Carticel 1-year (+2 months)

I'm now 14 months post-ACI (Carticel implantation) in my left knee, and about 6 weeks removed from my 1-year check-in with my doctor. I've got mixed emotions and a mixed review to offer.

(btw: a recap of my prior posts on my knee surgery/Carticel experience can be found by clicking here.)

Compared to either pre-surgery, or this time last year (two months post-surgery), I'm in great shape. I rarely think about the condition of my knee during my daily activities. In contrast, climbing stairs was painful pre-surgery, and only occurred two months post-surgery if I scooted up stairs on my butt, and even then I would try this only a couple of times per week.

Also positive is the subtle progress in knee health that I've made since my last update 5 months ago. I'd describe improvements as slow and steady, as I don't notice changes week to week, but I do feel more capable every month. (Along with more "life" in my knee every month.) I've also had friends notice that I seem to be walking more smoothly even though I generally only grade myself as "not walking normally yet."

You may be sensing a "But.....," and you're right. Here's a few critical observations:

-While my knee function has mostly returned, there is still an element of wear and tear (or stamina) that is humbling. Example: football tailgating season has begun, and I can definitely say that tailgating for 1-2 hours, walking into a stadium, sitting for 3 hours, and post-game tailgating for an hour or so is tremendously exhausting on my knee. Once home from the tailgate, all I can do was curl up on the couch, and also take it easy the next day. Note: I don't experience pain during the football experience - there's just cumulative wear or knee exhaustion. The positive spin on this is that with no pain, I'm just pushing stamina boundaries, and my hope is that this issue will diminish in time. (Downside: it is less obvious to me when I have pushed too far.)

-In general, my surgically repaired knee doesn't have the same springiness that my "good" knee has.

-Prolonged periods in dress shoes really, really take a toll. In response, I've traded style for comfort in my dress shoes (no more hard soles for me), which has made for an improvement.

-I also sporadically experience very intense but momentary pain when I torque my knee. These outbursts are diminishing in frequency, I think, but I probably have one once every two weeks.

I'm also a bit peeved that my recovery isn't complete one year on. All of the Carticel literature suggests recovery in 12 months, and I was hoping that I could rejoin my adult baseball team this summer. However, when I went to my doc for my 1-year check-in, he cautioned me that Carticel recovery is really a 1-2 year activity. I swear that in all of my previous interactions with my doc he stressed the need for a full year for the new tissue to adhere and recover, with no mention of the possible need for a second year. The doc also kept in place some restrictions on my activities - I still can't stand up on my bike pedals, and I'm nowhere close to running any time soon.

The doc also suggested that I place more emphasis on diverse exercise. Prior to my check-in, I was regularly cycling 15-25 miles 3 or 4 days in a row. (Performance wasn't perfect - my best days were always the first of several in a row, and anything beyond 2 hours was labored.) I have since cut back cycling to every other day, and am rotating in other no-impact exercises - swimming and walking. The negative here is that cycling in the Blue Ridge Mountains in the fall is a fantastic experience, and there's been a few days where I'm sad to not be able to cycle due to my new exercise schedule.

(That said, I've still pedaled 1,500 miles this year.)

So, if you were to ask me if Carticel implantation has been a good move based on my current knee health, I'd say that my knee health is better than pre-surgery, but has not yet reached my goals or expectations one year post-surgery. I'm very hopeful though that my knee health will continue to improve. If so (and there is reason to believe in further improvement), I should be able to give a good review for Carticel.

Carticel patient Q&A

I've had two blog visitors in the last month who have had good questions about my A.C.I. surgery and experience with Carticel. I thought it would be useful to post their questions and my answers in the hope that they would be helpful for anyone else scheduled or considering surgery.


First up is a note from Kevin:

1. In reading through the recovery/rehabilitation guidelines, I'm not finding much instruction on when I could return to work at a desk job. I'm a consulting engineer and work primarily in a traditional office setting (can be sitting all day, if need be - not much walking). My boss has told me the company will be flexible with working from home or rearranging things at the office for me. When in your rehab did you feel you could sit at a desk for 8-9 hours a day?
2. Any problems with insurance?
3. What kind of activities did your doctor say you could expect to resume if all went according to plan with the ACI?
4. How many hours/day should be budgeted for rehab during the first 2 weeks? 6 weeks? 6 months?

Basically I would like to get as reasonably accurate of a picture as possible of what my rehab schedule will look like…….

