Derek

Brief Outline:

Derek has a history of heart arrhythmia and recently had a tumour removed from his bladder. At his orthopaedic appointment, Derek was told that he needed a partial replacement for his right knee which could change to a total joint replacement by the time surgery happened. Whilst he had some concerns about having surgery for his right knee, Derek also had “confidence” and “faith” in medical professionals. He ultimately underwent a total knee replacement, which has improved his quality of life and ability to walk. 

Background:

Derek is in a relationship and has two adult children. He is a retired master baker and confectioner. His ethnicity is White British.

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Derek had been having discomfort and mobility issues with his right knee for about six years. Looking back, he thought that working in a bake house “shifting ten stone sacks of flour” and an injury from playing cricket were “probably the beginning of my problems”. Since then, he “always felt my right knee was weaker of the two”. His knee would sometimes ache after extra exercise but improved after a few days; however, “the occasions became more frequent and the pain became more constant”. Derek’s left knee “started playing up” too, which he thought may have been related to taking on extra strain. To manage the knee pains, Derek sometimes took paracetamol but did not want to take anything stronger because he already takes other medications. He found it helpful to compare to the pain of having a tooth abscess, which was “unbearable” on a level far beyond the knee pain.

Derek has been very happy with the healthcare received for his heart arrhythmia, which started about 15 years ago, and for which he had a number cardioversions and ablations before an implantable cardioverter-defibrillator (ICD). He takes medications for his heart and hypertension, including Entresto (valsartan) and Inspra (eplerenone), and has Repatha (evolocumab) injections in place of statins for high cholesterol. Derek also has an inhaler for asthma. He takes omeprazole to counter side-effects to his stomach from the other medications. Derek takes warfarin and has regular blood tests to check the INR (international normalized ratio). Derek recently had a bladder tumour which was treated very quickly, and he continues to have regular treatment to reduce the changes of a recurrence. He received conflicting advice about taking warfarin after his bladder surgery, which made him feel like “piggy in the middle”.

Derek found it “very frustrating” that his knee problems meant he was not able to be more active and enjoy retirement. He said he felt “a bit of a wimp” when he had to admit he could not do something, and disliked missing out on activities like going on walks with his partner. Between medication side effects and his knee, Derek had trouble sleeping and was “feeling grotty” most days. He had a walking stick and sometimes used it around the house, but preferred not to go out with it: “when something happens and we realise we’re not 21 anymore, we don’t like it”. Derek sometimes put bandages around his knees to “alleviate the pressure”.

After Derek saw a GP about his knees, he had x-rays taken. He also had a steroid injection which was “marvellous” at first, but only lasted a few days. He had hoped for another but was told it was no longer recommended because of the Covid-19 pandemic. Derek’s GP said that there would be various steps to go through before knee surgery would be considered. However, the practitioner who reviewed the x-ray told him right away that he needed a new knee. This felt like “mixed blessings” because it is “a major thing” but hopefully meant he could avoid having to first “subject myself to all these procedures that wouldn’t actually fix the problem”. Derek felt “very fortunate” to get an appointment after 18 months of waiting in the context of the pandemic, but under ‘normal’ pre-pandemic circumstances, he “might have been chomping at the bit”.

At his orthopaedic appointment, the surgeon showed Derek the x-ray of his right knee and recommended a partial knee replacement. The surgeon explained that he may need a total knee replacement by the time surgery took place. Derek mentioned his ICD device, which the surgeon did not seem too concerned by. Derek would have liked a better sense of how much his knee would improve, but understood that doctors are unable to give guarantees. He was glad that his partner joined him for the appointment and asked questions that had slipped his mind. Derek asked about treatments he has seen advertised online but the surgeon suggested sticking to NHS recommended options, so Derek decided to “not go down that road”.

After the appointment, Derek had a phone call about having the surgery sooner at a different hospital. He then learnt that he was not eligible because the alternative hospital did not have a cardiology department in case of any issues with his ICD. Derek felt “very disappointed”, but accepted that he would “just have to be patient”. Derek was aware that he was getting older and preferred to get surgery soon for a better outcome.

