TKR Physio Exercises - beauty or the beast!

Physio, physio, physio - after your TKR you will seem to spend practically every waking minute (and when you have restless legs, even the sleeping minutes) doing physiotherapy - working your knees and legs constantly. 

Initially you will have a therapist who ladens you with hateful exercises, then - like me - you may progress to a biokineticist and eventually you'll be doing your own thing.

I have a love-hate relationship with physiotherapists - I appreciate that the work they are doing will help but holy maloney does it hurt!!! And why must some of them be so dour! Smile - laugh - it eases the stress and discomfort ... truly - as a patient I can attest to that!

In the hospital, physio consisted of bending the knees, flapping the feet, trying to get myself out of bed and walking.  Step-down clinic physio ran me through the bendy knee, flappy feet, etc. routine in bed then I walked and climbed stairs and learned to get up from chairs and toilets and out of cars.

Home physio visits were not that much different from the hospital visits initially but we started doing standing exercises as well.

Simple exercises you can start doing prior to going into the surgery to build muscle memory (very important).  You will also do these post surgery (always check with your doctor and/or physio before doing these exercises - and remember to engage your core muscles all the time - tuck in your belly button as far as you can):

• Lie flat on your back on the bed - flap your feet (good for circulation);
• Lie flat on your back on the bed - alternate bending your knees to your chest;
• Lie flat on your back on the bed - put a ball / rolled towel under your knee and straighten your leg in the air;
• Lie flat on your back on the bed - tuck your feet up behind your buttocks and then force yourself up into the air (bridge);
• Lie flat on your back on the bed - alternately raise your straight leg;
• Lie flat on your back on the bed - alternately raise your straight leg then sway leg side to side in the air;
• Lie flat on your back on the bed - put a rolled towel under your ankle and push your knee back down into the bed;
• Lie flat on your stomach on the bed - tuck your toes in and push your knees back as straight as possible (great calf stretch);
• Lie flat on your stomach on the bed - bend your legs one by one.  This quickly became and still is one of my favourite exercises.  Post-op it may initially feel very wobbly and quite difficult to control, but this exercise seems to stretch the muscles over your knees.  After a day in the office sitting down most of the time, a few of these in the evening can feel quite blissful!

There are also standing exercises which you'll start doing week three'ish.

Absolutely the best was six weeks later when I could get into the pool.  I go to the rehab pool at Virgin Active gym, Tygervalley. The water is warm and it is bliss!!! Unfortunately now I have to go at 6.00 in the morning as the pool is full of kids till 8.00 / 8.30 pm at night doing swimming lessons! (I must be very old-fashioned - I reckon kids should be at home by 6.00 pm finalising schoolwork and getting ready for dinner and bed, especially the littlies I see at the pool in the evening.)

I love the pool - you will walk forward, back, sideways - nearly have a heart-attack when a week later the physio suggests you run, do lunges and star jumps ... it was years and years and years ago I did that.  There will be stationery and ambient exercises - just remember to engage the core muscles - and smile and laugh with everyone! 

You may also start cycling and using the eliptical trainer - eish! The "hate" part of my physio relationship!!

Important tips:  Try and do as much of the exercises as you can beforehand to strengthen your body and build muscle memory; Its really sore but keep on doing the exercises two or three times daily post op; Your legs may get sore especially in the beginning - but realise that you have hardly used many muscles in the past; engage your core muscles - will prevent back ache!!

Breath and smile, this too shall pass!!!

Home Sweet Home

I could not wait to get home but had some reservations:

(a)  the dreaded stairs;
(b)  I did not have a snatchy thingy to help me pick things up; and
(c)  I had not made a sling thingy to help me lift my legs from the bed to the ground.

The last two were recommended by the book - and I found I did not need them at all.

Stairs were fine - I took them slowly at my own pace and my housemate sorted out luggage. The stairs from the driveway to the house were fine as there was a railing.  The stairs from first to second level were deep and no rails.  I managed.

Two non-negotiable items if you can get them (luckily for me friends could assist with both):

1) Lifted toilet chair - I moved mine over the loo; and
2) Shower chair / stool - mine looks like a comfy garden chair - absolute, absolute bliss!

My greatest challenge was - and still is - to rise from a 90 degrees or lower angle. I was fortunate that my bed was high off the ground and both the loo and shower chairs were higher than 90 degrees.

