick just in case, and for climbing stairs.

I’ve also been using the Nintendo Wii Fit balance board to keep track of my training progress – with significant improvement in overall scores in the various exercises and double-digit decrease of my Wii fitness age (hey, I’m getting younger!). Just wish that I could spare more time for the various sessions.

27th Update – 1 year and 1 month

2008-06-30T23:55:00.004+08:00

57 weeks after Knee ACI

The knee is generally stable with occasional pain if I over exert it. This month I’ve been very stressed up at work and did not have much time to exercise. However, I’ve been going to physiotherapy sessions fortnightly and increasing the level of intensity. This afternoon, I was able to do stationary jog on the mini trampoline for more than 10 minutes. The physio said I could try some brisk walking.

My kids bought the Nintendo Wii Fit pad for me to exercise the leg and body posture. Wii Fit comprises a pressure board for you to stand on and 4 main categories of exercises - various Yoga poses, strength training, aerobic exercises, and improving balance & agility. In each category, there are many levels of difficulty, starting from the simple, such as, deep-breathing exercise and as one progresses, more difficult levels are unlocked. The Wii console keeps track of your training progress, measuring your weight and calculates your Body-Mass-Index (BMI); asks you to set personal target and tracks your improvement over time in a graph. Based on your performance, the program even attempts to determine your Wii age (fitness age as compared to actual). It’s a fun way to keep fit and exercise the body muscles.

26th Update – The First Year

2008-05-31T22:00:00.005+08:00

52 weeks after Knee ACI

Time passes by quickly – it’s already 12 months after my knee operation. There is no anniversary celebration – I’m still not ready to jog or restart my golf game. I still need the walking stick when getting around, mainly for negotiating steps and slope. My doctor, the professor said perhaps I should use a long umbrella, instead, as I don’t look good with a walking stick. Well, look doesn’t matter, safety is more important. I still have the occasional knee buckling although there is no more locking and the pain is minimal.

We discussed about the knee’s condition during the recent check-up. The newly regenerated cartilage is quite apparent in the MRI scan. The previous internal oedema (swelling with fluid) has subsided. The scan also revealed the old tear in the meniscus and some wear on the tibia (lower leg bone) as well as the knee cap. My leg can now be fully straightened and I can almost do a full squat. However, I still can’t do a single leg squat without pain. He suggested I continue with the fortnightly physiotherapy sessions and gave me six month supplies of glucosamine sulphate. He is quite satisfied with the progress of the healing, although it is a little slow.

25th Update – The Eleventh Month

2008-04-30T22:15:00.003+08:00

48 weeks after Knee ACI

Went for follow-up appointment in NUH with the lung specialist, 3 weeks after my pneumonia episode. Chest x-ray was quickly taken before I went to see the specialist. Nowadays, things are handled quite efficiently - there is no physical handling of x-ray film. The doctor used his computer to call up the high-resolution images on a large LCD screen. He showed me the “Before” and “After” x-ray images of my chest, side-by-side. You could clearly see that the lung congestion had fully cleared up, which meant that I’ve fully recovered and need not go for any further appointment.

Resumed my physiotherapy sessions after a 5-week break. The physio introduced a circular balance board with a half-ball underneath and asked me to bend my knee while balancing. This is for strengthening the joint and thigh muscles. I was also placed on a mini-trampoline, to flex the knee while balancing and to do stationery marching (I could also do some slow jogging on the spot).

I did not experience any serious locking of the knee during the period, except for the occasional buckling when stepping onto uneven ground. Could walk fairly well unaided, although I still use the walking stick to prevent fall and for stairs. After easing off the exercises during the past 3 months, I hope to step up the intensity from now onward. Still hoping that I can go for some brisk walking or slow jog soon…

24th Update – The Tenth Month

2008-03-30T09:00:00.001+08:00

43 weeks after Knee ACI

No progress report on the knee, but I did not have any serious buckling or locking during the month. Went to physiotherapy session only once earlier in the month and had to cancel all appointments for the rest of this month.

On Sat 15 Mar afternoon, I was quite energetic and decided to replace a faulty wall fan. Suddenly, I felt giddy, followed by fever. I went to bed early. Woke up on Sunday morning feeling well, but the fever returned in the evening, reaching a high of 39.5 C. That evening, I went to the neighbourhood clinic and the doctor said I had throat inflammation and prescribed antibiotic and lozenges. As the fever did not subside and I also had gastric pain, muscle and joints aches, I went to the same clinic again on Wed morning – another doctor changed the medicine to a stronger antibiotic. He also took blood samples for tests – but ruled out dengue, as my blood palette count was normal. However, my haemoglobin was abnormally low and white blood cells high. He warned that if fever still do not subside in another 2 days - to go to hospital. Couldn't sleep the whole of Wednesday & Thursday owing to severe back pain, fever and some breathlessness. On Good Friday, 21 Mar, I went to NUH’s A&E and was kept inside an isolation room. Portable x-ray and ECG machines were pushed into the room for my examination. Later in the afternoon, the duty doctor informed me that I had pneumonia and took blood samples for testing. I was subsequently hospitalized in an Isolation Ward for 3 days. Here, everyone who visited me, including doctors, nurses, visitors and even the cleaners have to wear mask when entering my room. Three young doctors came in on Sat morning and observed that I looked well with no fever, and asked whether I want to be discharged. Told them my symptoms of recurring fever in the afternoon and they told me to stay another day. True enough, the fever returned that afternoon. My consultant doctor, who is a Prof, visited me on Sunday and said my condition has stabilized and prescribed a strong antibiotic. I told him I also had blood in my sputum, but he said it is normal and should go away after a few days. He said I could stay until Monday or I could also be discharged and rest at home – I went home on Sunday and the doctor warned that I should stay home for the next 7 days and finished the full course of antibiotic and cough medicines.