In the lead up to his surgery, Derek’s knee went into “rapid deterioration” and walking became very difficult. He felt anxious during this period, but tried to maintain a “stiff upper lip”. Three months later, he had a total knee replacement. A total replacement was chosen over a partial to avoid the need for further surgery later on. Before the surgery, the hospital that monitored his defibrillator were contacted to let them know it would be turned off during the operation. His warfarin prescription was also changed to rivaroxaban in preparation of the surgery.

The surgery went well, though Derek felt that he was discharged too early. Looking back, he thinks that he was overenthusiastic with getting moving before the anaesthetic had worn off, which left him in a lot of pain when back at home. Getting up the stairs was a struggle at first.

A week after the knee replacement surgery, Derek was able to wean off strong painkillers and switch to paracetamol. Doing the physiotherapy exercises was painful, but he saw it as “good pain” that meant the knee muscles were building themselves up again. Derek was aware that these exercises were very important as his doctor had given him the sense that without them he could be “back to square one” with “no chance of putting it right”. He also attended a series of two-hour physiotherapy sessions, which were “very beneficial”. He continues to try to integrate the exercises into day to day life.

Recovery has gone well overall, though Derek’s pain levels are sometimes “zig zagging” from day to day. He feels that the surgery has met his expectations and he really enjoys being able to walk for exercise. Derek remains a bit wary about falling and landing on his knee as he does not want to cause any harm to the joint prosthetic. He has some pain in his left knee which causes occasional concern, but he hopes that the surgery on the right will continue to help by re-balancing the distribution of his weight. He continues to take paracetamol on bad pain days, but generally avoids taking painkillers. 

Derek’s knee would be painful after exercise and became more frequent and constant when walking.

However, I think I also did mention that when playing cricket one year, I did in actual fact rick my right knee and I think that was possibly the start of the major problems I had. It was painful at the time for about ten days. But I just self-medicated and it got okay. But I always felt my right knee was weaker of the two and its then in recent years then, as I say, it has got it’s got bad.

Well, I think it, it was, you know, if I did something did a bit of extra exercise, I would I’m a bit conscious of it for a few days and I was, think ‘oh I’ll stick a bit of Deep Heat on it or something, and be alright in a couple a days’ and generally it was. But then the occasions became more frequent and the pain became more constant and that was it. But having said that, it was probably about, my left knee was if you like it’s been the good one. But actually, up until about two or three weeks ago, my left knee has now started playing up. And I feel, you know, I always thought I was putting more I would’ve obviously been putting more strain on my left knee for obvious reasons. And I think that now is sort of been in to say, “Oi, mate.” My condition definitely is deteriorating, where I think I’ve put in my letter to [surgeon], getting on for two years ago now, I suppose or 18 months ago. Where I could walk up and down the esplanade here in in [town] without too much problems and probably walk round the town without too much problems. 18 months ago, it was becoming a bit of a trial. And I have to say that now, just to walk up and down the, I do have sort of good days and not so good days, let’s put it that way. But to walk up and down the esplanade now is quite an ordeal for me. In fact, I don’t, it is too far for me now.

Derek woke several times a night because of his bladder problems. He then found it difficult to get back to sleep again because of the discomfort in his knees.

Regarding how I feel, I think probably that in itself makes me feel pretty grotty, obviously it’s very, very difficult to sleep as well. I, also find that I’m generally having to go and pee generally a lot during the day under normal circumstances, like okay now it’s, I haven’t had this treatment since December 7^th but I did have a camera treatment yesterday which has made me pee more than normal.

Together with my knee, I find it very difficult to sleep because I have to get up during the night eight times plus, I would say, and of course then when I go, try and go back to sleep I’ve then got to try and settle my knee in a particular position, and then when I’m comfortable with my knee I drop off. Of course, then of course I want to go and have a pee again.