The sofa was too low - solution: I added four thin garden chair cushions - and still sit on them.  To raise myself I pile cushions on the side to push off with my hands.  Our couch looks ridiculous. On H's side are a 2 to 3 cushions for back support.  On my side?  Chaos. 4 garden chair cushions, plus a host of cushions at the back for support and a whole lot on the side ... cushion carnival!

We have an old bar stool which is light and, even now, gets carried around to where needed. In the beginning it stayed in the kitchen, but I even carried it outside when hanging up washing.  Hildegard cooked the first week or so and then I took over (I usually cook and she does the dishes).

In the beginning I spent a fair amount of time in bed, sleeping or doing my exercises. I had two extra pillows to prop my legs as needed - eventually got rid of them towards the end of January.

Diego keeping me company (note extra two pillows in the background)

On the discomfort level I experienced the following:  Pain, especially like severe growing pains; restless legs (they seemed to have a life of their own - best to just take sleeping pills and let the mind rest while the legs go all jumpy); cramps and at times a concentrated stitch pain or two - so severe it hurt to move my leg for a day or two. I also found that I was constantly, often involuntarily really stretching my legs. Physio did not seem concerned so I just accepted that it was part of the healing process.  If possible, take pain medication about 30 minutes before a physio session - helps cope with the pain. I found I had to take extra paracetamol some time after the sessions just to cope.

This is not the time to get neurotic about using drugs.  Forget about being brave.  Its going to be really sore - use drugs and get really friendly with ice-packs.  We tried to make our own ice-packs using water and surgical alcohol - varying results, but always helpful (see link for instructions)!

The magic word is exercise - exercise, exercise, exercise.  It helped that I had a few visits from the physio ... next blog - we get moving, moving!

Step-down clinic and stairs at home

I must admit that my gardening session yesterday only extended to cutting lavendar flowers - which I plan to use to fill up my lavendar wreath.

Back to the TKR:

I was doing rather well - and the wounds were looking really good - see pic below. This photo was taken on 11 December, one week after the op, the first time the dressing was changed (is it not beautiful!!):

In fact I was doing so well that my physician and physio suggested I go to a step-down facility.  If you don't know, a step-down facility still looks like a hospital facility but the care is less intensive and you are encouraged to do more for yourself.  The centre I went to also caters for rehabilitation patients, especially Alheimers, cardiac and stroke patients and patients who have lost limbs. My knee guy on the other hand did not think it was the right place for me but he was eventually convinced. 

He was right though - as I said to him at our first consultation, if I had his mobile number I would have phoned him during the night to come rescue me!!!!

I hated most of the step-down experience but on the other hand, it motivated me to work really hard to get out of there as soon as possible.

I felt really emotional when I left the hospital - Ward E's staff at Panorama Hospital are absolutely amazing!!! I was thrilled to discover that Discovery Medical Aid had a discretionary Care Programme for rehab patients, which covers reasonable costs of the rehab process.  This is a major, major, major benefit.  They covered the step-down facility and out-of-hospital physio sessions - awesome!!!

Panorama Hospital arranged to take me through to the step-down facility. I won't mention their name - don't want to give them more publicity than needed, but if you want information, contact me!

Sadly, I hated most of my time at the step-down facility.  They do awesome work but I did have the following problems:

• I was placed in a room with three elderly ladies, two of whom had dementia. I hardly had any sleep the first night as one of the patients was a stroke patient who had come in during the afternoon.  They insisted she use an adult nappy as they had not assessed her yet.  They would not take her to the loo or give her a bedpan.  We are taught from small not to wet our pants - and then, at her age, she was being told to just lie there and void herself, in her pants. Furthermore, they told her to ring the bell when necessary - but she was unable to do so because of the stroke - she could not reach the bell or push the button.  This poor woman was extremely stressed because she had an uncomfortably full bladder, could not get any relief and could not ring the bell.  Her solution: she kept thumping her arm against the bed trying to attract attention so that someone else in the room would ring the bell - which was me, because I was lying semi-awake in pain and the sleeping pill had no effect. The first night was awful - I was really sore and I was constantly being woken by a very frustrated patient.  Thank heavens on Thursday morning they moved me to a room at the other end of the centre where my fellow-patient was about my age and also had knee problems - why could they not have done this from the start?!!!!!