My fever has subsided since Sat, but the coughing is still bad, although there is no more blood in the sputum. I still felt weak, after two weeks of illness, but is anxious to return back to work tomorrow. Hope everythings turn out well...

23rd Update – The Ninth Month

2008-03-01T23:24:00.002+08:00

39 weeks after Knee ACI

I’ve to ease off some of the intensive physiotherapy exercises owing to the increased frequency of knee buckling and locking. Sometimes I also felt some low dull pain. Went for MRI with injection of radio opaque dye in mid February. The Doctor attempted to inject about 10 ml of dye into the knee with some difficulty as I felt extreme pain in the knee. In the end she did not use up all the dye. I was scanned twice, once with dye and another after the injection of the dye, a procedure called arthrography.

Saw my orthopaedic Prof the following week, and reviewed the results of the MRI scan. The good news is that it showed a newly regenerated cartilage layer covering the femoral knee bone. However, some lighter-shaded spots can be seen, indicating the lack of a uniformly smooth layer normally found in healthy knee. There were also some sign of over-growth at the edges, but the doctor is not too worried about it. The Prof said this is still early stage of recovery, being only 8 months plus. The uneven cartilage surface probably caused the occasional locking and buckling of the knee. The scan fortunately, did not show any injury in the meniscus cartilage which one of my physio suspected I might have. The Prof prescribed another 3 months’ supply of glucosamine pills to be taken trice daily.

22nd Update – The Eighth Month

2008-01-30T22:27:00.000+08:00

35 weeks after Knee ACI

8 months have passed since my knee ACI operation. Although feeling stronger, I don’t feel that I’m making much progress. I’m still using the walking stick to protect against accidental falls, as I’m still experiencing several episodes of knee buckling, in particular, going down stairs and walking down slope. Up staircase and up slope are ok. On several nights, I was awakened when my right leg was momentary locked up and I couldn’t straighten it without pain. It would disappear after some flexing of the knee. This is a bit worrying. Hope the scheduled MRI scan next month would reveal the cause of the problem, if any.

During my last fortnightly physiotherapy session, I was asked to stand on one leg and attempt a single leg half squad, but couldn’t do it with the right leg, as the pain was unbearable. My physio said I still have some way to go. He put me on a new leg extension machine to strengthen the front thigh muscles. After the Lunar New Year next month, I would be seeing the physio again before the MRI scan. The Prof (Orthopaedic) will then review my progress after the results are in. I don’t think I’m ready for any jogging sessions as yet, sigh!

21st Update – The Seventh Month

2007-12-31T16:51:00.000+08:00

31 weeks after Knee ACI

It’s now 7 months since my operation. My leg seemed stronger and I stopped using the knee brace even when I'm sleeping. The interval for physiotherapy session is now fortnightly instead of weekly. Didn’t go for any vacation trip this year, but my wife got vouchers for 2 nights' stay at hotels in Raffles City – it was a relaxing break. Whole family went for a movie at Marina Square – it wasn't that long a walk via City Link. Although tired, I thought my leg held up well, and I harboured the thought of weaning off the walking stick soon. However, 2 days later, on Christmas eve, I experienced muscular spasms/cramps 3 times on the right leg. It happened again on Boxing Day. As a precaution, I took out my knee brace and used it at night again :-(

Saw my physio last Saturday and he examined my knee. He thought it could be due to stress on the meniscus – he advised me to avoid any prolonged standing or walking. He also asked me to ease off exercises using weights and avoid any rigorous cycling for a while. He hooked me up on an ‘Endovac’ machine to massage the leg. This is an electrotherapy machine, using 4 large pulsating vacuum massage cups with embedded electrodes to stimulate the muscles. My knee felt much better after the session.

In my earlier update, my mother was hospitalised for several days for a mild heart attack and was subsequently discharged from NUH. She had a mild relapse one week later, but she seems all right now and resting at home. The episodes of illnesses with hospitalization have weakened her considerably and she nowadays spends much of her time resting in bed and on a sofa, although she can move around unaided.

20th Update – The Sixth Month

2007-11-29T23:46:00.000+08:00

26th week after Knee ACI

Tomorrow marked the sixth month since my knee operation. I can walk quite steadily; even climbing a few flights of stair is now manageable, although I still use a walking stick for balance. There is no point taking any risk to strain the knee, now that I’ve come so far. I saw my Orthopaedic doctor last week – he was happy with my progress. He asked me to persevere with the weekly physiotherapy sessions for another month or two, if I can afford the time, thereafter, fortnightly. He made appointment for me to undergo another MRI in early Feb next year to check on the progress of the knee cartilage healing. If everything goes well, perhaps I can start my first jogging session after another 3 or 4 months. He gave me another 3 months’ supply of glucosamine to take. At the physiotherapy session, I can now stay almost 30 sec on the balance board. I’ve also started on a new machine – the hip-thigh abductor to strengthen the upper thigh and hip muscles.

