It’s official. I’m now a bionic woman. I had to have knee replacement surgery on both knees, one performed in August and the other in November 2009. I’m still in recovery, as the muscles, ligaments, and soft tissues around my new knee joints have yet to settle down and settle in. There’s still some residual pain in those tissues, but generally things are going quite well, and my new joints feel great.
Setting the stage with a single leap
I was once quite athletic. I was a star volleyball player in high school and, at only 5-foot-3, could spike the ball by leaping straight up and slamming it down. I also loved skating at the local roller rink, long before rollerblading became popular, whizzing around on four-wheeled boots. But just after my 21st birthday, everything changed.
The rink had been cleared for speed skaters to take their turn, and I was flying. I came out of the turn, and straight ahead of me was a small tot, perhaps 5 years old, who had wandered into my lane. My choices were limited as there was no room to veer left or right, and little room to stop without causing a collision. Slamming into the little mite was certainly not an option, so I attempted to leap over her. I landed hard on the wooden floor, my right leg bent in front and my left straight behind me. I passed out from the pain in my left knee. I had succeeded in tearing every ligament I had in that knee, and life was never the same.
Living in pain and a diagnosis
Fast forward 23 years. I healed after the skating accident, without surgery—which, in the 1970s, would have been quite invasive. So I wore a leg splint and used crutches for about a month. Over the years, my knee would catch if I turned the wrong way or pivoted, and I would tumble to the ground in agony. But over the years my left knee seemed to stabilize, and I favored the right knee until it did. However, I was never as active and I began to put on weight, the bane of knee joints.
At age 55, the pain in my knee joints had become unbearable. For some time, I had quietly endured it, taken NDAIDS to help quell the inflammation, and visited my chiropractor to try to keep my legs on the straight, if not exactly narrow. Nothing worked anymore, and I walked with a pronounced side-to-side gait. I no longer enjoyed doing things that once gave me immense pleasure, like walking on the beach, window shopping, meandering through museums, or even exercising my dog, Poppy. My chiropractor was the first to realize there was something very wrong and to act on his instincts.
Dr. John M. Ruda, D.C. has been practicing in Arroyo Grande since 1992. According to Ruda, if a patient doesn’t respond to chiropractic care, medical intervention is called for, and he has a network of medical doctors to whom he may refer patients. He sees several hundred patients each month and refers someone each month for an orthopedic consultation for joint replacement.
“A lot of times people just have an old bone injury that causes accelerated advanced osteoarthritis,” he said. “We help by keeping the spine aligned correctly to slow down that progression. It helps keep weight-bearing pressure off the affected area.
“We tell patients that at some time you may need knee replacement,” he continued. “You’ll know when. You won’t be able to do things you enjoy.”
Degenerative joint problems can be weight related or related to another joint due to overcompensation.
“Joint replacement is more common today due to more active Baby Boomers,” Ruda explained. “We have an older population enjoying a more active lifestyle, and having good knee function is important to them.”
In my case, Ruda became concerned when things began to degenerate to the point where excessive joint play became evident and my knee joints became unstable. Last July, he insisted I get an X-ray of both knees immediately, so he could compare them side to side. The news wasn’t good. Both knees were in bad shape, but the left knee was worse. Bone spurs had formed, and my femur (thigh bone) was sliding inward off the tibia (shin bone) on both legs. Without surgery, over time, the joints would lay down more calcium and form more spurs, causing the joints to adhere and fuse, reducing mobility and range of motion to the point that I would require the use of a cane, walker, or even, in time, a wheelchair.
“Prior to knee-replacement surgeries,” Ruda remarked, “there were much higher instances of disability.”
Get thee to a surgeon!
Ruda’s concerns over the deformity that had progressed in my knee joints were seconded by the orthopedic surgeon to whom he referred me.
Dr. Marc W. Weise has been an orthopedic surgeon for 20 years, and has been practicing on the Central Coast for 11 years. He completed his orthopedic residency at the Ochsner Clinic in New Orleans, followed by a fellowship at the Cincinnati Sports Medicine and Orthopaedic Center. He’s had his own practice in Pismo Beach for the last four years.
Orthopedic surgeons usually specialize in procedures involving the entire skeleton, with the exception of the face, skull, spine, and most of the feet. Ankles, knees, hips, wrists, elbows, and shoulders—anything that bends—is fair game.
Asked how he settled on this particular area of specialization, Weise explained that, when in medical school, students rotate among various disciplines.
“I love mechanical things, taking apart things. As a youngster, I hated the sight of blood,” he said with a laugh. “But during my med school rotation, I found that I enjoyed surgeries more than internal medicine. When you take someone’s appendix out, and they have been in pain but then feel better, that’s very gratifying to a surgeon.”
