May, 2012 Issue

Fri, May 18, 2012

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By Jane Earle

About a half million knee replacements are performed across the world every year at a cost of about $11 billion. A beneficiary of research and money dedicated to treating injuries of highly paid athletes, knee surgery is a tried and true treatment that has been done successfully for more than 20 years. The protocols for restoring the knee to full use following surgery are also well researched and proven. That does not mean, however, that the operation is simple or without risk.

The surgery itself means making an incision up to about eight inches long down the knee. The top of the tibia and the end of the femur bones are cut off and a polyethylene prosthesis cemented into the tibia and a metal one implanted in the femur. Polyethylene replaces lost cartilage on the back of the patella (knee cap).

The major risks associated with the procedure are much the same as with any major surgery: hospital infection, blood clots and anesthetic. The risk from anesthetic is less if a general anesthetic is not used. The high risk of hospital infection is the reason for getting the patient out of the hospital as soon as he or she can safely go home, preferably on the second day after surgery. The second day rule has worked well for Dr. Dennis’s patients. While the average rate of patients contracting a hospital infection is .8 to 1 percent, Dr. Dennis has managed to hold his to .4 percent, half of the lower end of the average. The long white surgical hose worn on both legs for four weeks following surgery help to reduce clots. Travel by air, where blood clots can be a problem and is restricted for weeks or months.

The total cost for my knee surgery, including four weeks of physical therapy, was $53,612.92. It was all paid for by insurance except for one charge of $175.

At 8 o’clock on the morning of July 15, I walked into Adventist Porter Hospital in Denver and presented a half sheet of bright red paper to the attendant at the reception desk. She glanced at it, asked if I knew my way and waved me on.

I was carrying no identification, no insurance cards, no watch or any of the other comforts I never leave home without. The half piece of red paper told the receptionist that everything the hospital needed to know was already in their records thanks to the day I had spent three weeks earlier going through the extensive pre-operative battery of tests required of all joint replacement patients. There would be no paper work that morning.

I got into the elevator wearing shorts, a knit shirt and my freshly scrubbed and polished walking shoes with white ankle socks. I knew that when I left two days later I would need these solid, reliable shoes to keep my feet planted solidly on the ground. When I walked out of the hospital, I would be working with new and alien hardware in one knee and I wasn’t sure just how difficult walking might be. I was prepared. I had done all I could; the rest was up to Dr. Douglas Dennis and his team.

For four years I had agonized over the decision to have this surgery, the ultimate treatment for the painful and debilitating patella femoral syndrome which afflicted both my knees. I had rejected out of hand the recommendation of the first surgeon I consulted who had taken a look-see into the knee with an arthroscope and said I would need a knee replacement. I could still walk and go up and down steps with only mild pain and no dysfunction at that point. I was determined not to surrender my body parts to bionic medicine.

My arthritis specialist recommended I do a series exercises that included lifting weights with my legs to strengthen the muscles to better support my knees. I moved on to cortisone injections into the knee joint, then to gel injections. Finally, I committed to having my own stem cells harvested to be transplanted into my knee for the growing of cartilage. I went through the whole painful process leading up to the day before the cells were to be injected and was notified that there was something strange about my stem cells and the procedure couldn’t go forward. Steroids, stem cells, chicken serum; was this any less extreme than the bionic knee?

By then, I had both serious pain and dysfunction and it was obvious even to me that my only choice to remain active was replacement surgery. I had already consulted five surgeons and an arthritis specialist so I had a pretty good idea what the options were. I was also clear that Dr. Dennis was the right surgeon for me. He had done thousands of replacements and his protocols and patient management were meticulous, conservative and non-negotiable. My kind of doctor.

I arrived at the Joint Replacement Center and went straight into an examining room. Medical personnel came and went for the next hour, checking my temperature and blood pressure, one of them bringing me one of those fetching hospital gowns in exchange for my shorts and shirt. A nurse inserted a needle into my arm and connected it to a short tube so I would be ready to receive what fluids might need to be fed into my body during and immediately after surgery. Dr. Dennis came by and autographed my left leg so there would be no doubt about which one was going under the knife.

The surgery was scheduled for 10:30. At about 9:30, the anesthesiologist came in and explained to me that he would be giving me a spinal block and a second kind of anesthetic to block the femoral nerve to help reduce pain. The surgery would be under local anesthetic. While this pleasant man continued his briefing and began his work, I apparently drifted off because the next thing I knew I was in a hospital bed in a room on the ward and a nurse was wrapping a large ice pack around my left knee.

I was sitting in a half-upright position and during the ice pack operation realized that my left leg was slightly elevated and being moved slowly back and forth by some sort of machine. I didn’t feel very much and I was surprised that the motion didn’t make the leg hurt but it didn’t. In fact, I was a little confused by the fact that I felt pretty well.