So, I’m finding that my knee is not helping me sleep by any stretch of the imagination.

So, I’m not sleeping at all well at the moment because of that, but again all right it’s just one of those things which I’ve just got to, got to accept.

Derek says it’s frustrating to not be able to enjoy life in retirement and he was still adjusting to the change.

And, you know, obviously, we’re actually very, very happy down here. But, as I say, this is where it comes back to feeling a bit frustrated, you know, having, worked [laugh] pretty hard, now really, I’d like to have the benefits but, you know, but unfortunately, at the moment, because of, certainly as far as I’m concerned, my knees it has been an encumbrance. Although [partner], I have to say, thank God is pretty fit and she does her walking and all the rest of the bits and pieces, but not with me [laughs].

And yes, you know, I get, [laughs] a few years ago, you know, I was in and out of the car, yeah, right, yeah, hello everybody. No, now it whenever I get out of the car, I am always extra careful.

One leg first and then move my bottom round, get the other one out and then give myself a hand out and. I’ve always thought myself as a young -, you know, but as I say, you see the trouble really is, Abi, that particularly with us chaps, we all think we’re 21.

[laughs]

And when something happens and we realise we’re not 21 anymore, we don’t like it [laughs]. And that’s the real problem, if I’m honest [laughs]. But there we go.

Derek thought of people worse off than himself and told himself to “get on with it” but he did feel very frustrated that he couldn’t be more active.

But I joined the, when we moved down here, I joined the local cricket club and thought ‘well, you know, I could do something like umpiring or something like that.’ But I couldn’t stand now. I couldn’t do that now without a shadow of a doubt. You know, we were hoping to do a bit of croquet or do a bit of something. I couldn’t do that at the moment, unfortunately, which I find very, very frustrating. Because I do like to be, do like to be active and I find my present incapacity very frustrating. But, you know, then I look round and I see people far worse than me and I think ‘well, what am I complaining about?’ [Laughs].

Well, I mean there are, [laughs] dear oh dear, there are some elderly people round here. And, you know, on the Zimmer frames and God knows what else and all the rest of it and you know, little buggies and all the bits and pieces. And I think well, what should, you know, ‘how should I complain?’ In fact, a good friend of ours as well who, she doesn’t live round here, but actually she was a school colleague-, my partner is a school, retired schoolteacher. Her great schoolteacher buddy had, I can’t think of it but anyway, she had to have both her legs amputated. And I can’t think what she had now, I’ll think of it in a minute. Anyway, and of course, I always think to myself, her name is [name of friend], and I always think to myself ‘well my God, [friend] would like to have my complaint’. So, you know, I’m always a little bit, thinking ‘well there’s a lot of people far worse than I am, you know, shut up and get on with it’, if I can put it that way. But yeah, there are times when I do get frustrated because I do want, you know, I would like to certainly be more active than I am. I certainly would like to, at the very least, walk around the town and do a bit of shopping without having to sit down every, every so often.

Derek occasionally took paracetamol but was hesitant about taking stronger painkillers because of medication he took for other conditions.

I don’t like taking, cos I take so many pills generally for my heart, I don’t like taking painkillers, however you know I do. When things are a little bit worse than normal.

Sometimes, certainly at night, sometimes I wake up and take a couple of paracetamols. But to be perfectly honest with you, they don’t, paracetamols now don’t seem to have much effect. I haven’t been down to the doctor to take stronger ones because with all the pills I am taking, you know, [laugh] I don’t want to start going down the road of taking strong, strong painkillers unless of course, I’m advised to.

But I’d rather not [laugh].

Derek is hoping that after knee replacement surgery he can get back to activities he enjoys, like walking.

Well, nobody likes to have surgery, but on the other hand if that’s going to make my lifestyle that much better then of course I’m looking forward to it, but as far as that’s concerned, I’m looking forward to being able to be able to go a nice walk, we’ve some beautiful walks around here and as I say my better half is, she’s a walker, and she says, “Well can you come a little way?” Or whatever the case may be, and I do when I can.