My mother returned home after staying 5 days at SGH as the blood circulation on her left foot had improved. However, on yesterday afternoon, she suddenly felt shortness in breath with rapid heart beats. She was rushed to NUH A&E Dept. Doctor said her ECG was abnormal and suspected that she may have a heart-attack, a silent form of heart attack, as she did not feel any chest pain or discomfort. She would have to be warded in the Intensive Coronary Care Unit for 3 to 5 days. Just visited her in the evening, she appeared better after doctor gave her several injections into her stomach. For those who want to know more about heart attack, here are some links:

http://www.nhlbi.nih.gov/health/dci/Diseases/HeartAttack/HeartAttack_WhatIs.html

http://www.nhlbi.nih.gov/actintime/index.htm

http://www.webmd.com/heart-disease/heart-disease-heart-attacks

http://www.mayoclinic.com/health/heart-attack/DS00094

http://www.nlm.nih.gov/medlineplus/heartattack.html

http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=187

http://www.arrhythmia.com.sg/article01.htm

19th Update – Learning to Balance

2007-11-14T23:30:00.000+08:00

24th week after Knee ACI

Continued with my weekly physiotherapy at NUH Rehab Centre. This coming Saturday’s session would be my 20th. I’ve made fairly good progress so far. I can walk quite steadily, but to prevent fall on uneven ground and steps, I still need a walking stick. I’ve continued to make steady progress in my exercise routine and have reached level 8 on most of the machines, such as cycling, leg press & leg curl. I’ve also reached 400 strokes on the rowing machine. The physio also introduced a balance board and asked me to stand on it for as long as possible without tipping the board. I’ve seen others do it without much problem, but I could hardly last 10 sec before loosing my balance. To balance, you need to get all the leg muscles working together. Surprisingly, it was quite tiring to do this.

My mother returned home from St Lukes Hospital for a week but was re-admitted to hospital for blood circulation blockage in her left foot. She was ambulating around her room on Sunday night when she suddenly felt giddy and lost feeling in her leg. I checked and found her blood pressure high and her left foot turned bluish. We immediately rushed her to Singapore General Hospital (SGH) and she was admitted to the ward. Doctor gave her blood thinning injections into her stomach and her condition improved. She has been seeing a specialist at SGH for her leg problem and the doctor has previously given us a letter to watch out for this symptom. So, I’ve resumed ‘running’ around, visiting hospitals again, sigh!

18th Update – The Fifth Month

2007-10-31T23:31:00.000+08:00

22nd week after Knee ACI

Yesterday was the fifth month since my knee ACI operation. I’ve made steady but significant progress. You can tell that when I sometimes ‘lost’ my walking stick, leaving it somewhere and absentmindedly walked away without it. I only realized something is missing when I lost my balance or needed support. At the weekly physiotherapy session, I’ve increased all my exercise loadings to level 7 at most gym machines, such as on leg press & ankle flexing, leg curl and magnetic cycle. I’ve also been using the rowing machine, which moves both the legs and arms, increasing from 200 strokes initially, to 330 strokes in 10 minutes, recently. The physio said that I might be able to go for light jogging on the treadmill from the ninth month onward, if I continued to progress at this rate. This is good news, meaning that the implanted cultured cells are transforming well into new cartilage. From now on, I will probably update this blog fortnightly instead of weekly, unless there is significant change to my progress, or I feel like expressing my thoughts on other matters.

I saw my eye doctor last week and he said my eye is almost fully recovered. He advised me to use up the remaining eye drops and would see me again in 3 months’ time. I’ve also resumed tending my backyard garden, something that I couldn’t do for the past six months, since my first arthroscopy operation in April. As I still couldn’t squad or climb, I only do some light gardening work. Many of the plants had wilted away, including 2 of my favourite papaya trees, owing to the lack of attention and care. Fortunately, one younger one still survives, and my mango tree is still fruiting well.

My mother’s spinal problem has also improved – she can now walked short distances without pain, provided she put on the abdominal brace. She would be able to go home from hospital this coming weekend, if she continues the good progress of recovery.

17th Update – Back to the Norm

2007-10-24T23:09:00.000+08:00

The 21st Week after Knee ACI

My leg is getting stronger and I can walk short distances without the walking aid. However, stairs and uneven ground still pose a challenge – I still need the walking stick for balance and support, and to prevent the knee from buckling. I still go to NUH Rehab Centre weekly for my physiotherapy session. As my eye is recovering well, I have gone back to the norm in my physiotherapy routine and started to step up my exercise intensity and duration. For instance, I’ve raised the cycling machine resistance to level 7 out of a max of 9, and where time permit, cycled twice a day, at my workplace and at home. The knee flexion has also improved to about 140°, but I can still feel some stiffness in the knee.

My mother’s condition has also improved and she can sit up unassisted in bed, although she still feels the pain in the back. The nurse would wheel her to physiotherapy sessions everyday at the hospital. She would probably have to stay at the hospital for another week or so. We celebrated her 80th birthday yesterday at the hospital with a birthday cake. My brother set off the fire alarm when he lighted up the candles. Fortunately, he also bought a big cake for the staff and nurses, so they weren’t that upset. I’ve been ‘running’ around to visit her everyday at St Lukes Hospital, going for my physiotherapy session weekly at NUH and also to see my eye doctor at the Eye Institute at Tan Tock Seng Hospital. All these moving around should be good for the leg, as long as I take my time and avoid overloading the knee.

16th Update – Taking the Train

2007-10-17T23:54:00.000+08:00

20th week after Knee ACI

Have been using and handling the walking stick fairly well. As I had to attend a workshop in town during the past two days, I decided to take the MRT train, but was unsure how I would cope travelling in a crowded train. However, it turned out well. Made 4 trips over the two days and on every occasion someone would give up their seat for me. This really reaffirmed my faith in the kindness of Singaporean. One on them was seating with his young son – he asked his son to sit on his lap and signaled me to take the vacated seat.

My eye is also recovering well and the redness in the eye has subsided. I’m still required to instill the eye drops, but I need to do this only 4 times a day now, as instructed by the eye doctor.

My mother is still in hospital. Doctor said her conditions have improved, although she still felt sharp pains on her spine whenever she shifted her position in bed. As there would not be further treatment other than complete rest in bed, we were asked to transfer her to a community hospital, so that she can continue her daily physiotherapy session and cared for by nurses. She is now recuperating in St Luke Hospital in Bukit Batok.

