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Wednesday, May 13, 2020

LIfe Chronicles: The Case of the Artificial Knee

Long before I started thinking about craft beer, I was playing sports or enjoying some form of active recreation. You think you're indestructible. It never occurred to me that I might one day have knee problems or, perish the thought, need to have knee replacement surgery. How naive I was.

Pre-surgery: Bone-on-bone
A year ago this time, I was taking steps to deal with an arthritic left knee. Both knees had been problematic for a decade or so, the result of too much racquetball for the last 30 years; too much tennis, football and related high impact activities dating back to boyhood. Meniscus tears in both knees were repaired arthroscopically in 2006.

By 2013 or so, the left one was bothering me again. It was a different pain. X-rays showed narrowing space between the bones on the medial (inner) side. I was nearly bone-on-bone. The orthopedist told me I'd eventually need to have the knee replaced. I did what I could to extend the life of my natural joint, but it had gotten so bad by late 2018 that I had trouble walking my Labradors or doing much of anything.

Getting a knee replaced in American healthcare is a process. You jump through a lot of hoops along the way. When I saw my primary care doc for another issue, I mentioned the knee. She suggested I get x-rays while I was there. I don't suppose she was all that surprised when the films showed severe osteoarthritis in the knee.

The first thing they ask you in that situation is what your goal is. Are you going to be okay with limited activity and a lot of TV watching or do you want to be active? That info helps them formulate a treatment plan. In my case, I hoped to stay active. I wasn't interested in wearing a brace or being significantly limited in what I could do.

My primary care doc gave me a prescription for an anti-inflammatory medicine, a drug that had helped quite a bit when the arthritis first appeared. It was ineffective at this point. She also referred me to orthopedics, but first I got a cortisone shot. That's one of the hoops you have to jump through before they consider more invasive treatment. Some people respond well to cortisone. In my case, the shot reduced my static (sitting) pain, but did little to reduce the pain during activity.

Not responding well to the cortisone shot put me in line for more aggressive therapy. When I saw an orthopedic doc, he reviewed my films, considered my general health and told me I looked like a good candidate for partial knee replacement. That was the case because my knee appeared to be in relatively good shape, except on the thin medial side.

If you do a little research, you'll discover partial knee replacements aren't as common as total replacements. There are a variety of reasons for that. Age is one factor. Some people wait until they're quite old and their knees are completely shot. The medial side of my knee was ruined by activity, not age, which meant the less invasive partial replacement was an option for me.

Why did I prefer a partial replacement? A number of my friends and work associates asked that question. The answer is that a partial replacement is far less invasive. You keep your ligaments, tendons and knee cap. With a total replacement, all that stuff is gone. Recovery from a partial replacement also tends to be faster. And you can always replace a partial with a total someday.

Although I was a candidate for the surgery, the orthopedic folks had to (again) remind me of less invasive options (like wearing a brace) and walk me through the risks of surgery. One of those risks is that some patients don't derive much benefit. They get the surgery and don't get the results they were hoping for. It's not a huge percentage, but it is one of the risks.

My next stop was an MRI tunnel. An MRI, they told me, would confirm for the surgeon that my knee was what they were seeing on the x-rays. What they evidently don't want to do is go into surgery without seeing the entire picture and discover problems that didn't show up on the x-rays. Surprises like that aren't very welcome in the operating room, I guess.

The MRI was fine, supporting what they were seeing in the x-rays. They felt comfortable about the surgery. This was last summer. I found they were scheduling several months out, which meant my surgery would likely happen in the fall. In the end, it was scheduled for October 30, just a few days after I was set to return from a trip to Kauai.
One day post-surgery

I had to be careful with my legs on that trip. Why? Because one of the concerns with a surgery like this is infection. All of the medical people I interacted with warbled on and on about that. They don't want you showing up for surgery with a bunch of cuts or scratches on your legs. That meant I had to be careful when I was mingling with the ocean and rocks.

The surgery itself was quick. I arrived in the morning and was quickly put into the prep area. My left leg got the sanitation treatment. Again. I got a spinal block and they gave me some medications to help post-surgery. With a partial replacement, they expect to send you home the day of the surgery. They don't want you hanging around sucking up hospital space and staff time.