But again, I joined the local cricket club and I thought well unfortunately I won’t be able to play cricket anymore. Well, that’s okay, but I might be able to do a little bit of umpiring. Well, it would be impossible quite honestly for me, even just to stand during even a short cricket game to just to stand on my knee, I would be so uncomfortable. So, I’m looking forward, I sincerely hope to it being done and I’ll be able to do these little things which I’m not being able to do at the moment. In particular going on nice walks, and not having to worry and think, “Oh,” and sit down every couple of minutes, or whatever the case may be ‘cos my knees playing up as we term it.

Derek had a medical friend whose knee surgery wasn’t successful and his mobility didn’t improve and although he knows “these things can’t be guaranteed” it is “in the back of my mind.”

I did point out to him that a great friend of mine, who actually was, was a GP, had a  knee replacement and it had not been a success. Which obviously concerned me a touch, though I think my doctor friend who had the knee replacement actually was s in his eighties actually. But you know, obviously these things cannot be guaranteed and it’s a question of keeping my fingers crossed, but I would obviously like an indication of how successful an operation is likely to be.

You know, if it all goes as well as [partner]’s replacement went, then that would be pretty marvellous, that’s obviously what I’m hoping. But of course, the concerns really are, you know, my old friend Doc [name], as we used to call him, Doc [name], that’s not telling you his name, that’s not divulging any names I’m sure [laugh]. But my old doc friend who as I say, finished up in a wheelchair. That’s something that that of course, would be of great concern to me. But I’m, you try and push these things to the back of your mind.

Derek feels the benefits of knee replacement outweigh the risks. He feels fortunate that he has an option to try and fix his knee through surgery.

I mean, I always think when you are having a procedure, it is a balance, in fact whatever you do in life, if you’ve got to make a decision, there’s fore’s and against. And I mean, I, just thinking so much to myself, well, the way things are going at the moment and particularly now the left knee is playing up, if nothing is done, the chances are probably going to finish up in the pasture anyway. So, you know, aren’t I fortunate in having an option to try and, to have to try and put it right.

Derek’s positive experience of healthcare for his heart condition, bladder tumour and his wife’s illness gave him confidence in having knee replacement surgery.

But as I say, when we first heard that [partner] had breast cancer, quite honestly for some time the world just stopped turning if I could put it that way. But I mean, she’s received marvellous, marvellous treatment and, which we’re very fortunate and she still is, the way they’re looking after her as well at a particular hospital where she goes to, which is a centre for breast cancer, I mean, absolutely superb. And the hospital I go to for heart is one of the leading heart hospitals in the country. And I mean, the treatment I have had has been fantastic.

And what is great at that particular hospital is that when you’re talking to anybody, they make you feel as if you are the only person, you are the only patient they’ve got. And you feel so, they’re so concerned about you and nobody else. And, you know, that sort of things like that are very reassuring. And I have to say that I found that similar experience when I went to my local hospital here for my bladder tumour. And that sort of treatment I feel rather than being one of a number like, “Next please, yeah, alright, right,” you know. No, no, no. The sort of treatment that I have been fortunate to receive at my original hospital and now at the hospital for my bladder tumour, I feel that I’ve been most fortunate and I’m just hoping and praying that fortune is going to continue [laughs] with my knee [laughs].

Derek’s knees rapidly deteriorated while waiting for knee replacement surgery, meaning he could only walk a few paces. It was worrying to not know how much longer he might wait for the operation.

My knee was slowly deteriorating, but about three months before the actual op there was a rapid deterioration, I could hardly walk a few paces, I was in despair is not the right phrase, frame, is not the right expression but I was anxious let’s put it that way.

How did you manage with the kind of the pain and the mobility impacts then?

Well stiff upper lip, and just to, I didn’t have any option. To, just got on with it, but of course my mobility was very much restricted. I couldn’t walk more than a few paces in the end.

