Research - Partial Book Review

After a week with a recurrent gout attack, I'm just about back to normal. This blog is really a partial book review of:
Hip and Knee Surgery: A Patient's Guide to Hip Replacement, Hip Resurfacing, Knee Replacement & Knee Arthroscopy. Robert Edward Kennon. c. 2008 Robert Edward Kennon. Thanks to the Ottawa Civic Hospital Patient Library for the loan of the book.

Of the 3 knee compartments, frequently the medial or inner side of the knee wears out sooner. This would be my situation. There are several options available for this circumstance; orthodics, off-loader braces and partial knee replacements. (p 77) I already have orthotics and knee braces though not prescription ones. Assessment is that they help but are not sufficient for long term relief.

There is the possibility of injury which I thought may have happened last week as I slipped on the stairs and seemed to have sprained an ankle. The pain and swelling continued to increase and turned into a symptoms more characteristic of a return attack of gout. Past instances of weight loss have instigated a gout attack so it is not unusual. The customary prescription for an anti-inflammatory appears to have solved the problem as of this morning with the added benefit that my knees feel wonderful. Must be careful not to over do it.

The other development is a popping or slipping feeling at times, particularly in my left knee. It seems that it is possible for a meniscal tear (p. 80) to develop which could create this sensation. Again, this is another question for the surgeon.

Again there is the warning of a sedendary lifestyle developing which is actually worse for arthritics. Swimming, cycling and leisurely walking are recommended as they do not require significant weight bearing. Exercise can be difficult; however, I think that developing upper body strength through the use of weight exercises, many of which can be done seated, will help lose weight and build up the arm and shoulder muscles to help take the weight off the knees when climbing stairs, getting into and out of the shower or tub as well as the car.

The autho- doctor even talks about the use of a cane! I have been using one with the attack of gout.

Hyaluronate or hyaluronic acid is a 'viscuous substance that normally lubricates the joint.' The doctor estimates that about 'two-thirds of patients feel better after the injections.' Benefits include few side effects. The most significant are the possibility of some swelling and most devastatingly, no effect at all. The process is expensive and a typical series includes weekly injections for 3-5 weeks with significant improvement usually taking about a month. Injections can be repeated at 6-month intervals. I may have to reconsider past thoughts on the syndisk prescription. The book does not speak to the long-lasting effect of the treatment which is an issue for me.

The book deals in the next chapters with knee replacement. I've read through the chapters but will re-read taking notes before continuing with the review.

Next week is the big weigh-in after a month of lifestyle changes. I have found that it is easier to make the planned alterations when the customary patterns are in place. With the arrival of my oldest daughter and son-in-law there have been too many opportunities for extra dining and the occasional sip. The gout attack stimulated complete withdrawal from alcohol consumption. I felt I lost consideable weight over the week. However, the last four days have had a party atmosphere. I've been more relaxed than in years and the opportunity to cook for a larger group has been fun. I suspect that much of the weight loss has been negated.

We will see. Afterall this is a lifestyle change not a diet and these occurances are part of life. I guess we will just have to limit their frequency.

Reading & Accident

Here we are with two postings on the same day!

Now there is a new complaint. Slipped on the stairs and have sprained my ankle. It is really quite a sight - hobbling around with a cane on two arthritic knees and a sprained ankle. In keeping with the new philosophy of compassion, we have to take this as training for my wife and myself in preparation for the operation.

She got to help with some cooking which she hasn't done in years. On the diet front we are real pea soupers and don't want to give it up just because the canned (convenience) varieties are chock full of salt and MSG. So this morning, after the swelling went down a bit, we made pea soup together. Followed the basic recipe on the package of dried green peas with a few of the usual modifications. After the tasting later today, I'll post the recipe if it passes muster.

Earlier I raised the subject of fiction and everthing being relevant. One of my passions is spy novels. There is even a list of what I've read in the past couple of years. The novel finished last night was: First Daughter by Eric Van Lustbader.Tom Doherty Associates, New York. 2008. Van Lustbader was a favourite years ago for some of his Japanese novels; Ninja, Miko, White Ninja, Kaisho and Floating City are all titles I read 10 or 15 years ago. Good solid pulp fiction with a smattering of sex and lots of hand-to-hand fighting.