15th Update – A Walking Stick

2007-10-10T12:01:00.000+08:00

19th week after Knee ACI. Resumed Physiotherapy

I resumed my physiotherapy session at NUH as my right eye has healed quite well after the eye operation. However, I only tried some light muscle strengthening exercises, with reduced load. I felt some stiffness in the knee after the 2 weeks break from physiotherapy. In the meantime, I’ve totally weaned off crutches and bought a walking stick for $19. It has adjustable height on the bronze anodized aluminium stick, with cushioned grip and a wrist strap, a thoughtful design.

I returned to work this week and even attended a 1-day workshop in a hotel. Moving around was manageable with the walking stick. But try taking a buffet lunch with a walking aid – it was awkward and not fun. I eventually had to limp around for food without it. The eye vision is very bright and clear after the lens replacement, but I still have difficulty reading as I’m using temporary glasses meant for distance, especially for safe driving.

I’ve been visiting hospitals quite often during the last couple of months and now even more so, as my mother was hospitalised since Monday for severe back pain. She suffers from osteoporosis and has past histories of fractures in the spine. Hope she recovers soon.

14th Update – Taking a Break

2007-10-02T18:59:00.000+08:00

2nd Oct 07, Tue. The 18th week. 4 months after Knee ACI

It’s now 4 months after the knee ACI operation - not much update for this week as I’m taking a break from all physiotherapy exercises, after the eye operation. I’m also keeping away from computers, read less and watched TV in moderation with sunglasses, but I’m listening more to radio and music.

I fitted a temporary lens on the right side of my specs at a neighbourhood spectacles shop for $20 and went for my 2nd post-op eye checkup last Friday. The doctor was quite happy with the results of the eye tests. He said the operated eye looked good and the redness in the eye has also gone down significantly. I would have to instill 2 types of eye drops, anti-microbial and antibiotic, every 3 hourly and sleep with a plastic cartella eye shield for 4 weeks.

13th Update – The Eye Operation

2007-09-25T18:00:00.000+08:00

19th Sep, Wed – 25 Sep 07, Tue. The 17th week of Knee ACI.

Went for my cataract operation yesterday and saw the eye doctor today to check on the operated eye – the operation was smooth and I can already see fairly well. Although a relatively common operation nowadays, the greatest risk is still getting an infection. I have to strictly avoid any rubbing or get into contact with dust, dirt, smoke, fumes, and even water. Doctor said that owing to my past history, there is always the danger of retina detachment in my case and I should immediately go to A & E should there be any symptoms. I was granted 2 weeks medical leaves, to be extended, if needed. I know I shouldn’t strain my eye looking at computer screen and posting this blog – actually most of my draft had already been composed on Sunday and posted in the blog but not published. I only need to log in to edit a little and click “Publish”. Blogs are such powerful Internet media and relatively easy to use as you do not really need to know any programming or web building skills – everyone should try it, don't need any software and it’s free.

My left eye was fitted with an artificial lens in 1999 after a cataract operation. At that time because my right eye had a myopia of about 800°, the doctor decided then to fit a 500° lens on my left eye so that the difference between the eyes would not be that great. However, the myopia on the right eye continued to go up until the present 1,100°. The large difference often causes strain to the eyes, as the image sizes are different. This cataract operation on my right eye probably came at the right time – the doctor has now fitted a lens equivalent to 300° on the right eye. He said he could have balanced the degrees on both eyes, but a 200° difference is considered not a problem. The lower degree will enable me to read better and allow prescription of thinner and lighter spectacles. The problem now is that my present spectacles cannot be use. I had to dismantle the right lens as looking through it causes giddiness. Normally, it would be advisable to wait at least 6 weeks for the vision to stabilise before fitting a new permanent specs. In the meantime, I’ll probably get a set of temporary glasses.

Last Saturday, at NUH Ortho Gym, I informed the physio that I would skip the next physiotherapy session owing to my eye operation. He said I could still continue with light flexing of the limbs at home to prevent the muscles from stiffening. He observed that my leg has grown stronger and could support almost 100% of the body weight. I tried and was able to limp around the gym without the crutch. He suggested that I should also try moving around carefully without crutch at home, except when climbing stairs and walking outdoor. Perhaps a walking stick will help.

12th Update – From Knee to Eye

2007-09-18T08:01:00.000+08:00

12th Sep, Wed – 18 Sep 07, Tue. D106 – D112. The 16th week.

Saw my Orthopaedic doctor/prof at NUH last Thursday. He was satisfied with the healing of my knee. Since I could now stand steadily with no pain and even limp several steps without crutch, it indicated that the implanted new cartilage cells are growing well. However, he reiterated that I should continue with the use of the crutch for the next couple of weeks in order not to exert any undue pressure on the newly grown cartilage. He advised that I should continue with the weekly physiotherapy session, but tone down the exercise intensity, if it causes the knee to ache. He prescribed lots of glucosamine to be taken thrice daily (gave me 10 weeks supply)! The load bearing on my right leg has now reached almost 95%. The physio spent some time with me on the parallel bars handrail, trying to correct my gait, which has a tendency to lean towards the left. The unassisted knee flexion has also improved and I can now also do a partial squat (left knee fully bent and right knee half bent).