My response:

- I found the carticel literature produced by Genzyme (the company that makes carticel) to be very helpful and pretty much spot on in all things. If you haven't received this stuff yet (I did, after my first consultation), I highly recommend you get it (and get multiple copies - your physical therapist and others will find it handy to read to.) I'm talking specifically about a green spiral-bound guide, and a small green pamphlet that is the summary of the green book.

-I found the recovery/PT to be pretty easy, as long as you stick to it. No particular exercise is too difficult, and no session was too tough. Adding up all of the movement exercises over an hour could leave you tired, but I always found it to be a good kind of tired. Sometime sore, but not in pain.

-I was really, really lucky to have a great support team. I moved back in with my parents for a month post-surgery, and friends and family were a HUGE help.

-if I could go back pre-surgery and do one thing it is to start a diet. Post-surgery you do a LOT of sitting around, and inevitably you put on some weight. A pre-surgery diet would not only make this a little easier to accept, but also lightens the load on your knee.

1. Ah, returning to 'regular' life. Here's one area where I found the guidance was a bit too optimistic. To answer your question directly: how long until you could sit in the office for 8-9 hours/day: I'd say 1 month. (But you can contribute well before then, working from home or half-days.) Here's why I say that:

I work a desk job too, and was told that I should expect to miss a full week of work, but after that, I could go back to working at my desk. Everyone's reaction to getting chopped open is a bit different, but I'd say that I didn't really get back to work for 2 weeks, and I'd say it was a month before I was good for anything but answering emails and other "light duties."

My implantation surgery was on a Thursday, and I expected to be back to reading emails and maybe joining teleconferences during the next week, with the expectation that I'd be back "in the office" the week after (i.e. 11 days post-surgery.)

Even with all the care that I was getting - getting driven around, etc., I was surprised by how draining the recovery was and how small things became big accomplishments - like taking a shower, or walking between bedroom and living room. (btw: you're going to live on 1 floor for about 2 months. Stairs just aren't worth it.)

The first month post-surgery is a blur to me now. I wasn't a vegetable, and certainly remember feeling like I was getting things done, but everything for the first month took 4X as a long as you'd expect - even simple things like reading a book. In the early days post-surgery, I'd fall asleep in the middle of a chapter in the middle of the day. This got better almost every day, but still, I was surprised how drained I was, every day.

btw: one piece of advice from my experience: get an iPad to keep you busy during the recovery.

I didn't do any work other than reading a few emails for the first full post-op week, and worked lightly from home in the second week. My third week was effectively all half-days. (Luckily this was vacation season in the summer.) It was only by week 3 when I could think better and focus.

As for the physical dimension, you'll be mobile pretty quickly (with a walker), and you could get back to your office quicker than I did. PT and doc check-ins won't really interrupt your work day, but don't underestimate how draining just getting from the parking lot to your office will be. Also: for the first month, your repaired leg will be in a locked brace running from ankle to thigh. It's not as bad as it sounds, but it has a few implications: 1) you'd definitely rather wear shorts during this time, 2) you can still get around with the brace on, but it is cumbersome and you learn real fast to minimize movement - no getting up to pick something off the printer ever half-hour.

The one thing that could keep you at home is the required time in the CPM machine. (CPM= continuous passive motion. It's a gizmo that just keeps lightly moving your leg, whether you are awake and watching TV, or sound asleep. It's not difficult, but the first week or two requires rotating 1 hour on/1hour off schedules. You really can't go back to work when you need to spend 4-8 hours a day in the CPM. Unfortunately, I can't recall if the CPM was only for 1 week, 2 weeks, or 3 weeks. I know we returned the machine to my doc at the 1 month check-in.

2. Insurance: I was really, really surprised by the insurance process. (I'm with Anthem Blue Cross/Blue Shield here in VA.) For starters, my doc's office took on the challenge of getting approval from my ins. company - I really had almost no interaction with the ins. company. There was a problem, though, in that we set a surgery date based on a regular turnaround time by the ins. company. My approval process went long, though. I was very nervous that this was a negative, but it ended up being a paperwork issue - my referring doc (my 1st orthopedist, who eventually referred me to the carticel doc) hadn't sent some particular info. One other tidbit to be aware of: I heard that insurance approval can sometimes be complicated by body weight. (i.e. insurance isn't going to pay to fix the knee of a 400-pounder), and that BMI (body mass indicator) is an important screening criteria with some companies.

The one negative in the pre-surgery process is that I never knew what my financial obligation was going to be - there aren't fixed prices for something like this. I had an idea of what the whole deal costs, and I thought that I'd owe 20% of it - which ended up being accurate - but NOONE could tell me this with enough certainty.