The interesting thing about First Daughter is that it has a strong religious undercurrent. The daughter of the US president-elect is kidnapped just prior to the inauguration. The retiring president leads a group within the novel who are fundamentalists and are using the kidnapping to complete unfinished business dealing with Islamic movements and perceived scientific groups headed in the wrong direction from their point of view.

It is strange when the pulp fiction is considered in the light of Armstrong's The Case For God. Going back to the earliest religious roots, she makes the case that the current popular views of religion, church and atheism, stem from relatively recent re-interpretations of ancient writings. With the religious right such a force in US politics today, contemplating the impact on major global decisions especially in the context of fundamentalist Islamic thinking is a scary proposition. It's reassuring to learn that calmer thinking on historical principles is taking place.

All of this to say that reading is a fine diversion and can take our minds away from self to think compassionately about others in worse situations.

Reading & Research

There hasn't been an addition for a couple of days as I have been researching and reading. A favoured professor, Dr. Eli Mandel a noted Canadian poet and English Literature lecturer at York University, used to say that "Everything is Relevant." We had some fine graduate seminars when students tried to challenge his verbal dexterity to prove that bizarre comments and analyses just didn't hold water. We were never able to best him. For me, the conclusion drawn, which has been a life long precept, is the formation of a steadfast belief in serandipity. The happenstance of what one reads can be very influential. It is also a fervant conviction that fiction has much to contribute to our understanding of the real world. So here are some of the materials I'm looking at.

1. Synvisc. In an earlier blog I indicated I would reseach the product and work towards a decision on whether to use it. The web wasn't particularly helpful as most of the easily available information was marketing type stuff.

At the suggestion of friend Alison, I contacted the Patient & Family Library at the Ottawa Civic Hospital. What a great resource with extremely helpful people. They willingly have taken on the task of finding future oriented research on knee replacement.

With the librarian's help, I leaned that synvisc is a brand name for 'Hyaluronate acid' & derivatives. Synonyms which may be useful for further searching are Hyaluran, Hyaluronan, Hyaluronate, Hyaluronate Sodium, Hylan, Hylan Polymers, and Sodium Hyalurnate. It is used for knee, skin and eye problems.

W. Neal Roberts, Jr. writing in the Online Journal, 'UpToDate' in September 2006 offers an analysis of cortisone and Hyaluronic Acid Defivatives. www.utdol.com/online/content/topic.do?topicKey=tx_rheum/5757&view=print

Dr. Roberts' recommendation is that use of the injection comes with modest expectations primarily in OA of knees in patients who have failed to improve with cortizone shots. He suggests limited usage because of the expense and the 3-5 injections needed for treatment. He does note that it may be a good solution for diabetics who become uncontrolled on cortizone treatment.

It seems that the Hyaluronic Acid treatments only post pone the need for surgery if I read the literature correctly. Perhaps it will be useful to manage the second knee while recovering from the first operation.

2. Karen Armstong. The Case for God. Alfred A. Knopf. New York. 2009
Ms. Armstrong lectured in Ottawa last week but unfortunately we weren't able to attend. Instead we bought the book based on the review two Sundays ago in The Citizen. I was particularly influenced to look further into her writings by the comments about compassion and her interest in having the subject included on TED: Ideas Worth Spreading http://www.ted.com/ which is always an interesting site to visit and browse. As I said above, everything we are exposed to can be relevant and we will see what comes from the book.

Part I of the book is an analysis of religions throughout history and the way different cultures have developed an approach to what could be considered God within their context. The first reference to compassion is in the discussion of Buddha.

"The texts indicate that when the Buddha's first disciples heard about anatta (no self,) their hearts were filled with joy and they immediately experienced Nirvana. To live beyond the reach of hatred, greed and anxieties about our status proved to be a profound relief. By far the best way of achieving anatta was compassion, the ability to feel with the other, which required that one dethrone the self from the centre of one's world and put another there. Compassion would become the central practice of the religious quest." p. 24

It strikes me that these thoughts focus on a failure of this blog and indeed on the fundamental characteristics of much posted material. The point of view is clearly self-oriented as we document the process of arthritis progression. Perhaps it will prove helpful if in some way we can insert a compassion for others into the thread of thought. I'm not sure how to follow up on this notion but it no doubt will come to the surface again. Maybe just the motivation to share the few simple things I discover through this blog is helpful.