I met with Weise in July, a few days after Ruda had seen my X-rays. Weise had seen them, too. My left knee, he told me, had a build up of calcium at the medial collateral ligament—one of several I had ripped to shreds during that fateful accident at age 21. There was no cartilage left in either knee; they were bone against bone, and a varus deformity meant my joints were angling outward. That explained my side-to-side walk, called a Trendelenburg gait. Great, it had a name. I should apply to the Ministry of Funny Walks.
But there was more. Weise also noted the bone spurs—what he refers to as “calluses of the bone”—that act as stabilizers.
“The bone gets thicker and expands, like skin, when exposed to stress,” he explained.
The result was that my femur was sliding medially on the tibia on both knees.
He told me other possibilities, but said my best option, at this stage, was a complete knee replacement on both knees.
“How does Aug. 6 sound?” he asked.
“Is he kidding?” I thought. That was just less than three weeks away. My husband made the final pronouncement: “She’ll be there.” Well, that was that.
At this point, Weise explained the type of implant, called an appliance, that I would have and how the surgery would progress. The term “knee replacement” is something of a misnomer. Only the cartilage on the ends of the bones is replaced. The replacement appliance features a metal alloy attached to the bottom of the femur and plastic underneath the patella and on top of the tibia to create a new joint that moves smoothly and without pain.
Surgeries also used to involve a long incision, up to 12 inches, made over the knee. Newer, minimally invasive surgery requires a smaller incision of about 5 to 7 inches, resulting in less tissue damage inside and out. It also can mean a shorter recovery period and better knee function because of decreased scar tissue. The damaged sections of the joint are removed and the femur and tibia reshaped to hold the appliance, attached with screws into the femur and cemented to the tibia. The new joint is further supported by the surrounding ligaments and muscle tissue.
Knee replacements have come a long way since the first attempts in the late 1800s. Weise explained that early experiments included silver and even glass implants. I’ve heard of a glass jaw, but a glass knee? Another early procedure involved using soft tissue cut from the side of the hip, rolled up and stuffed inside the knee. Yikes! One of the first modern devices, the locked-hinged implant, made of stainless steel, worked like a door. It stabilized the knee, but movement was restricted to bending and straightening, and a normal knee doesn’t move that way.
The early 1970s saw the innovation of unrestrained resurfacing of the knee, which allowed the natural ligaments to hold the knee in place. This procedure was an improvement because the range of motion for the knee was more natural and the appliances lasted longer. This was a major milestone, according to Weise, as was the distinction between left and right knees. Earlier appliances were adapted for use on either knee.
Weise said experiments are now being performed with tissue engineering. A three-dimensional model is created out of collagen and populated with cells that produce bone on one side and cartilage on the other. It may soon be possible to grow bone and cartilage for implantation, although it can’t duplicate real cartilage, which has myriad layers.
One of the main compromises with the modern devices, Weise explained, is that the plastic portion must be hard, unlike natural floating meniscus. The hard plastic that’s attached to the tibia, with its flat surface, allows the knee to roll as it should, but it wears down over time.
According to Weise, 90 percent of typical knee joint replacements will last for about 20 years. There’s no present data for anything longer than this because either the patients or the surgeons die. The American Academy of Orthopaedic Surgeons is now working to create a database containing a national joint registry to better track the data.
Operation isn’t a game
The first order of business was an MRI of my hips, knees, and ankles, which was then sent to the company that manufactures the implants. Weise had explained that newer surgical procedures were replacing the older method of aligning the leg with the new implant by inserting a rod into the marrow channel of the thighbone, to be removed once the appliance was in place.
The alignment of the leg is now done by computer imaging, based on the MRI, which also calibrates the size, screw insertions, and cutting guides required to implant the appliance. The appliance is custom-made for each patient and for their left or right knee. “Cor blimey!” remarked my British spouse. “It’s like ordering custom parts for a classic car!”
During surgery, I was to be put under general anesthesia and given a spinal tap to numb me below the waist. Like many people, I have always perceived surgery as something that happens while you’re sleeping—kind of like a visit from Santa Claus or the Tooth Fairy. You go to sleep and awaken to find new toys or shiny coins under your pillow. I would go to sleep, the Knee Fairy would come, and I would awaken with strong, new knees. It’s actually much more complicated than that.
The surgical team for my surgery consisted of my surgeon, Weise; an anesthesiologist; a first assist nurse, a scrub technician; and a circulator, who’s also an R.N.