Last Thursday afternoon, I also went for an appointment with my eye consultant doctor at The Eye Institute in TTSH. My right eye was diagnosed with cataract about 3 year's ago. By the end of last year, the cataract had "ripen" and the eye doctor advised me to go for the cataract operation early this year, but I decided to delay it to the middle of the year as I was expecting the knee operation then. As the knee operation was subsequently carried out on 30 May 07 - the eye operation had to be postponed a second time. The eye doctor suggested that I carry out the delayed cataract operation as soon as possible, now that my knee operation was over and I’m recovering well. The date of operation will be on next week, 24 Sep 07, although I would have preferred a later date, perhaps in Oct when I’m physically and mentally more ready. However, the doc is not available that month. The nurses were very quick and efficient, and made me complete all the necessary pre-admission checks and assessment late into the evening, so that I do not have to make another separate trip to do this. Nowadays, cataract operation is quite advanced, requiring only a tiny slit on the cornea in order to replace the lens, and vision can be restored the following day. Both The Eye Institute in TTSH and The Eye Centre in SGH have the latest equipment for advance cataract operations. It can be performed during a day surgery and you can go home within half a day.

Someone suggested that I should perhaps start another blog on my experience with eye operations, since I’ve had several ops over the past 9 years. But I don’t intend to do so, as Singapore has very established eye treatment centres and information on eye treatment is readily available. For the record, my left eye had retina detachment in 1998, some 9 years ago. It started with internal bleeding and soon the black spot was like an eclipse enveloping almost a third of the vision. The operation was successful and my vision was fully restored. The following year, I had a cataract operation and two other operations to remove the out-of-position scleral buckle (plastic backing to prevent further retina detachment). In 2001, the eye doctor used the cryopexy procedure, using metal probe frozen by liquid gases to “burn” and scar a retinal hole, which had developed in the retina of the left eye. The healing process would seal the retinal hole. In 2002, cryopexy was applied again, this time to my right eye as a preventive measure against future problem developing. In 2004, cataract was found developing on this right eye, the myopia of which, has since gone up to almost 1,100°. I’ll post an update after my cataract operation next week.

11th Update – Return to Work

2007-09-11T08:00:00.000+08:00

5th Sep, Wed – 11 Sep 07, Tue. D99 – D105. The 15th week.

Returned to work yesterday. Driving to work was ok, although it was a long journey and the traffic was quite heavy. Climbing the 3 flights of stairs to my office, however, required considerable efforts. My thoughtful colleagues saw me driving in and helped me with my ‘heavy’ laptop bag. It’s great to be back at work! Since I’ve been regularly accessing my office emails and the organisation’s intranet from home via VPN, I’m quite up to date with the happenings in my workplace, so there aren’t much backlog of work to clear or delayed decisions to make. My colleagues did a great job, covering my duties and keeping the Plant running well, freeing me from worries and allowing me to recover with peace of mind. I must really thank all of them. Spent some times uploading updated archived files and renewing expired passwords. We have a small gym here, at the same floor level, so there is no problem continuing with my daily exercise and workouts during lunchtime.

At the 12th physiotherapy session at NUH last Saturday, I tried out on another 2 gym equipment. The first workout was on a leg curl machine, where I have to bend my lower leg downwards against a 5 kg load to strengthen the hamstring muscles. The next workout was on the horizontal leg press where I place my right foot against a plate and flex my ankle against a load, to tone my calf muscles. My muscles still ache with the effect of that day’s exertion. The unassisted knee flexion has, in the meantime, improved to 130°. The forced bending of the knee has also improved to some 138°. The max load bearing that the right leg could bear has reached 90%, which means I could now limp several steps for a short distance, without the crutch. The physio, however, advised me to continue to use one crutch so as not to place undue stress on the right knee and also for climbing stairs.

10th Update – Stepping Up

2007-09-04T08:00:00.000+08:00

29 Aug, Wed – 4 Sep 07, Tue. D92 – D98. The 14th week.

I’m stepping up my exercise routines to strengthen the leg muscles in preparation for my return to work next week. I’ve weaned off one crutch in order to put more load on my right leg. I could walk with one crutch with a limp on flat ground, except for the occasional in-balance, when I nearly tripped.

At the 11th physiotherapy session at NUH, I increased the leg press load to 6 kg and also tried using one leg to press 3 kg of load. At the parallel bar handrail, I tried stepping on and over a rubber cushion using the right leg – this momentarily put the full load bearing on the right leg. It was difficult at first, but once I gained the confidence, I could quickly step on and over it. I told the physio that I would have to negotiate a few flights of stair when I return to work. Climbing stair still requires fairly strenuous efforts. He demonstrated some techniques to climb stair without the crutch. I tried, but it wasn’t easy, as my leg was still not strong enough yet. The unassisted knee flexion has improved to 125°. The forced bending of the knee has also improved to 135°. The max load bearing that the right leg could bear has progressed to 80 - 85%.

Except during sleeping at night, I’ve also weaned off the use of the knee brace. However, rubbing cream and balm on my aching legs finally brought out the rashes. All along, I’ve maintained very good hygiene of the leg to avoid the rashes. It’s really ironical that, just as I was starting to wean off the brace, the rashes came. Maybe I was allergic to the capsaicin in one of the more expensive glucosamine creams. The cheaper one with chondroitin sulphate was OK.

I’ve also started to drive on a few occasions, since I’m now able to exert enough force to apply the emergency brakes. However, I always have someone accompanying me, just in case there are problems that I would not be able to handle, for example, tyre punctures. I’ve just received a letter and membership card from AA Singapore, informing me that I’m now a “life member”, meaning that I don’t need to pay annual subscription any more. This is for those who have been member for 30 years, what a long time!

9th Update – Pressing On.