Other reading materials will be mentioned in future postings.

Physiotherapy

Made the appointment with the physiotherapist and have been doing my 7 exercises for the past two weeks. The set is designed to stretch and strengthen the leg muscles.
1. Calf Stretch - stand facing a wall, put hands on wall and step. Put weight on front foot and stretch calf of back leg. Repeat 5 times holding each time for a count of 20.
2. Toe stand - standing on both feet, go up on toes and hold for count of 5. I have balance problems and can't do this on one leg. Physiotherapist says this exercise will help train my knees to balance. As I strengthen the muscle and lose weight, the exercise on one foot will become possible. I am to alternate 1 & 2 to balance the exercises.
3. Thigh stretch. Lean against wall with feet out far enough that you can see your toes (quite a way in my case) and bend knees slightly sliding down the wall about 3 inches. Hold for count of 10. Repeat 5 times.
4. Rolling Pin - wrap a rolling pin in a towel and put between thigh muscle and the wall. Roll pin from hip to knee working the kinks out of the muscle. This is my favourite. It feels fantastic. Do both legs and remember to lean into the wall hard enough to get the benefits.
5. Clam - Lie on side in bed with knees together and bent about 30 degrees. Lift upper knee in a open clam shell movement. Repeat 10 times each side.
6. Loop belt over ankle. Lie on stomach and pull foot back as far as knee will allow. Hold for count of 5 and repeat 10 times.
7. Stand on one foot. Anytime standing in one place stand on one foot. Cleaning teeth, shaving (not always such a good idea,) washing face, washing dishes...you get the idea.

Been doing these three or four times a day though not all at each time. I am beginning to notice a difference, particularly with my leg strength and flexibility as well as a marked improvement in my balance.

The last cortisone shot seems to have lasted much longer. It about three weeks ago and I still have not had to take more than two aspirins on any day. With the shot and the exercises I felt so good this past weekend that my wife and I tackled the leaves on the front lawn. We collected 4 large garbage pails of packed leaves. Carried them to the back, dumped and spread them over the raspberry patch. They will make not quite enough mulch for the winter so will buy a couple of bales of straw to top up. This year I haven't been able to remove the old canes. Hopefully I will be able to do it in the spring.

One other item on the weight loss front. We decided to follow the popular advice and take a fibre supplement. Got talked into a special supplement at the Health Food Store, 'FibreSmart.' It has defatted flax seed, acacua fibre, guar gum, fennel seed, L-glutamine, marshmellow root, slippery elm bark, triphala ad stevia rebaudiana leaf. I particularly enjoy the thought while drinking it mixed in our morning juice of the slippery elm bark.

Neither of us has noticed a huge difference but the extra methane isn't too troublesome.

Weight Loss Plan

It's now time to report on the great action plan outlined in the last blog.

The first item on the agenda is a weight loss plan. I'm in the 1000 lb. or more loss category. Over the years I've lost and gained many times. As an experienced if not successful dieter, most of the advice available is well known and has been followed at one time or another. This time there is a new resolve and a defined target that relates to more than weight reduction. The idea will be to develop a modified lifestyle that can be sustained for the duration.

So... the big weigh-in records 255 lb. Now for the plan of attack.

1. Salt & MSG
There is an advertising campaign current on television encouraging us to manage our salt intake. MSG is also a favourite target and blamed (on the internet) for dozens of side effects including obesity. It isn't good to believe too much of what turns up on the net but like the fuss over climate change, much of the suggested activity makes good sense for the management of the biosphere whether or not human activity is the cause for a real or perceived climactic alteration. So salt and MSG will become a management point for "Jason-sphere."

For the past two weeks salt has been eliminated from our cooking and the salt cellar isn't on the table at meal time. My wife has always avoided adding salt but I am astonished at the tastes of food reasonably prepared without salt. I've been going through the spice rack more carefully and have been making more use of the oregano, pepper in various forms, and some of the Indian spices like cumin, coriander and the other basics for curry. I don't add enough that one can taste the herb or spice but sufficient that the flavour seems to be enhanced in a similar fashion to the effect of salt. I always thought that removing salt was a good diet device because the food tasted so bland that one didn't want to eat it anyway. A change in spicing seems to dispel that myth.