My surgeries were both scheduled for 6 a.m., which means the surgery team has arrived by 4 a.m. First Assist Nurse Mollyo Landry assists the surgeon during the procedure and never leaves the room. Some surgeries have lasted as long as 13 hours or more, and these nurses have serious stamina. Landry has been a nurse since 1971, and a first assist at AGCH since 1999.
“Sometimes first assist nurses work up to 23 hours when on call,” she said. “We catch a bit of sleep in the lounge on the sofa.”
Among her many, many tasks, she greets patients as they are brought into the OR—a visit than can cause a sense of unease, I can tell you. All the bright lights, blue scrubs, and surgical implements—it’s a bit unsettling. According to Landry, “We have only about five minutes to connect with the patient and gain their trust. I try to make some personal note about a nail polish color or something personal to make the patient feel comfortable, and that we see them as a person, like a family member.”
Shirley Fletcher, an R.N. for 15 years, was the circulator for both of my surgeries and has been with AGCH for two years. The circulator is the first person to meet with the patient before surgery. She gathers important patient information, including any allergies and when the patient last ate or drank anything.
The circulator is really a patient advocate who protects the patient during surgery—including double and triple checking which knee is being replaced—and acts as a troubleshooter. She also serves as a liaison for the patient’s family, a service for which I was extremely grateful and that my husband found most reassuring.
All of the surgical nurses told me patient safety is their biggest concern. They take in-services courses on a regular basis to learn about the latest advances and continually update their training. According to AGCH’s Media Relations Communication Manager Anna Scott, “We always remember that we have people’s lives in our hands.” President and CEO Rick Castro added, “We really try hard to set the stage for the patient and their family through education and care. Strangers walk into the hospital at a time when they are very vulnerable, and it is a privilege to have their trust.”
AGCH recently earned top honors for its joint replacement program from HealthGrades, the leading independent healthcare ratings organization, Scott said.
A recent study by HealthGrades evaluated patient outcomes in 5,000 hospitals around the country. Arroyo Grande Community Hospital was recognized for its quality orthopedic care, and is five-star rated for its joint replacement program and total knee replacement for the seventh year in a row.
Scott added that Arroyo Grande Community Hospital’s Joint Replacement Program has also earned other awards for its standards, experience, and care.
Let’s get physical
Following surgery, I was hospitalized for five days. I had been told by Weise that I would be out of bed and moving the day after surgery, and that physical therapy was to start right away. “Yeah, right,” I thought. There had better be serious drugs involved. There were. Once the spinal tap wore off, I was given a pain button, which, when pressed, released a dosage of morphine
into my IV. The button, however, was set
to release the morphine only at predetermined intervals, and this method was brief. After two days, it was removed and I was given oral painkillers.
I discovered two things: When you have been on strong pain medication, it relaxes your bladder and guess what? The catheter I’d had was also removed after two days. Talk about motivation to get up out of bed! The other things I discovered were the constant passive motion machine and the ice pump. The latter looked like a small ice chest with a hose attached to a plastic pad wrapped around my knee. Flick the switch and cool water circulated continuously through the pad, alleviating pain and swelling. But the motion machine was my favorite. Padded with soft lambskin-like fabric, it cradled my knee and, when switched on, would bend and straighten my leg at a preset angle. I could lie back and nap while my leg was exercised for up to an hour or more. This made getting up and moving about much easier.
I also learned that before my knee was to bend in the machine, they wanted it to straighten. Flexion is attainable over time, but extension or straightening isn’t. There’s a very small window of time after surgery to get the knee to straighten perfectly at zero degrees before it can stiffen due to internal adhesions, thus reducing mobility and range of motion.
Five days after each surgery, I was discharged from the hospital. Gentiva Health Home Services immediately stepped in and sent an occupational therapist and a physical therapist to work with me in the comfort of my home. Because I was taking blood thinners after the first surgery to prevent clotting, a nurse also visited each week to monitor my vital signs and send reports to my doctor.
Born in Eindhoven, the Netherlands, physical therapist Nicole Hemmers met her American husband there, where he was also studying physical therapy. They returned to the United States in 1999 and married. She’s been a physical therapist since 1997 and has worked with Gentiva for almost seven years. She combines a hectic work schedule along with raising three children. Hemmers visits patients in their homes within the first 24 to 48 hours after discharge, depending on the patient. Some patients have balance problems or are at risk for falls. She sees patients until they’re strong enough to go to outpatient physical therapy at the hospital or other location. She also sees people unable to go to an outpatient practice for physical therapy.
The most challenging aspect of her work, she said, is patients and their caregivers who may do things that put them at risk. She and occupational therapist Paul Hollenbeck were both concerned about the throw rugs in my bedroom as potential tripping hazards. I also had to take care not to fall over the small methane cloud that follows me around, my elderly and gaseous dog Poppy, an English Staffordshire terrier. Things I took for granted suddenly became potential fall hazards, including taking a shower and using the toilet.