3. The expectations that you'll read about in the carticel literature are pretty accurate - no running or abrupt movements for a year. That said, I've been swimming, bicyling, and walking without difficulty for months now. I was swimming in month 3, and crutch-free at 4-months. Just in the last month (month 7) I've gone from thinking "just the thought of running is painful," to "yeah, I could see myself running in 3 months."

4. Rehab: actual daily demand is pretty light - like less than hour. My schedule was (roughly) go to a PT place every other day for about an hour. On the "off" days I did a series of leg lifts and other simple movement exercises which took less than a half-hour. Warning though: when you're only a week or two post-op, even these exercises will drain you pretty good. (the PT is a bit lighter for the first few weeks, concentrating on movement. Later, when building strength, you'll do the 1-hr PT period.)

I'm 8 months post-surgery, and I'm surprised to say that I'm still endurance-limited. I can do about an hour and half (max) of continuous activity (like biking) before needing a break for my knee. I'm told this is normal, and that over time this figure will rise, but that I shouldn't try to "power thru" my limits.

Kevin, I hope this helps. Please feel free to contact me with any additional questions or clarifications.

Cheers,

Tim


And the second note from Lisa:

How much help will I need the first week or two post-op? I live alone and some patients said I will need someone to stay with me 24 hrs a day for the first week or two and others said I wont need much help at all.

My other concern is how much Genzyme charges for cell growth. First I was told they accepted only what Aetna would pay and nothing from me, then they send me a letter that I am responsible for the balance. My issue is Carticel will not tell me how much they charge for the cell growth. Did you receive any invoices for your cell growth?

Thank you for sharing your experience,

Lisa

My response:

The first week or two post-surgery is pretty slow - except for days where you have PT scheduled, all you really do is alternate between however you like to rest (TV, reading, bed, etc.) and sitting with your leg in a CPM machine. (You've heard about the CPM machine, right?) The days will fly by, as you'll find yourself randomly drifting off to sleep while reading or watching TV, which was good for me, and hopefully for you too.

PT days are straightforward too. Think of it as basically an hour of coached movement exercise - no weights, no machines.

I don't agree with the idea that you'll need help available 24/7, unless you have one of two challenges:

1) your house or apartment has stairs on the inside or outside, or

2) you don't prepare to live as smoothly and simply as possible for the 2-3 weeks post surgery.

Here's what I mean: stairs are very, very, bad, immediately post-surgery. They're difficult, draining, dangerous, daunting, and the devil, all rolled up in one. A simple flight of stairs up to an apartment, or to a second story bedroom is enough that you'll want to plan your days around your up/down trips. In addition to the challenge of the stairs, they can be very dangerous - you'll be on some kind of painkiller for ~2 weeks, and stairs + drugs don't mix well. I lived on one floor of my 2-story house for about 2 months post-surgery, with a few exceptions when I very slowly scooted up/down the stairs on my butt, and I'm glad that I did so.

Having someone around - even just a visitor every day or two - can really help out a lot with regards to stairs.

Prepping in advance of surgery can really reduce your interactions with stairs and make daily life post-surgery less demanding. Moving everything you need to one floor - or even one room would be a big help, as would doing all of the laundry, grocery shopping etc. in advance. Don't even dream of carrying a laundry basket for the first month post-surgery, and you definitely won't be pushing a grocery cart through a store. (I stocked up on shelvable foods (spaghetti, etc) and relied on friends to bring by things like milk, fresh veggies & takeout.)

Along the same lines of planning, for the first month or so you'll want to really coordinate your trips out - you wouldn't want to go to PT in the AM, then make another trip out in the afternoon to visit the drug store when you could combine these into 1 trip out, to minimize your work, and make the most of any friend who is escorting you that day.

(Oh, one other thought about having help and prepping: showers are a much, much bigger challenge than I expected. I'd try to have someone on call in the next room for your first couple of showers, and definitely prep your shower pre-surgery by finding a seat or stool to put in the shower. (I highly recommend a plastic lawn furniture chair.))

So, solo life immediately post-surgery is completely possible, just take it easy, listen to your body, and make sure your survival doesn't depend on anything that HAS to be done.

(While solo life is good, I really appreciated every visitor, sometimes off-loading stupid stuff on them ("Can you get my book?") but every little bit makes life easier post-surgery, and your friends want to help.)