The popular target for salt and MSG is the so-called convenience food. Because we prepare most of our own meals, I didn't think we used these kinds of foods which were categorized in my mind as the microwave and serve type of product. An examination of our cupboards suggest that thinking needs to be revised. We enjoy our soup and sandwich at lunch. I particularly enjoy canned pea soup so that has been a staple for years. Reading the label, MSG and salt are too high on the ingredient list. We collected a box full of soup cans and took them to the food bank. Maybe we shouldn't give away unhealthy foods but as in many life situations, it's how one chooses to look at it. For the past couple of weeks I have prepared the main meal of the day with the idea of having something to work with for the lunch time soup the next day. I've always done this but not as frequently as is now the case.

Another product that has been removed from the fridge is parmesan cheese in the Kraft container. We noticed that adding parmesan to our soups really enhanced the flavour. No wonder, salt is the third ingredient. I would guess that salt is a fundamental part of cheese making but there is no need to purchase the 'convenience' packaged product. We will try the fresh grated parmesan for a while and see if it proves salty as well.

As may have been noted from the chile recipe, we are fans of hot sauce and have about a dozen different varieties in the fridge. Looks like many of them are high salt reservoirs though with the small quantities used, hot sauces may not be the best target for reduction. Certainly prepared barbecue sauces can be eliminated. I will look for a recipe for home made barbecue sauce and try that.

2. Alcohol Consumption
We are wine lovers and I particularly enjoy both blended and single malt scotch and the occasional shot of gin or vodka. Over the past few years I have become a two-bottle-a-week man. Clearly here is a target for reduction which will benefit both waistline and wallet.

A number of tactics have been learned from past exerience and both will be implemented. First of all, use the shot measuring glass. Just measuring the 1.5 oz limits how much gets into the glass and helps reinforce the count of how many during the evening. Rather than stop cold turkey, I am limiting consumption each evening (the only time I tipple) to two drinks and have stopped the wine altogether. 3 oz. of hard liquour seems to be enough to satisfy any urges and I will diminish the quantity as the weeks go by.

The second line of attack is to find a hobby that gives me something to do with my hands while watching television. With the baseball post season underway, it is particularly apropos to start now. When I quit smoking 28 years ago I took up knitting. I still have the golf club covers that were made with nicotine cravings. For this venture I have decided to make a couple of scatter rugs for the family room. Years ago I had done something called French Knitting or more popularly, 'corking.' It's a hand craft that is taught to kids on many occasions. A search was conducted throughout the house for the corking spool to no avail so down to Michaels to get a new one. We got two because my wife wants to work on the rugs as well. As you can expect, the old corking spool turned up not more than 12 hours after the new purchase. They were only $7.00 each but just the same... Mr. Murphy strikes! Last night I cast off the first knitted strand at 42 feet. My we have watched a lot of TV! However, the idea appears to be working and I am happy watching the ball game, corking and sipping my water.

This is a much different approach than focusing on quantities and types of food. We will address these in the next few weeks as the first life style changes become engrained.

Meet the Surgeon

October 1, 2009
Here is the text of an e-mail sent to close friends and a few family members.

Had a good meeting with the surgeon at the Civic Hospital this morning. He says I'm in a gray area. My knees are bad enough to operate on and they could do so within a couple of months. However, he cautioned me that at only 64, I have a lot of hopefully active life ahead of me and it is likely that the artificial knees will wear out in 10 - 15 years or so. They can replace the artificial knees but the degree of success is not as high as with the primary replacement. That is to say that there is reduced mobility and the possible continuation of some pain at that time.

He spoke of other treatments. Losing weight, having physical therapy and having another kind of shot, syndisk (sp?) that frequently helps sufficiently to delay the initial operation a bit. I have had two cortisone shots now and they usually only give three. (That was surprise information - thought I could have them every month) I would say that the cortisone helps but is not the answer. It is unfortunate that I had the second cortisone shot just before the meeting with the surgeon. My knees felt very good and it was hard to insist on an operation when they weren't hurting much at the time.