2007-08-28T17:42:00.000+08:00

22 Aug, Wed – 28 Aug 07, Tue. D85 – D91. The 13th week.

At the 10th physiotherapy session at NUH, I worked on the exercise routine for almost 2 hrs, and with increased intensity. The Leg Press load was increased from 4 kg to 5 kg. I also ‘walked’ for almost 30 mins on the platform with parallel handrail, although limping along with an unsteady gait. Physio said I should press on to increase the partial load bearing of the right leg and where possible, try to wean off one crutch, so that more load would be taken by the right leg. I’ve also measured the max load bearing that the right leg could bear – it has now progressed to 75%. The physio asked me to be patient, in order not to injure the knee during the physiotherapy and exercise session. I would be able to work out on other gym machines, once I could achieve almost full load bearing on my right leg.

Meanwhile, I’ve raised the resistance on the cycle machine to Level 6, but not increasing the cycling time and distance (as advised by the physio). The unassisted knee flexion improved from 117° to 120° this week. The forced bending of the knee has also improved to 135°. My good (left) knee can easily bend to 147° unassisted - so, I still have a long way to work on my range of motion on the right knee.

Both my knees do hurt somewhat from all the exercises and the limping around, but I’m careful to keep all the workouts up to the pain limit, and numbing the aches with the help of glucosamine capsaicin cream and muscular analgesic balm. Although my appetite has been good, I’m still able to maintain my post-ops weight, which is some 3.5 kg lower than before the operation. This lower weight is good for the knee as less stress is placed on the legs.

8th Update – The 12th Week, Good Progress.

2007-08-21T08:30:00.000+08:00

13 Aug 07, Mon – 21 Aug, Tue. D76 – D84. The 12th week.

Time flies - today is already the 12th week since I underwent the ACI operation. I’ve also started to partially wean off the knee brace, which I’ve been wearing almost 24 hr a day. I now wear it only when I’m sleeping and when I need strenuous effort to move around, such as, climbing stair and going to hospital for appointment. This is to prevent the knee from buckling. The wound is also healing well, although with some pain from time to time, probably caused by the various daily exercises and partial load bearing. The “pins and needles” feeling (paraesthesia) on my foot has also gradually faded away. There is still some swelling on the knee, but you can make out the profile of the kneecap now.

At the 9th Physiotherapy session, I tried walking with one crutch. I initially thought I needed the right crutch to support the right knee, but I was wrong. Using the left crutch to move in synchronization with the right leg actually helped to support 50% of the walking load. I also tested how much partial load my right leg can bear currently, by setting up 2 weighing scales and gradually shifting the load to the right leg – it had improved from 59% two weeks ago to 70% currently. To be able to walk with some limping, the right leg must bear at least 90% of the body weight - so I still have to work on it. My unassisted knee flexion had also improved from last week’s 105° to 117° now. When forced, the knee can now bend about 130°. The physio said I’ve made good progress.

Right leg can now bear 70% partial load

I have stepped up my cycling workout to reach 15 km (340 calories) daily and also raised the resistance to Level 5. However, my physio advised against over stressing the knee on any one particular exercise. Too much cycling can actually put localized stress on the knee. It would be preferable to work on a wide variety of muscle exercises progressively, so that the strengthened muscles can together support the knee. Another exercise introduced was to lean against a large inflated ball at the back against a vertical wall, while I rolled up and down, bending the knee slightly, a variation of the back wall-slide introduced in the previous week. To date, I’m now doing some 22 different types of exercises.

My car battery went totally dead, even though my brother has helped to start the engine once a week to charge the battery. Anyway, it was time for a replacement as my present battery lasted about 3 years. AA Singapore responded within 1 hr, even though I told them I’m not in any hurry to fix it. A new “Zero Maintenance Battery” was fitted, costing $94.

7th Update – Learning to Walk

2007-08-12T23:35:00.000+08:00

3 Aug 07 Fri – 12 Aug Sun. D66 – D75. The 10th week.

Went to the 8th physiotherapy session at NUH yesterday. The physio said I could start learning to walk. However, I walked with great difficulty and efforts using the four-leg walker. To strengthen the walking muscles, he made me lean backward against a flat wall and slide slightly up and down, loading and bending the knees in the process. Later, on a platform with parallel bar handrail, I made tentative attempts at walking without crutches, between the parallel railings. I was happy that I could walk, albeit supported by the two railings and made several rounds, until stopped by the physio, as he did not want me to overwork the knee at this stage. The physio wanted me to continue with all the isometric exercises, as well as my twice-a-day cycling sessions at home. I’m now pedaling a total of some 50 mins a day at level 4, equivalent to cycling 13 km with 300 calories expended. My flexion angle however, has not improved. Unassisted it was only 105°, but could reach 125° when forced. The physio, however, was not worried, as he said it would improve with time, since my knee still had swelling, which restricted the bending in any case.

During last week’s 7th PT session, the physio introduced another 3 exercises. The first was the inclined cycle, pedaling horizontally instead of the normal cycle, which is vertical. This required more efforts. Lying on my right, I also did the inward leg raising with weights. With this, I’m now doing leg raising in all four directions. To strengthen my knee stability, an elastic band was looped over the knee while standing and by moving away from the anchoring point, increased the resistance. I also increased the leg press load to 4 kg.

With the new added routines, there are now some 20 exercises which I’m doing, summarized into the following categories – 7 in the lying position; 3 in the sitting position; 3 standing; 4 active motion / walking exercises and 3 on exercise machines.

6th Update – Active Motion

2007-08-02T16:32:00.000+08:00

27Jul, Thu – 2 Aug 07, Thu. D59 – D65. The 9th week.

I finally weaned off the Continuous Passive Motion (CPM) machine as I have reached the machine’s max limit of 120°. I’ve rented the machine for 7 weeks or 49 days to be exact, costing me some $818 (inclusive of delivery cost and GST). Reflecting back, my daily routine for the past 7 weeks had been quite regimented, faithfully performing the trice-a-day CPM sessions. From now on, I’ll be doing more active motion of the leg.