• The food was horrible - same caterers as Panorama Hospital so therefore cannot understand why it was so bad.  My first dinner (served at about 5.30 pm) was hard carrots, musty rice and something that was supposed to be curried mince - I think ;

My first meal at the Stepdown Clinic

• They refused to give me the medication prescribed by my doctor as it could be habit-forming and gave me something else which was not as effective. Furthermore it took ages for my medication to arrive which meant that I had a longer stretch between medication (there's a pharmacy downstairs but they order from a pharmacy two blocks away!)  Thank heavens I found some Stilpayne in my bag and self-medicated throughout the night just trying to cope with the pain.  Big note here - especially in the beginning, take your medicine as prescribed - wait too long and it takes ages to get the pain back under control;

• My knee guy had insisted that the dressings are not to be removed till our first appointment - but the step-down clinic's doctor insisted on removing the dressings and replaced them with an inferior quality product which meant that the dressings constantly peeled off.

The biggest concern about me going home was that we live in a multi-level home linked with stairs, stairs and more stairs.  I was warned that it would be really difficult to handle stairs after the surgery.  This was a problem as that meant I would not be able to get from our driveway into the house and from the lounge / kitchen level to the bedroom / bathroom level.

BIG NEWS! They're wrong!!! With a little persistance and much repetitive exercise, I mastered the flight of stairs in one morning - I had to, I wanted to get out of there asap. They reckoned I'd be there a week - I reckoned much, much less.

Timeline: 

• Admitted Wednesday afternoon - lousy dinner so ate a slab of chocolate left by a visitor; Awful night - but best thing was that the only "disabled" toilet (i.e. one with the necessary handles to drag yourself up off the loo) was quite some way down the passage - I got a fair amount of exercise Wednesday evening;
• Thursday morning - saw the doctor, who promptly removed my dressing despite the specialist's request not to; horrible breakfast, ate nothing; I was moved to a new room; taught how to climb stairs (NOTE TO SELF: there is no right way, only a suggested way - adapt whatever method works best for yourself); taught how to shower and how to use a toilet that does not have the necessary "handicap" handles; walked more, climbed stairs; physio session - informed all I was leaving the next day - they laughed saying I would likely be there for another week as I had to first pass the checklist; Worked even harder;
• Friday morning had the best meal ever at the facility (suggested by my roommate - muesli & yoghurt)!!!  Told all I was ready to do the check-out evaluation ... did it twice to convince them and left at midday!!! YAY!!!!!

It was time to go home!

Walker to Crutches

All in all I spent 8.5 days in hospital and 2 days in a stepdown facility (more of that later). 

Day 2 was bend the knees day.  Day 3 - I stood.  Big tip:  from before you go in just keep telling yourself they're just knees and you can stand.  I've heard a number of people mention that they had problems standing because they could not get their heads around the thought of prosthetic knees.  Unless, in the extremely rare event that they messed up big time, your new knees will hold you.

You'll need to keep on repeating this mantra as the physio shifts you out of your bed and gets you to stand - for me, with support of a walker. Legs were like jelly, it was sore and there were pipes all over the place (drains, catheter, intravenous) - however, I stood!!! And then sat down probably less than a minute later.  That afternoon I took my first step in the walker - ain't science incredible!!!

Two great tips: whilst lying in bed keep on flapping your feet up and down as often as you can - helps with the circulation. And use the icepacks constantly - really helps with the swelling and pain management. Furthermore, as soon as the pain and discomfort allows, try to start bending your knee up to your chest.  In all likelihood there may initially only be a millimetre movement but its all in the head and the head's going to be the thing that you have to convince that you can actually move your leg/s.

A big bonus was that I was moved to another room with my bed right next to the window - I am ever grateful to the sisters who decided to move me (their reasoning was that I was going to have to stay in longer than the others).

This was my new view from my bed - Table Bay peeping through the branches and ocean in the distance.



View from my new bed  - beautiful!



Table Mountain at night

Table Mountain on a rainy day

Physio was short but intense - just keep reminding yourself that this sore is good - you're going to be able to walk better.

Furthermore, laugh a lot during the session - real laughter using the belly.  Belly laughter, where you engage the diaphragm, releasing endorphins in the brain, chemicals that activate the same receptors as drugs like heroin, to pain-killing and euphoria-producing effects (Read more: http://healthland.time.com/2011/09/14/its-no-joke-why-laughter-kills-physical-pain/#ixzz2O5BCEiU5).