As for finances, I can't give you a precise answer, but I'll tell you my experience. I had (and have) a very regular health insurance policy with our local Blue Cross. I too sweated pre-surgery as nobody could give me any exact financial answers, and I got letters from Genzyme and others that scared me - like the one that says "if you cancel the surgery once your cells are thawed (a day beforehand), you're going to pay for everything,even if there is no surgery."

Ultimately, the finances were a pleasant surprise. I'm pretty sure that the all-in, total of everything, cost for me was ~$64,000, but my insurance covered >90% of everything. I think the balance from Genzyme for growing up the cells that I had to pay was $963, and I had a couple assorted bills for everything that might have added up to another $2000 (anesthesia was one, follow-up doc visits was another - nothing too big on its' own.)

(PT was a separate issue - my insurance covered something like the first $750 in PT. My PT bill was much more than that, and I partially blame myself, because my PT folks were very adept at offering additional services to make a bit more money. I never realized that when they said "do you want knee mobs?" (manual massage of the knee) I was committing to an additional charge.....every time.)

Best of luck with your surgery!

Cheers,

Tim 

I hope you find this helpful. As always, please feel free to send me an email through any of: my profile page, my Facebook link (lefthand column) or write questions in the comments section. To see all of my posts regarding my ACI/Carticel experience, click here or "Knee Surgery" in the label cloud to the right ---->

Small knee update, with cool graphics

It is early March in central Virginia, and the high temperatures this week will all be 70 degrees or better. The unseasonably warm weather has allowed me to undertake some quality cycling, and allows me to gauge my progress in recovering from articular cartilage implantation surgery (carticel) eight months ago. 

Though I am still not permitted to stand up on the pedals - essential for climbing in anything but the lowest gear - I surprised myself yesterday by accidentally choosing a cycling route with 2 x category 5 climbs. (>1mile each, with an average grade >3%), so I realized that I maybe ready to do one of my favorite rides that has a good amount of climbing. This also allows me to do a direct comparison with my pre-surgery performance - something that I've stayed away from. 

Today's moderately hilly route was 20.2 miles, with 413 feet of climb. My pre-surgery rides of this route averaged 1:09, an average speed of 17.3mph.

Today's (post-surgery) ride was 1:20, an average speed of 15.1mph, so I was ~13% slower, but I'd say that the wind was a bit heavier than usual today, and more importantly, I was a bit heavier today. (I still haven't worked off all of my post-surgery and winter weight gain.) Wind and weight probably explains at least half the performance gap, so all in all, I enjoyed a good ride, and seem to be recovering well. 

When inputting the ride data into a tracking site that I use (www.mapmyride.com), I noticed a new, cool option that I'd like to share: 3-D flyover of your cycling route. Take a look below, and pay attention to the speed of the flyover - the flight accelerates or slows based on whether the course is downhill or uphill - very cool.

I can't believe that this very cool technology can be applied to my simple bike rides in central Virginia.

Carticel @ 8 months

I had my 8-month post-surgery check-in with my carticel knee doc yesterday and got a very positive review.

First, here's a recap of where I am @8 months: after Carticel implantation for a defective femoral condyle last summer, I am fully mobile, with roughly equal strength in both my "good" and "recovering" knees. Knee pain has been minimal, and typically only after prolonged effort, although I have occasionally had sharp pain when torquing or turning my knee. Walking straight and climbing stairs are completely without issue for me, though my walking gait is not totally back to normal.

(Here's my prior Carticel patient blog entries, from oldest to newest:

Carticel patient experience

Carticel patient status update

Tips and advice for Carticel patients to be

Carticel recovery @ four months

Carticel implant recovery @ 6 months

For the last ~2 months I have been doing my own exercise and PT after completing formal PT. I have been wearing a short unloader brace on my recovering knee for short periods on strenuous days and during all physical activity (e.g. biking, PT.) Exercise has been limited to no-impact activities (elliptical trainer, stationary cycling, swimming, etc) though on warm days this winter I have cycled outside, racking up ~140 miles over ~10 rides. Doctor's order were to limit biking to routes that do not require me to 'stand up' on the pedals, so I have minimized hills - not an easy task when you live at the base of the Blue Ridge Mountains. My longest ride is ~1:30, though around 1:15 I start to "feel it" in my knee.

Doc update:

I passed each knee test with flying colors - the doc reported knee flexion at 145 degrees, and he was very happy with the tested strength of the knee. I was asked to squat and also to lightly jump with my feet shoulder width apart. Doctor Z reported mild surprise at how well I managed both tasks. (These were both things things that I hadn't tried since surgery 8 months ago, and my initial (internal) reaction when asked to squat was "are you sure that's a good idea?")