The other consideration is whether to have a full or half knee replacement. They say that a half knee replacement would give me mobility and pain relief and not be so difficult a recovery. It will likely wear out in the same 10 - 15 years or so. The gray area is that with the half knee replacement there is more bone left to work with so the second operation if needed for full knee replacement is much more successful.

It is all a bit strange. I was so totally prepared for the operation on both knees. But I was surprised at my reaction last night. I didn't sleep very well and was mulling over the risks and danger of the operation. Really thought I was past that. So when the caution flag came up this morning in the meeting, I was taken by surprise but also felt a note connectng to my night of unrest.

It appears that there is only about 2 months of delay from the time I make the decision. So the decision we took this morning is to delay the final decision for a couple of months. I made an appointment to see the surgeon again on the first week of December.

In the meantime I intend to lose some weight which will make the entire process easier. I have a prescription for physiotherapy which will make my leg muscles stronger and more flexible. I will research the new injection and decide about it when the cortisone injection wears off which will be in a couple of weeks if past experience runs true to form. If the new injection works well enough to delay the operation for a year or two, then that could be good. Otherwise, I would give the go-ahead to schedule the operation which would likely be in February or March of this year.

That is the situation now. We will take another couple of months to decide whether to choose the surgery and mid-winter is not a bad time to have it. They suggest two weeks off work so that I can focus on recovery. Desk work and reduced schedule should be possible after that.

On reflection, I wonder if the Surgeon and his assistant weren't playing "Good Cop / Bad Cop?"
The assistant saw me first and presented all the cautions. The Surgeon came in and explained the practical details of the operation. It's probably a pretty good approach to make sure the patient (me) really thinks about the decision.

Hurrah: An Appointment with the Surgeon

September 15, 2009

The surgeon's office has called and I have an appointment for October 1 for the first consultation! That's just over two weeks after the referral and much faster than anticipated. Who says the Canadian medical system can learn from the Americans? But let's not get on that polical hobby horse.

Now it is important to prepare for the consultation. The handout from the Arthritis Clinic spoke at length about a half knee replacement. It will be important to find out the plus/minus on that approach and whether it is best for me.

Haven't had much time to research the new developments in artificial knees. The first internet search uncovered a lot of material from the Arthritis Research Centre of Canada. Spent an hour or more reading through some of their materials. It seems they focus more on what might be called sociological and statiscal aspects of the disease. At least with the time I've spent, there didn't seem to be many research projects on medical subjects and only one on artificial knees.

The second search yielded a different set of responses. There has been time to check only 30 or so of the listings. Many of those first listed are dated 2007 and earlier which seems a tad ancient for what I'm looking for. There are sites that explain the knee surgery but so far not any that indicate much about future trends. One interesting article from the Mayo Clinic does talk about partial knee replacements for younger people who can expect a full replacement in 10-15 years. Will need to find out what this means.

I've also booked for the second cortisone shots on September 28th. The last shots were helpful but didn't seem to bring significant relief for very long. But remember - You overdid it in the garden- dummy. Maybe the shots are accumulative and the next set will last longer?

With my weight, I'm on the edge of type 2 diabetes and take a self-inflicted blood test every week. The reading runs along at 6-something so I've been able to control sugar levels with diet and some exercise. The last test spiked to almost 8 which worried me. However, I was checking the information on cortisone and noticed that it could cause an increase in blood sugar. That will be something else to watch for after the next shots.

My wife says that if something isn't complicated, I will make it so. I don't think I will have to try very hard on this subject.

Sobering Thoughts and a Good Memory

It's September 4th and I have just finished reading the literature and watching the DVD received during the visit to the specialist. They offered the opportunity to be part of a research study which I accepted enthusiastically.

To this point it had not occurred to me that there might be a choice of solutions for arthritic knees. My cousins Bruce & Jean have both had knee replacements. Our good friend Diana had both knees replaced a year ago. The operations were very successful for all three and they have encouraged me to get the job done as soon as possible.

The handouts emphasized that the decision is for serious surgery which should not be taken lightly. Success rates are very high but there is pain after the operation, work to rehabilitate and always the chance of infection. I must say that I'm a little less gung ho and must think about the operations more carefully.