By the end of the week I was walking short distances in the room with the walker. Early the next week I was introduced to my funky royal blue crutches (apparently the walker made me look old!).  Initially I was nervous of balancing, but I soon got over this - what incredible freedom! By the following Tuesday, I was walking down the passage - about 30 metres ... Awesome!!!!

And then it was time to learn how to handle daily living - info about the stepdown clinic in my next post.

Tomorrow's a public holiday so I plan to do some gardening ... more than a year since I've been able to comfortably say that!!!

D-Day

4 December 2013, my 49th birthday! As usual, lights came on at about 5h30 - and I really, really quietly sang happy birthday to myself  - rather pathetic.  I was starting to feel rather nervous.  All the usual readings were done - BP, temperature and glucose. I was given a small bottle of liquid to wash myself with - and promptly spent ages in the shower as I was not sure how soon again I'd get to enjoy this luxury!

Time to get my mental attitude right.  I am a laughter facilitator and a Care Clown. Research has shown that children who laugh prior to surgery handle the trauma of surgery and recuperation better than their peers.  Laughter also relieves stress.  Time to be uber-cheerful!  I smiled and joked with the nursing staff and fellow patients, laughed with them when they remarked on my birthday gift and giggled that at least I would be getting a morphine trip as an added bonus. I laughed all the way into surgery and shared my "laughing children less trauma" story with all - everyone was commanded to be cheerful. "Happy Birthday" says my doctor all geared up in scrubs.  TV screens everywhere. The anaesthetist walks in, we greet, time to drift off.

I don't recall much about the rest of day one except that it was really, really, really sore!  From the outset: it is flippin' sore ... but so so so worth it a few weeks down the line.  People I'd spoken to had tried to "protect" me and said it was rather uncomfortable.  Wrong.  It is mega sore - I've never had kids but one woman said it was worse than natural labour.  However, the pain does ease over time and the rewards are great (not something everyone claims about kids!).

OK, now that you're traumatised by the reality check:  after the op all I recall I was constantly sucking on ice chips and had something on my feet - sock-like and pulsing, one kept on falling off. Thank heavens for the morphine drip and the occasional injection. Unfortunately the drip was faulty and stopped working during the night - the next morning I was a super diva! The feet things were some form of compression sock - one still kept on falling off. Day 2 was also a bit of a daze - especially the morning.

That afternoon the physio came by. This is absolutely the worst moment ever.  Nobody warns you about this so take note - even sensitive viewers.  This tiny, slim woman's goal was to get me sitting up with my legs over the bed.  This is hell.  It felt like every stitch was being ripped loose. I was in total fear mode so I froze - not conducive to a good physio session.  My logical mind eventually realised that she would never do anything to jeapordise the surgery and wounds. My emotional mind felt very differently.  I do believe they should warn you beforehand what you may feel.  By the time I was finally sitting I was crying, it was sore and the drains were bleeding. A good time to sort out drain-dressings. I sat for a few minutes - and then she wanted me to lie down and put my legs back up on the bed.  Was she mad?!!! 

But yes, even that you conquer.  Day 2 passed in a haze of pain and medication. The amazing thing about pain is that it is so internal.  From outside you saw a large person lying on a bed with some tubes and occasionally groaning and moaning.  Inside my head it was hell - really painful, hazy with medication, lingering fear - outside calm, cool and collected, inside - a roiling mass of emotion and feelings.

It was tiring and I was so grateful for the drugs. Tonight I sleep, tomorrow I'm expected to stand.

Charmaine

The Final Countdown

MRI? Done. Blood tests? Done. Hospital authorisation? Done. I had put in  for provisionally eight weeks leave (six weeks sick leave + two weeks annual leave) and we were now ready for the final countdown.

The TKR book suggested I should pack in shorts and sneakers.  Shorts? With my Rubenesque figure?  You must be joking!!!!  Time to haul out the not-yet-used recently acquired second-hand sewing machine and used-ages-ago overlocker.  We were going to make a dress (something I don't wear).  Something loose and flowy inspired by a designer dress I had seen years ago.  Yep, I know - I won't wear shorts but I was about to make a designer-inspired dress by Habits in Cape Town.