I mentioned my (minimal) knee pain and knee tenderness (especially after prolonged activity, like biking for 1:30). Doc reported that this is normal - the new tissue in my knee is only 8 months old, and the analogy he used was that in the case of newborns, new tissue doesn't handle full weight stress until 9-12 months after birth. (i.e. when the baby starts walking.)

My guidance going forward is basically a continuance of existing guidance: continue with no- and low-impact exercise (biking, swimming, etc.), though I can now restrict brace wear to only those times when there is an obvious need for care. (In other words, I do not have to wear the brace while biking, but I should put it on if I know that I will be spending time walking over uneven ground, such as a walk in the Blue Ridge.)

I'll see the Doc again in 4 months, at which time I will probably (possibly?) be permitted to do some light running and other physical activities involving turns.

So, I'd say this sums to "so far, so good!"

Carticel implant recovery @ 6 months

In connection with yesterday's post celebrating my first post-knee surgery bike ride, I thought it would be worthwhile to post a six-month post-surgery update.

In general, my knee health is good and improving. Knee strength in my surgery leg has reached the levels of my "good" leg (as measured by knee extension and leg press exercises), and I haven't walked with assistance of any kind in more than two months. I have also reduced the amount of time wearing my unloader knee brace from all waking hours to half time (plus during any physical activity.)

I would not say that I am walking normally, but probably @ 80% of a normal gait.

I am a little concerned about two things that may be related:

1) the bruise on the interior of my repaired knee continues, though it is somewhat less intense than when presented to my doc two months ago.

2) I do not have any persistent knee pain - even during demanding activity, like climbing stairs, but I do have intermittent pain on the inside of my repaired knee when I put mild torque on my repaired knee. (i.e. when I turn on this knee, typically counter-clockwise, even when wearing the knee brace.)

#1 and #2 are probably connected.

I am very conscious on the condition, so being smart I am only likely to experience this sort of pain once or twice a day, and the pain goes as quick as it comes. It does make me wonder if the implantation has some sort of flaw (or if the doc missed a spot), which is mentally challenging, but still too early to tell.

I seem to avoid or minimize this torsional knee pain when I take the precaution of mildly "popping" my knee into alignment, which is accomplished by taking all weight off of my leg and performing a very slight clockwise turn of my leg.

I have increased the attention I pay to lateral knee exercises (of which there aren't a lot), and I'll check in with my Doc again next month, and I'll be eager to hear what he thinks about this.

In general, though, I am still improving, and experienced my first totally pain-free day last week. I do find that their are daily limits to the amount of activity that I can handle, but this has been on a continuous upswing since getting rid of my crutches in early November.

(I really only experienced this on days with substantial walking, such as touring in Europe late last year, and moving between business meetings in Boston this month.)

Looking forward, I am really, really excited about biking season, and have told my baseball team that I aim to be playing with them again this summer, which means my recovery is right on track, though right now, the thought of running is painful. (Maybe that's my age, and not my knee speaking.)

Please feel free to get in contact via email or the comments section if you have any questions about life with Carticel, or the recovery process.

Carticel recovery @ four months

I reached my four month anniversary two weeks ago, and to celebrate, I decided to absolutely abuse my new knee.

(The decision was more like "I've got some business travel to do in Europe. What if I used my spare time to do a walking tour of wherever I happen to be, and count on only needing regular sleep to recover?")

Before further explanation, let me catch up on the last two months: I transitioned from my full-length leg brace (ankle to thigh) to a much smaller unloader brace which I wear only when awake. The smaller brace allows complete freedom of movement, and as I learned, is firstly for protection, not recuperation. (In other words, it is designed to keep you from doing anything stupid, whether intentional or accidental.)

Along with the new brace, I have graduated from mentored physical therapy to a self-guided physical therapy program, also graduating from increasing range of motion to increasing strength. My typical routine is a 5-10 minute cardio warm-up followed by a series of lifts - leg extensions, leg press, hamstring  lifts, and thigh abduction/adduction, finished with a cardio session of 20-30 minutes either stationary cycle or elliptical. (Though typically shorter intervals with the elliptical.)

I alternated every day between the above lifting routine, and aquatic sessions - 15-20 minutes of chest-deep movement exercises and up to a mile of lap swimming. I highly, highly recommend having an aquatic component, btw.