At the 6th physiotherapy session, the physio started on a series of active motion exercises. He introduced me to the leg press machine, pushing a 3 kg starting weight. He asked me to stand and tiptoe repeatedly on both legs, supported by the hands, effectively putting almost 50% load on my right leg. Another exercise added to my daily routine was to stretch the leg forward, backward and sideward while standing on my left leg. Ironically, as the right leg is slowly taking over the partial weight of the body, the left knee has taken its toll and started to ache. During one of the stretching session at home yesterday, my right leg suddenly cramped up painfully, thus serving me a warning, that I should not push the rehabilitation process too fast and too hard.

I’ve also been increasing the resistance level of the cycle machine to Level 3 (out of a max of 9 levels) and cycling twice a day. To keep track of my daily exercise output, I would be totaling up the distance and calories equivalent of the workout, starting a few days ago at Level 1, 3 km & 80 calories, and gradually progressed to 7 km & 160 cal yesterday. Cycling also helps to maintain the flexion of my knee. I fixed up a device to measure the progress of increasing the flexion angle, which is currently at about 125°.

Measuring the flexion angle after exercising with weights

Saw the Prof this morning - he was satisfied with my progress and asked me to persevere with the physiotherapy treatment, both at NUH and at home. He noted my determination and said most physiotherapists would be happy to have a patient like me. He asked me to gradually learn to walk with the aid of the crutches and avoid over straining either of the legs. He extended my medical leaves to 9 Sep 07. He said to try to return to work after that and let him know if I encounter any problem during the next appointment on 13 Sep 07.

5th Update – The Breakthrough

2007-07-26T21:01:00.000+08:00

19Jul – 26 Jul 07, Thu – Thu, D51 – D58. The 8th week.

Continued to gradually increase the range of motion (ROM) on the CPM machine and was able to breakthrough the previous pain barrier at 85° - could now reach 110° and more. At this angle, my body is quite contorted and uncomfortable, as can be seen in the photo.

No Pain, No Gain

At the 5th physiotherapy session in NUH, I increased the pedaling angle to 270° on the cycle machine, but still couldn’t pedal it a full round. The physio tried to put me onto another knee exercising machine, but my knee flexion angle was still not high enough to get onto the machine. He asked me to work on increasing the knee flexion on my home cycle machine and to continue to increase the partial load bearing on my right leg. He said I have to work out on the other machines in order to make further progress.

Tried several days at home to push the pedal on the cycle machine and finally, I managed to breakthrough the second pain barrier by forcing the pedal full round of 360°. With this breakthrough, I now have another means to improve the flexion of the knee, as well as to get some workout on the cycle machine. There is some soreness and pain, but as the saying goes - no pain, no gain. My daily exercise routine now includes the followings:

1) Straight leg raising with 2 kg ankle weight
2) Side leg raising with 2 kg ankle weight
3) Back leg raising with 2 kg ankle weight in prone position
4) Back knee flexing with 2 kg ankle weight in prone position
5) Leg raising sitting on a chair, flexing the knee
6) Ankle - calf muscle flexing using an elastic band
7) Horizontal towel-assisted heel slide and knee bending
8) Crunches and isometrics
9) Morning sit-ups, 205 to 505 times
10) Upper limbs workout using 2 kg dumbbell
11) Cycling slowly at zero resistance, 20 to 30 mins
12) Ambulating with crutches with partial load bearing.

4th Update – Putting My Foot down

2007-07-18T18:51:00.000+08:00

13 Jul – 18 Jul 07, Fri – Wed, D45 – D50. The 7th week.

Have been increasing the flexion range of motion (ROM) gradually by 5° a day, from 30° to 60° on the CPM machine. Felt a little soreness in the knee, but otherwise, it was not really painful. Have also started to put my operated foot down on the floor. Got pins and needles feeling whenever you put any pressure on the foot. The medical term for this symptom is called paraesthesia. This is probably caused by the long period of non-weight bearing and the nerves have "fallen asleep’’. I read that this is quite normal and it will gradually fade away after putting repeated pressure on the foot. During my daily session of sunshine, I would deliberately put the foot down on the hot pavement. The burning sensation would overwhelm this pins and needles discomfort.

Went for my 4th physiotherapy session yesterday. It was a long session, lasting almost 2 hrs. Have progressed to doing a series of leg exercises with ankle weight. The physio noted the good progress I’ve had with the ROM on the CPM machine, but said he wanted to test the limit of the flexion. He put my leg on the Gym’s CPM machine and started raising the flexion angle beyond 60° – stopping only when the pain came on at 85°. Next he set me on a cycling machine. I tried but could only pedalled about 180°. Putting pressure on the pedal from the good left leg, my stiffened right knee joint was forced to flex as far as possible within the pain limit. This was alternately repeated in the reversed direction. This is what I call self-inflicted torture :-( There are many machines in the Ortho Gym which I saw other patients using. I’ll probably be using these machines in due course – there’ll be many more painful episodes to overcome. To keep up with the momentum and the ‘good’ progress, I’ll be going to the Ortho Gym again this coming Sat…

On a cycling machine - forcing the right knee to flex

Every morning, upon waking, in addition to the leg exercises, I would be doing the crunches & sit-ups – these exercises help to give the body some workouts. I would move both my arms, as well as slide out the healthy leg during the sit-ups – this is also like swimming breaststroke with one leg or simulating the rowing action. The trick is to move all the limbs and upper body, and yet not strain the operated leg. Did 610 sit-ups on Sunday - why 610? I originally intended to do only 305, but since I felt good and energetic that morning, I thought I could add another 100 or 200, but ended up doing another 305 sit-ups instead :-)

3rd Update – The 6th Week, Turning Point?