I see people far worse off than me so I just think well I’ve got to take my turn. But I mean yeah it has been going on far longer than I would have hoped. But you know even so I’m, I appreciate the fact that something can be done.

Derek had been turned down from one hospital where waiting times were shorter because he was advised that he should have his knee surgery at a hospital that had a cardiology unit.

I received a telephone call from the hospital saying would I be prepared to go to another hospital to have the operation, as the present hospital that I am under has obviously a long waiting list for obvious reasons. I said yes I would , two alternative hospitals were mentioned, we went through a, a questionnaire on the phone as I was asked if I had a pacemaker, well I have an ICD plus defibrillator, and immediately the conversation then was stopped regarding questions, and I was told well because of that we do think you ought to remain where you are as they do have a heart unit there, and just in case, we believe that you should have this operation only done under conditions where there is a heart or cardiology facility.

I obviously accepted that, and I was told, “Well I’m afraid again it’s where we were trying to trying to shorten the time where you would have the procedure, you’ll now just have to take your turn with the hospital that you are being dealt with presently, being dealt with. I of course accepted that I appreciate the fact that they’re still looking after me and I will just have to be patient.

Derek noticed that his pain after total knee replacement surgery followed a zig zag recovery where he had “good days and not so good days.”

So, I did have the operation. I was delighted to have it, obviously there was the normal amount of pain, I wasn’t able to sustain the strong pain killers for longer than a week as they had nasty after effects, so I maintained paracetamol at 8 paracetamols a day.

And how quickly did you start to see sort of the pain go away and sort of see some benefits from your knee replacement?

Well, I should, I likened it not to having a bad cold or flu, generally you know if you  have flu, and once you start getting better you know you start getting a little bit better every single day. And the graph goes straight upwards. I did find however with this that it wasn’t the same. I had good days and not so good days.

And one day if you like I’d feel, “Oh you know this is feeling a lot better today, a lot less pain today.” But then the next day I could then be, you know the pain could return. So, although I felt that the graph was generally moving upwards, it was zig zagging upwards, if I could put it that way.

Derek managed to go up and down stairs the day of his operation. He found it harder to move around after his anaesthetic wore off.

Well on the, I had the operation I think early Saturday morning, and by the time I came to and it was Saturday afternoon, because I was still anaesthetised from the waist down, quite honestly it felt absolutely brilliant. And I was able to get up and I was hobbling around on crutches and a team of physiotherapists came along to see me, and even I was going up and down the stairs and they said I was making remarkable progress and that I could go home the following day. So, I was absolutely delighted about that. But of course, then what happened during the evening and during the night of course the anaesthetic completely wore off and on the following morning of course I was in quite a bit of pain.

And I couldn’t do the what I did the previous, the previous afternoon.

So, I did go home and to be perfectly frank with you, I think I went home a bit too early because when I did get back home there were difficulties particularly, I had great difficulty and I was extremely worried about actually just getting up the stairs. But eventually I did manage that, but there we are. I was on strong, still on strong painkillers, so that was my return home.

Derek found it beneficial to exercise with others at the physiotherapy sessions he attended. He felt it pushed him to do more.

But I appreciated the instructions to, to do my exercises, it was impressed upon my mind very, very strongly that if I didn’t do them then the whole thing could have been a waste of time and the whole thing you could be back to square one, again, and there would be no chance of putting it right. So, if I didn’t do the exercise then forevermore, I would be in pain and in trouble.

So that was an incentive to do the exercises as you can well imagine.

And do you think that that’s part of the reason why it has been such a good outcome for you?

I think obviously it’s I think first of all it was the skill of [name of surgeon], of which I’m eternally grateful, and, and secondly, yes, I think it’s the, the exercises and also the I, initially I, I had written exercises to actually do, but then when I got to the classes that really was a great help.

Was that in terms of someone being able to sort of check that you were doing the exercises correctly, and sort of giving you advice as you go?