Don't be fooled - really easy to adapt using some ancient printed viscose cotton and ribbon to thread through for shoulder straps. Light, loose and flowy so that it should not bother the dressings. To complete the fashion statement I also packed easy-to-slip on Crocs and a loose shirt.  To sum up, suggested packing: 

• Something loose to wear to and from the hospital (or shorts);
• more pj's than you think necessary or family / friends who will help out with laundry;
• more undies than you reckon necessary (or ditto re family / friends);
• Shoes you can slip on when walking in the room and up and down the passages - I found the cheap flat cotton slip-ons quite adequate; 
• a gown;
• besides general toiletries, lots of pleasant-smelling wipes (baby wipes are great) as you will be bed-bathed for at least a week and wipes are a handy way to keep feeling fresh;
• easily-absorbed body lotion;
• talcum powder;
• lip-balm;
• chronic medication;
• face cloth;
• ear-phones for TV.

Add as you need. I took books, magazines and a book of sudoku puzzles - and hardly touched any.

Monday morning I decided my dress looked way too bulky on top and needed some adjusting.  I then prechecked myself into hospital, packed, went through my e-mail and watched TV, trying to keep calm.  At 12h00 Hildegard, my housemate and a good friend, took me through to hospital and I was admitted. The staff were very friendly and I was wheeled off for x-rays. The pathologists drew blood, the physio visited and explained what would happen when I woke up after my op, the aneasthetist visited and we chatted about my adverse reaction in the past to certain drugs. A physician popped in, realised I was previously with another physician (Dr Richard Wilson - my miracle doctor) so called him up instead - a cheerful reunion; and then a visit by Dr van Huyssteen, the specialist. By then it was time for a nap, early dinner, BP checks, glucose level tests; thermometers and more smiles. 

I made a point of being as cheerful as possible and laughing with everyone.  There's method in my madness!

We're about to have ..... lift-off!!!

Coping with the MRI

I think I mentioned I saw Dr Adriaan van Huyssteen in January and that I could only have the ops done late in the year once the new sick leave cycle kicked in.  Originally was going to have the ops done in October but then moved it on to December due to work commitments.

In the interim I worked out in a coolish pool at Planet Fitness Aurora with biokineticist Simon Maskell - and in this time also learnt to swim properly ... amazing the unforeseen benefits of an operation!

When I originally saw the Doctor he injected cortisone into the the most painful knee. The injection was not as painful as I expected and the improvement was almost immediate.  However, this did not stop me stumbling about like an ancient arthritic pug!  I learnt that you can only have limited number of cortisone injections in the knees so decided to hold out as long as I could.  Unfortunately, when I went to see him late September it was too close to op time so no more injections.  Keep that in mind if you're doing pre-op pain management. 

Because we were using the Smith & Nephew Visionnaire system, early in October I had to have new x-rays as well as MRI scans on both knees (these are e-mailed to to the USA where custom blocks are cut and sent to SA - prosthetics custom-made for your body - apparently extremely beneficial - see on page).

If you have not had an MRI before be aware - its very very noise and I found it quite claustrophobic. They put on headphones with classical music but ithe sound level was just too soft.  I had to keep telling myself that the fear was totally unfounded - I think my main concern was that I could not just get myself out of the tunnel.  It's small, I'm big and my legs weren't working too well.  Initially the thing that kept me there was the thought that, if I stopped the process, we would have to start all over again!! Second knee I had it all figured: 

1. the MRI sounds are like a very loud hum interspersed with a grindy sound - or may be the other way around.  Well, I reckoned there should be about 8 grindy sounds so concentrated on that - naturally lost count and then just started all over again;
2. more importantly - I am a Laughter Facilitator!  I teach Laughter Yoga and I know how awesome the power of laughter is, even if you don't feel like it.  Laughter drastically reduces the stress hormones - so I started laughing.

Hope this helps you with your next MRI scan - laugh and you'll confuse everyone!

Approximately two weeks before the op I had to go for blood tests.  The same day I decided to buy new pajamas - a necessity as its not something I usually wear!

Lunchtime - chat later!

Fighting Fit - Orthotist, Biokinetist and Planet Fitness

Yep, another post on the same day - long posts can be so exhausting to read!

To follow up on the last post - I was really comfortable with my appointment with Dr Adriaan van Huyssteen so decided to cancel my appointment with Dr Spike Erasmus.  Besides being comfortable with the doctor, this would also be much easier for my support team as Panorama Hospital is closer to my home.