2007-07-12T23:40:00.000+08:00

5 Jul – 12 Jul 07, Thu – Thu, D37 – D44. The 6th week.

The 6th week – this is the turning point, when the semi-liquid cells start to consolidate into semi-solid form. Someone mentioned that this cartilage cell implantation is like filling a pothole with normal cement. You use a formwork to keep the cement in place; it will achieve initial setting over a day or so and achieving the final full strength over 28 days. The time frame for cell remodeling takes much longer, 6 weeks for “initial setting” and 2 to 3 years for recovery to full strength. In my case, owing to the severity of the cartilage damage and my age, my time frame may be more likely to be on the slow setting mode.

Saw the Prof this morning. He said he intended the rehab programme to be slow during the first 6 weeks, capping the range of motion (ROM) to 30° for my case. As the wound healing appeared to be good, he said I could now commence increasing the ROM from 30° to 90° over the next couple of weeks and intensify my workouts in the Ortho Gym. He extended my hospitalization leave until 10 Aug 07.

During my physiotherapy session yesterday – the physio mentioned that my leg muscles have shrank by at least 1 cm owing to atrophy from disuse. He said he would want to start the active motion and weight training as soon as possible, in addition to isometric exercises. I heard that this is going to be tough and painful. At home, I’ve also been exercising conscientiously – was able to reach 505 sit-ups. My family felt that I shouldn’t strain my back – but not to worry. My sit-ups are not full sit-ups, more like ¾ relaxed form of sit-ups - something like swimming butterfly stroke, dry swimming on the bed. At over 200 sit-ups, I would start sweating and my heartbeat could reach over 110 per minute, almost like getting an aerobic workout. To reach the lower aerobic range for a normal person, the minimum heart rate can be estimated from the following formula: (220 – your age) x (0.65), and with deep breathing.

2nd Update – The 5th week of Rehab.

2007-07-04T16:22:00.000+08:00

30 Jun – 4 Jul 07, Sat – Wed, D32 – D36. The 5th week.

Yesterday was the 5th week since my operation. My knee was progressing well, though a bit slow. Last weekend, with the help of a friend, I was able to travel and attend a classmate’s son wedding dinner in a hotel, bringing along my tripod footrest. Getting out of the house and meeting some old friends really uplifted my spirit after having been cooped up at home for so long. Many of them were not aware of my recent operation and said they would definitely read this blog. After enquiring about each other’s well being, it dawned on me that my ’ordeal’ seemed pale in comparison to what two of them have gone through. One suffered from compressed nerves in the spine and was painfully bedridden for one whole month in hospital, injected with painkilling morphine until he got high and doctor has to change drug to prevent him from getting an addiction. He has since recovered. Another was in and out of hospital last year and had already undergone 6 operations on his fluid-swollen leg owing to chronic diabetes. Despite all his problems, his PhD study (and thesis) is almost completed – we really admire his persevering efforts and spirit. He has lost a lot of weight but is still cheerful and independent, moving around steadily with the aid of a walking stick.

I’m getting stronger each day, could raise my leg without pain. Continued with my daily exercises conscientiously. I’ve been doing numerous leg raising exercises and have also progressed from 155, 205 and now 305 sit-ups, this morning. Went for my second physiotherapy session in NUH yesterday afternoon. The physio measured the angle of my bent knee without the brace, for range of motion improvement – but it still read only 30°, meaning it hasn’t improved much yet. Continued with the use of EMS - electronic (electrical) muscle stimulator treatment on my thigh. The EMS sent weak electrical pulses via 4 gel electrode pads causing muscular contractions. Together with my own tightening of the quadriceps, it would exercise the thigh muscles. I was also able to flex the ankle tensioned with elastic band 100 times, did 50 sideway leg raising and 25 backward leg raising in prone position. Physio observed that my thigh quadriceps muscles still looked ‘wasted’ – atrophied from disuse. He wanted me to go to the Ortho Gym weekly to rebuild the muscles. I read that such muscle atrophy is similar to that experienced by astronauts after their prolonged stints in space at zero gravity conditions.

Gel Electrodes Pads of the EMS

Found the following articles useful:

References:

KNEEGuru – Principles of Knee Rehab
http://www.kneeguru.co.uk/html/gym/principles/objectives.html

UpToDate, USA - Physical therapy for knee problems
http://patients.uptodate.com/topic.asp?file=bone_joi/7872

Centre for Sports and Shoulder and Elbow Surgery – Osteoarthritis Rehabilitation
http://www.sportsshoulderelbow.com.sg/faq_5.php

Alexandra Hospital, Singapore - Electrical Muscle Stimulation (EMS)
http://www.alexhosp.com.sg/disease_info_details.asp?id=227

1st Update – Hygiene & Exercises

2007-06-29T16:00:00.000+08:00

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

2007-06-22T17:00:00.000+08:00

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.

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

2007-06-22T14:47:00.000+08:00

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

2007-06-22T14:44:00.000+08:00

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

2007-06-22T14:33:00.000+08:00

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

2007-06-22T14:22:00.000+08:00

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

2007-06-22T14:17:00.000+08:00

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

2007-06-22T13:59:00.000+08:00

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

2007-06-22T13:47:00.000+08:00

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.

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

2007-06-22T13:38:00.000+08:00

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

2007-06-22T13:30:00.001+08:00

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

2007-06-22T13:16:00.001+08:00

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

2007-06-22T10:22:00.000+08:00

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

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

2007-06-20T22:10:00.000+08:00

Click any spot on the diagram to enlarge the chart.

Annex B - The Next Few Months

2007-06-20T22:03:00.000+08:00

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.

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&amp;amp;amp;amp;amp;amp;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 ?

2007-06-19T19:54:00.001+08:00

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/