I thought I had a complete approach, but I was reminded at my four-month check in that I need to continue the leg lifts with ankle weights in addition to the gym & pool work.

For the last month or so it has been very exciting to see increases in leg strength. The progress has been obvious just looking at my weight lifts, and by my speed and strength in the pool. Also, by and large, I have been pain-free even during my most aggressive workouts, though plenty of times I have rapidly fallen asleep on my couch following a good workout.

I have also weened myself off of the pain meds, including ibuprofen (Advil), which I'll take 1-2 times per week.

On to my 4-month update:

So, at four months, my doc, Dr. Zaslav, was very happy with my status. No problems, good flexibility and good strength. I won't see him for another 4 months, and in the interim I am allowed to wind down my use of the unloader knee brace, and wind up outdoor cycling - though only on flat ground, and without standing up on the pedals. (I need to wear the brace while cycling or working out any way except swimming.)

The only item of interest at my 4-month check-in is a minor discoloration (bruise-like) on the inside of my knee, roughly corresponding to the site where the carticel was implanted. The discoloration ebbs in intensity, seemingly depending on how intense my use of the knee was that day. The doc didn't know what this might be - he'd never seen this phenomenon before, so we didn't take any action or curtail my workouts. Has anybody else had this discoloration?

Your host @ the Arc de Triomphe in Paris, November, 2011. Can you guess which leg has the brace on?

To celebrate, I flew off to France, Scotland, and London. (OK, it wasn't a celebration so much as a necessary work trip.) I did manage to spend time walking around some of these great places (and I'll post some picture highlights in a subsequent post).

I was fully mindful of my knee health, and always intend to let my knee determine the duration and pace of touring. However, I completely forgot the advice I received post-surgery: always stay ahead of the pain.

I would set off from my hotel with the intention of stopping mid-walk for a stop at a cafe or Starbucks no more than every hour or so. I was pretty faithful to this approach, but inevitably, I'd get tired before I found a cafe, or have to walk a bit further than expected. In retrospect, I should have had the intention of stopping every 45 minutes, but be prepared to go an hour (if it takes 15 more minutes to find a cafe), instead going an hour, and sometimes struggling to an hour and 15 minutes.

I found myself being able to go less and less far between breaks, but typically didn't realize it until my limits were only 10 minutes or three blocks between rests. (At one point, I was down to resting between blocks.)

To make matters worse, my overnight rest cycles were about the same as they had been at home. I should have budgeted an extra hour on touring days.

There was a mild knock-on effect - I found myself lagging in a few of my business meetings. One meeting - scheduled to go two hours - rant to almost 4 hours. I didn't realize it at the time, but I was absolutely pooped by the start of hour 3, and found myself getting a little bit silly in the meetings. Hopefully I didn't make the wrong impression.

The other negative is that once I made it home, I took three days off from my physical therapy routine. Not good, but definitely necessary.

A couple of observations/ideas/advice for Carticel patients:

-Very important: get a good seat on your flights. I scored an exit row seat with plenty of legroom for both long flights. I really didn't have any problems in-flight or post-flight as a result. If I hadn't scored, I probably would have been worse off, and being squeezed into a seat with less legroom would have certainly gotten in my head.

(Incidentally, my doc offered to write a prescription for business class seating, but as a consultant, the price of the trip came right out of my pocket, and I wasn't about to pay $3,500 more to make the trip.)

-Don't underestimate the walking mileage that you'll rack up in the airports. Always, always take the elevator if available - that walk to the gate or bus stop is always longer than you think.

-Consider taxi rides instead of subway/metro travel. I tended to get all-day passes for the metro/Underground, which certainly encouraged me to ride between tour destinations, instead of walking (which was smart), but eventually you'll have subway journeys with long walks to transfer, or plenty of stairs. The taxis are definitely more expensive but an investment in knee health.

-Dial down your touring ambitions and be smarter than me when it comes to knowing your limits. By the time I got back to my hotel room, all I could do was crash for the day or night. I lucked into hotels with good fitness facilities (including in one case a pool), but never did any PT as I was too pooped.

-Do NOT backpack - used wheeled suitcases! The last thing you need as a recovering patient is 25 or 35 more pounds of stress on your knee.

-I am extremely thankful that my trip wasn't a month earlier (month 3). I don't think I could have made it.


My final verdict on the trip will be determined by my strength tests tomorrow, when I'll learn if I grew stronger, or atrophied while traveling. For now, though, it is off to the gym for me!


I hope this update is helpful. As always, please feel free to ask me any questions in the comments section or via email.