I also decided that I would need to get Fighting Fit.  I needed to

1. talk to others who had bilateral total knee replacements - a challenge as I did not know anyone who'd even had one TKR;
2. get more knowledge, maybe buy a book or something;
3. get fitter.

The book was the easiest of all - I love Google! If you are contemplating knee surgery get yourself Total Knee Replacement & Rehabilitation - The Knee Owner's Manual, written by orthopedic surgeon Daniel J. Brugioni, M.D. and physical therapist Jeff Falkel, Ph.D., P.T., CSCS.  This book sets out everything and answers practically all the questions you have and even those you did not realise you had!

Next, get fitter.  I decided that I would have to join a gym with a heated pool and Planet Fitness Aurora had a special on, so I joined for a year. I then went to see Simon Maskell, the biokineticist.  A really super and knowledgeable guy who makes a tough workout really enjoyable.  Planet Fitness people were sweet.  However, their pools were a problem (and still are it seems).  I hate cold water and their supposedly heated pools were usually too cold for me.  Furthermore they were constantly experiencing problems with the pool pumps.  Big plus was that the rehab pool was available from 18h00. 

In retrospect the few months in the pool with the biokineticist was one of the best things I could have done.  Besides a brilliant doctor and a very positive attitude, I reckon this is one of the biggest attributes to the apparently remarkable recovery I've had.

Talk to others?  Well the husband of the coffee shop owner we occasionally frequent has had bilateral knee surgery and his wife said he is doing really well - I still have to meet him and share notes at some time.  And a colleague had bilateral TKR  towards the middle of the year, said he was recovering well and that there was a little discomfort - he lied ... it hurts like hell in the beginning - but only for the first few weeks.

Next - Op day looms!

Finding a Knee Guy

Wow, how time flies!!   Five weeks since the last post and I haven't even started talking about the actual TKR! Well it is now 14 weeks - yep, today is day 2 after the op 14 weeks ago!

As I said in my last post - start from the very beginning - ok, TKR beginning:

Late January last year my knees were really sore and I decided to go see a knee guy.  Everyone was referring me to Spike Erasmus, the knee guru, but he is based in Stellenbosch - not exactly convenient.  I'd had a really good experience at Panorama Hospital in Plattekloof, Cape Town, a few months earlier when I was admitted for extremely high blood pressure (220/160) and this awesome physician, Dr Richard Wilson,  successfully diagnosed  Conn's Syndrome (tumour on the left adrenal gland).  An adrenalectomy was performed by Dr Jonothan Leith and, for the first time in more than 15 years, I have normal BP, like an average of 127/73! The care at Panorama was also excellent.

With such a positive experience, I decided to Google and check out knee specialists at Panorama Hospital and then Google reviewed them. What I learnt is that there are not many reviews for doctors - is there a certain code about that? I definitely avoided the one that advertised cheap treatments - I reckon my body's worth more than bargain basement prices and decided to make an appointment with Dr Adriaan van Huyssteen - just because I liked the look of his webpage, no other reason.  I'd also made an appointment with Dr Spike Erasmus for the following Thursday.

First order of the day after filling in the paperwork - go for X-rays.  I'd struggled to walk to the rooms now I was expected to traipse the hospital corridors trying to find Radiology!! Thank heavens Lizelle Brink, Dr van Huyssteen's awesome Administrator, called for a wheelchair - I knew I was in the right place - they cared!

After the X-rays the doctor called me in. Youngish, professional, well-spoken - and concerned about what he saw on my x-rays.  I honestly thought it was probably some stretched ligaments so was horrified to find that there was practically no cartilege left in either knee and that there were already signs of osteophytes.  He discussed all options but said that ultimately total knee replacement was the only way to go.  I was quite shocked. Definitely more serious than some stretched ligaments.  I raised the possibility of having both done at the same time.  He was not enthusiastic, but practicalities are that I have to work for a living, only get 30 days sick leave over a three-year period and don't earn the type of money to take extended unpaid leave. Would have to have one done and then wait three years in pain for the other knee to be done.  I don't think so!!!  I anyway had to wait till the end of the year for my new sick leave cycle to kick in.

So it was decided.  We would do both knees at the end of the year using Smith & Nephew's Visionnaire system.

Now to get Fighting Fit!