My surgery took less than an hour and I woke about 45 minutes later. A nurse was massaging my feet. The spinal block hadn't worn off and my legs were fairly numb. I guess massaging the feet gets blood moving and helps bring the feeling back. They gave me some food, Pretty soon, the feeling in my legs returned and I was able to get up. They want you up and around quickly with a surgery like this to help prevent clotting. I probably overdid it. They worry about patients falling. I didn't.

The medical people expect you to have some pain after knee replacement, though they admit everyone is different. I was given over-the-counter meds and told to take them for several weeks. For pain, they game me Oxycodone and told me to take it as needed. They advise you to stay ahead of the pain. I never had much pain, but I took the Oxy for a couple of days, then stopped.

I slept in a bedroom on the main floor of the house for the first week or so. That first night, the smoke alarm in that room started chirping a low battery warning. Perfect. Rather than wake up my wife who was sleeping upstairs, I ambled downstairs (cane-assisted) and got a new battery, then stood on a chair and replaced the offender. Maybe I should have handled it another way. No harm done.

They had given me an ice machine and advised me to use it and elevate my left leg several times a day. The idea is to keep swelling down and speed healing. I followed that advice faithfully. I was given exercises I could do in or out of bed. Those exercises were similar to the ones I had done years earlier following arthroscopic surgeries and I did them as directed.

The medical people pushed me into attending physical therapy sessions. I hadn't done formal PT after my scope surgeries and was skeptical about it following knee replacement. Most people who have knee replacement need PT. No doubt about it. But I had learned to do my own and I'm disciplined enough to do the exercises religiously. The people in the PT clinic were terrific, but they didn't offer much of anything I couldn't do on my own.

Post-surgery: No bone-on-bone.
In fact, their approach was so conservative that I didn't have the desired range of motion in my new knee when I visited my orthopedic office for a follow-up two weeks post-surgery. My PA (physician assistant in orthopedics) was mystified. He gave me an exercise to remedy the issue, which worked well. The PT folks were contacted. Honestly, I don't think they knew what to do with me. Most of the people I met in PT were significantly older than me and had gotten total knee replacements. Totally different bag. I quit formal PT soon after my follow-up appointment. My PA green-lighted that.

My early recovery was fast, maybe too fast. I was driving and walking the dog within a week. I probably did too much. Then I started having odd pains in the repaired joint about six weeks out. I wondered if something had gone wrong. My PA advised me that many patients have strange pains during the recovery process, which can take six months or more. He would have been happy to see me, but I begged off, realizing what I was feeling was probably normal.

Four months after surgery, the odd pains began to fade. I passed through six months a few weeks ago and can confidently say I'll have a full recovery. I walk without pain, can even run if I want to. I know I'll ski again. Golf won't be a problem. Keep in mind that I could never have done those things again without the surgery. No chance. I don't know about racquet sports. Pickleball I will definitely play. After the pandemic ends, I'll hit the racquetball around and see how it feels. Maybe I'll play again occasionally, maybe not.

How does the knee feel? The orthopedic folks will tell you that a replaced knee will not feel like the real thing. That's definitely the case. There's a plastic spacer/pad between the two metal pieces, invisible in the x-rays. That pad simply can't mimic the natural joint cushioning. It gets a little clunky at times, but feels a whole lot better than bone-on-bone. Trust me.

Some of the people I played racquetball and tennis with over the years either have considered or will contemplate having this surgery. It's not a big deal. It was an easy decision for me because my knee hurt every minute, regardless of what I was doing. I was absolutely unable to do normal things, like go on any kind of significant walk. Now those things aren't a problem. Even an ill-mannered Labrador puppy is okay.

My thanks to Dr. Eric Bosworth and the folks at Kaiser Permanente, particularly the team at the Westside Medical Office in Hillsboro. They made my journey relatively painless and positioned me for a good outcome. Thanks also to my wife, Laura, who took care of me during my recovery and encouraged me to follow the advice of medical people. I actually complied with some of it.