It was about then that a tall man in surgical scrubs and cap came into the room. He asked how I felt. I said I was fine but I must have looked puzzled because he said, “I’m Dr. Dennis, your surgeon. I just wanted to tell you that your surgery went very well and when they get you up tomorrow, you can bear full weight on your knee.” Really? Full weight? It seemed unlikely. I dropped off to sleep. Meantime, whether I was asleep or awake, the machine moved on for the next five hours doing its part to prevent the forming of scar tissue around the incision.

Dr. Dennis’s program calls for getting the patient out of the hospital on the second day after the surgery if it can be done safely. This is to try to prevent infections, one of modern medicines biggest problems. I was eager to go. While the care at Porter was excellent, it was constant. Someone was there checking and changing and moving things all the time. I needed to get some rest and it wasn’t going to be in the hospital. The day after surgery, true to plan, the physical therapists came in, insisted I first flatten my leg and then bend it. They were thrilled to see I could get it almost flat and bend it a little. Then they had me on my feet, something I was sure was not possible. They assured me it was so I stood up. The big surprise was that it wasn’t any more painful to stand up than it was to sit on the edge of the bed.

This isn’t so bad, I thought. Later that day, I was helped into the shower by the same therapist and walked around the ward—twice. By now the anesthetic was completely gone from the knee and I could feel the pain. It was significant but nothing I couldn’t manage. Because of my allergy to narcotic drugs, I couldn’t take any pain medicine that actually reduced the pain. I had to manage with Tylenol and anti-inflammatory drugs and the ever present ice pack.

On Friday, two days after I entered the hospital, the nurse delivered my shorts and shirt and shoes and I dressed to go home. I was also wearing the necessary but decidedly unattractive white surgical hose which would be part of my ensemble for the next four weeks. I was wheeled down to the car but my walker, which was to be my constant companion for the next four weeks, was waiting in the back seat ready to facilitate the trip into my house.

I came home on Friday and began physical therapy on Monday. The rush to begin physical therapy is in order to try to prevent the formation of scar tissue around the incision. The more scar tissue that develops, the more painful the rehabilitation. The horror stories of rehab for knee replacement surgery are legion and I had heard my share of reports of screaming patients. My therapist was Kurt Schulze, a tall, lean calm person who asked me to get up on a table and began to move my leg to evaluate my knee. He had been through hundreds of knee rehabs by the time I came along and knew what he was doing, to say the least. A tiny doubt did cross my mind when, toward the end of my rehab, he had me on a machine where I was pushing 60 pounds (half my weight) with my feet in a routine designed to strengthen my thigh muscles. As always, he knew what he was doing and a week later I graduated. I worked with Kurt three times a week at Active Motion’s clinic in Cherry Creek and I did my prescribed exercises at home on the days in between. The key is to progress a little every day by faithfully doing the exercises. While most patients go through six weeks of physical therapy and many do even more in order to get to the necessary flexibility to restore the leg, I was finished by the end of the fourth week. I would have been so proud of myself except that Kurt explained to me that my relatively easy time had to do with the way my body heals; no scar tissue. I was just lucky.

I was back at the joint replacement clinic again six weeks after the surgery to have X-rays and to see Dr. Dennis. We looked at the pictures of my knee implant together and he pointed out to me the polyethylene prosthesis on the top of the tibia and the metal device that capped the end of femur, all held in place by bone cement impregnated with barium. He said it was just as it should be and he was very pleased with the result. To me, it looked like one of the text book illustrations I had seen when I was researching knee replacement surgery. It probably doesn’t get any better than that.

How to Get It Right

Probably the single most important issue in having a successful knee replacement is to select the right surgeon. There are hundreds, if not thousands, of skilled and experienced surgeons in the United States who routinely perform this surgery successfully for their patients. The patient’s own family physician is the best source for a recommendation of a good surgeon in your area. Most doctors will give you a list of a few surgeons they know and respect. You may want to interview more than one surgeon to find the one whose approach to the surgery and the patient best fits your needs.

The Internet is a great source of information about total knee replacement surgery. There are literally thousands of sites that will come up in a general search. The large surgical centers all have sites that will describe the operation and provide illustrations of how it is done. The Mayo Clinic site, for example, is very good as is New York’s Hospital for Special Surgery.

In addition to selecting the right surgeon, it is a good idea to go to a hospital that is experienced in the post operative care of knee patients. It is a good idea to inquire into the hospital’s infection rate because infection is a particular problem with joint surgery.

Finding a good physical therapy clinic or rehab center is critical to a good result. Your doctor will likely be the best source for this information.

Finally, the best result will be achieved by the patient who is in the best possible physical condition before the surgery because it will shorten the length of recovery. It is also necessary to follow the surgeon’s and the therapist’s instruction. There is a reason for each of the medicines, procedures, equipment and restrictions. Ignoring any one of them could delay or prevent a full recovery.