Tall, willowy, blond, and speaking with a delightful Dutch accent, Hemmers visited three times a week for three weeks, each session more grueling than the last, but also more gratifying as I saw my range of motion, muscle strength, and balance improve. She told me this is the most rewarding aspect of her work.
My physical therapy continued at Arroyo Grande Community Hospital’s Physical Therapy Department. Headed by Ed Cardoza, PT, the department also holds a joint replacement class every Monday for potential surgical patients. I was required to attend this class prior to my first surgery. Cardoza covered every aspect of the procedure from the time I was admitted until I was discharged.
Physical therapists Don Zimmerman and Robert Zvada worked with me for several weeks, encouraging and motivating me, as well as holding my hand when I cried—and I cried a couple of times! I had thought that the Spanish Inquisition had been banned and dissolved centuries ago, but no! These guys meant business, and I would bend and straighten my knee!
Straightening it actually came quite easily for me, however bending was another matter. The ideal angle of bend is between 120 and 130 degrees. So far, I am at 116 degrees, but that’s because I have something every cowboy loves: fat calves! It’s hard to bend when the pudge won’t budge.
The greatest challenge, Zimmerman said, is getting patients used to the pain and persuading them to move. Having had a hip replacement himself, he’s more empathetic: “I know what’s involved pain-wise. That very first day when they get you out of bed—wow!”
The latest aspect of physical therapy is the use of a Nintendo Wii game system to enhance balance and prevent falls. I sucked at most of the exercises, but aced the ski run and got pretty good at the yoga. Thanks to the physical therapists at Gentiva and AGCH, I now walk as straight as I did at age 21 without fear of falling, and I have lost 35 pounds so far since the first surgery in August.
Living with heavy metal
Two questions I asked Weise: Can my implants break or be injured? And do I have any limitations after recovery? He told me that some of the older steel devices can crack, and that titanium is still used in some prosthetics as a coating or mesh for bone to grow into, but it’s not as strong for sheer stress and it abrades more easily. He said that 99 percent of modern appliances, including mine, are made of an alloy of chrome, cobalt, and the hard, stable metal molybdenum. There are also two types of devices that incorporate a ceramic/metal coating because ceramic is best for resisting sheer stress, but not for fatigue and cracking. Hip replacements benefit from the use of ceramic, but knee replacements still require the strength provided by metal.
Weise also said that knee replacements can be abused. Some patients think the new knee will last forever and continue activities or the lack thereof that got them into trouble in the first place. He warned me that I wouldn’t benefit from jogging, running, competitive ball games, extreme hiking, or high-impact aerobics. I should also avoid the stairs. Walking, biking, swimming, yoga, stretching, and other gentler activities will improve strength, enhance weight loss, and help maintain the integrity of my implants. He told me a second replacement surgery is more invasive with a longer recovery period, and long-term results aren’t always as good as with the initial surgery.
Weight gain is a significant factor in most knee surgery patients. I was concerned that I wouldn’t even be a candidate because of my weight, but Weise said I was the exception to the rule because I was highly motivated. Patients who don’t lose the excess weight—or who gain weight after a knee replacement—can expect the replacement to wear out faster, and there are increased chances of infection, clots, and pulmonary issues during and after surgery for heavier patients. However, as in my case and surely many others, before the surgery I could barely walk and exercise was practically impossible.
“Motivation is critical,” Weise told me. “It is hard to lose weight by merely dieting. Exercise is essential.”
Finally, getting through airport security will now take on a new meaning, so know what material your knee implant is made of. When going through security, do everything like you normally would—just know that the minute you set off the alarm, you’ll be pulled aside for screening by a hand-held metal detector or a full body pat down. Tell the TSA agent you have a knee implant. Weise told me the little card you get from your surgeon doesn’t mean much, as any terrorist can get one. Its purpose is to show the location of whatever metal you have in your body. My husband and I are quite the pair now when we try to clear airport security. We simply plan ahead, go a little early, keep a sense of humor, and it always goes quite smoothly.
Having come through this experience, I thank everyone who helped me get a leg up, as it were, throughout the course of my surgery and recovery. I am especially grateful to my husband, Ian, our grandson, Samuel, and my stepson, Jason, who were attentive, motivating, and loving throughout every stage of the process. It may not be based in medical science, but there really is something to be said for TLC!
Contributor Ariel Waterman is enjoying her new knees. Send comments to Executive Editor Ryan Miller at rmiller@santamariasun.com.
This article appears in Jan 21-28, 2010.