Yes, I think so and the fact that there were some other people there as well, you, you wanted to keep up although it wasn’t always possible to you know if we had to do something, I dunno, twelve times, you did your best but alright you, you, if you had to give up you gave up after ten, whereas if you were probably by yourself, you’d have probably given up after I dunno six or seven or something.

But you had other people to do it with sort of you know keeps you going a bit and you think to yourself, ‘Well come on, keep going, don’t be a wimp.’

So [laughs] I think that that’s actually good that you, you’re actually exercising with other people.

Derek says he can bend his knee back further each month. He had been told it could take a while before it returns to normal.

Well, you know I still, I can’t sort of completely bend my knee, but you know it’s still, I feel it is getting better and betterer, if I put it that way and I was told it’d be two or three years before it actually returns to bang on normal.

Which you know, which is fine. But now I can’t bend my knee as far back as yeah as my left one, and I don’t expect to but yeah, I can certainly bend it back far more than I could’ve done two or three months ago. So if you like every month that goes past so, I can, it’s getting easier, let me put it that way.

Derek maintains his knee function through walking regularly and incorporating exercises into his daily life.

I think initially I might have overdone it a bit actually, but do you know I probably  went for probably a longer walk than I should have done, which then the following day would then put me back. So, I’m a little bit wary about how much I do push it, but it has been impressed upon me how important the exercises were initially and I still try and obviously maintain full use of my knee if I put it that way by my going on walks and generally sort of if I’m standing around somewhere trying to stretch it and do one of two little exercises anyway whilst I’m just standing around if I’m waiting for a bus or something like that.

Derek can walk a lot further after knee replacement surgery. He no longer has to plan going for a walk, he can just go.

Oh, most definitely. I’ve been able to walk a lot further, yes most definitely. Uphill is a - still a bit of a bind but no most generally I have been able to walk a lot further and also you know to stand, whereas I couldn’t really stand before now most certainly I can. As I say I try and do a little exercise if I’m standing around for some time so whereas I would have to think about going for a little walk I now just don’t think about it, I just, we just go for a walk.

Derek prefers to read information step by step when the consultant tells him what stage of the process he is at.

Have you had anything like leaflets sent to you or given to you at appointments?

Yes, I have. And there are, I haven’t read them all through because I don’t want to know if it’s really bad, you know, if it’s really bad news. I’d rather do it stage by stage, to see what the consultant has to say and then okay, if the consultants says, “Well this is what’s got to be done.” What’s the point about reading about anything else? I’ll then like to mug up about, you know, what is going to happen once I know what is going to happen.

All that does, it just sort of frightens you all the more doesn’t it. But, you know, if the consultant says, “Well this is the stage we’re at,” well then read, read, read about what stage you’re at. ‘Cos actually it, it seems to me pointless reading about something which please God might not happen. All it does is upset you.

Derek was told by a friend about a “cold ice cuff” to help knee pain which he used after his knee replacement surgery.

Well actually funnily enough a pal of mine actually is having a similar situation, he’s had it, I’m in contact with him, and what was of big help I got a cuff which I, which I used to put around my knee which was an ice pack but it was from, forget the name of them, but it was a big cylinder which you put ice in and then okay you lift it up and the ice then all, you know comes out of a cuff, or a collar, the very cold water comes, iced water comes down the cuff. That really was a great help when I was in pain.

Was that after the surgery or before you had the surgery?

That was before I had the surgery.

Before, yeah.

I’m sorry, after I had the surgery.

Oh okay. Yes.

I actually put, put frozen peas on my knee either general before the op, but then I was told about this cold ice cuff just before I had the op, I mean for what they are they’re very expensive, they’re a hundred pounds each, and when you look at it you think, “Well crikey what the, you know a hundred pounds for that? That’s ridiculous.” And really you, it, for what they are for a hundred pounds you would say crikey that really is so over the top, which I think it is. But on the other hand, from the relief that it gave me it was well worth it.

Was that the [city] team that had told you about that device?

No, it was a friend actually.

It was a friend?

Who’d had a knee op herself.