One element of the questionnaire was particularly thought provoking. In a series of 4 questions, we are asked to choose, hypothetically, whether for a pain free period of time now would we forego the operations and endure the future pain. It seemed an easy decision to choose 10 or 8 years pain free. But at the 6 and 4 year intervals it became more obvious that the immediate good life wasn't long enough.

On reflection, I think I would answer the questions differently. I wouldn't want to live with the pain I have now when I'm 75 and an operation may be more difficult. However, it is a complicated issue. First of all, who knows whether we will live to 75? Secondly, can we anticipate that there will be significant changes over the next decade which will allow us to 'grow a knee replacement' for example?

Certainly the decision bears more thought. The questionnaire opens a number of points to consider that are much deeper and more philosopical than anticipated. How long to I expect to live and enjoy the current lifestyle? How do I anticipate meeting my family obligations? What near-future developments could benefit me?

It's not as though I haven't had a life-long experience with arthritis. My Mother was diagnosed with arthritis when she was 17 years old. She was able to lead an active, fruitful life as a farm wife. Some of my earliest memories are of her infrequent 'bad days' when she had to stay in bed. At seven years old, Dad would send me in from the barn to 'help Mom get supper.'

I can remember the day when Aunt Grace dropped in to find Mom on the couch coaching me how to make an apple pie. I had the apples peeled, the bottom crust in the pie plate and the apples, cinamon and sugar in. But I couldn't for the life of me get the top crust on. Aunt Grace arrived at about the sixth attempt. We all had a good laugh at my seventh try. When she tried, she said the life had been rolled out of the dough and she couldn't do it either. So she made a second small batch of pastry and with a second set of hands I got the lid on.

The kitchen experience has served me very well throughout my life. My wife Linda was quite inexperieced in the kitchen when we married. As a result, I have done most of the cooking throughout our soon-to-be 40 years of marriage. Pies are still definitely NOT a specialty. Chile is.

The little reminiscence makes me think that arthritis did have a positive influence on my life. Without that forced introduction in the early years, it is doubtful that I would list cooking as one of my special interests.

Now I have to go back and add it to my profile.

First Appointment with a Specialist

The decision to attempt a blog journal comes a month or so after some of the more significant events. Therefore, the next entries are "catch-up."

August 28, 2009 marked the first visit to the Arthritis Clinic at the Riverside Hospital. There had been several discussions with my family physician and after 12 months or more, I finally agreed that it was time for the next step. Within two weeks a referral appointment was made.

I saw the x-rays of my knees showing the inside half of each knee rubbing bone on bone. The arthritis specialist said he would refer me to a surgeon and suggested a cortisone shot in each knee.

The shot was wonderful. Within a couple of hours the knee pain had subsided and walking was easier than it had been for months, even with 8 anteric coated aspirins. I had so much energy that on the following weekend I tackled the load of topsoil that needed to be spread over the new perennial beds. That load of topsoil had been waiting since the spring. The work went well and it was a wonderful feeling to be able to move, lift and work in the garden. We need a sense of accomplishment for our well being.

It was interesting that there was a real energy boost because getting around was so much easier and pain free. I hadn't realized how much the effort to walk was debilitating. I've been tired for a year and didn't know it!

Unfortunately, the pain relief was short lived, largely because I overdid it. Clearly my own fault and I should have known better but then we are always prone to exesses in our pleasures. So it is back to the aspirin regieme. It's better because 4-5 seem to do the job.

The specialist said my knees were bad enough that I could have a second cortisone shot in a month. I filled the perscription and am anxiously waiting until the 28th of September. This time with a new resolution of what not to do.

Hopefully the surgeon will call to establish an appointment soon.

Journal Premises

Having been diagnosed with osteoarthritis in both knees, the journal will track my thoughts and reactions to medications, fitness, relationships to those closest to me and my state of mind as decisions are made. Hopefully the journal will document the process toward probable operations for knee replacement, recovery and life with artifical knees.



There is no intention to become a medical expert. Rather, it is the exploration of the disease and the personal impact it has on one individual attempting to sort through relatively complex new information and interpret that information as best one can. Looking back, one will find mistakes, folly and maybe even some fortuitous wisdom.



Maintaining a sense of humour is a priority.