Musings on getting a total knee replacement
In the predawn hours of a Pandemic morning, my partner Jan is driving us through mostly empty streets toward the surgical wing of one of south Denver’s major hospitals. Medical magic is about to be enacted upon my 77-year-old body.
Lost inside my head, I hardly notice the dark world passing outside the car. The fact that I am not actually nervous rolls around in my mind. I think back to all the long hikes I’ve done, especially those months in the Himalaya. I imagine keeping a 7-minute-mile pace over decades of trail running. I wonder if kicking those scuba fins through thousands of dives contributed to the osteoarthritis that has devastated my knee’s articular surfaces. I mentally review the MRI images revealing the undeniable result of so many pounding miles, stressful movements and destroyed shoes, and I picture the bone-on-bone image of pain and non-functionality that has brought me to this moment.
We arrive and I am thankful to discover the usually bustling medical complex seems quiet at this early hour. Jan stops the car and hurries around to my side. Being a septuagenarian with a bone-grinding knee joint, I accept her strong assistance as I get out of the car. I hobble into the empty lobby on my secondhand OPW (Old Person’s Walker, my crude name for the support device I actually do need). I experience another flash of gratitude recalling how Jan anticipated this and bought the walker for me at a thrift store for seven dollars.
I watch my dear Jan drive off towards the parking structure she remembered to scout yesterday. I am the only patient in the admittance area. After the hour-long preadmission two days ago, I’m not surprised to discover the polite and friendly attendant behind the virus shield is expecting me. The majority of my experience with hospitals has been as a visitor so I’m all eyes and ears and intensely interested in everything. Waiting for Jan’s return, I peruse the large electronic board listing today’s schedule for the operating room multiplex. For some reason I’m amused to discover I’m the first of about three dozen major surgeries scheduled here today.
Jan reappears and we meet an all-business but chatty nurse named Molly who leads us through a door. Looking like three masked bandits, one with a walker, our trio traipses through halls lined with various rolling beds and equipment clearly staged for serious purposes. We arrive at the pre-surgical area where I’m confronted with half a dozen bays each filled with hi-tech beds and copious amounts of monitoring equipment waiting behind open curtains.
Molly indicates one of the bays and I step in. She slides the curtain to provide the three of us with what passes for privacy in a hospital. In a blink I’ve exchanged my street clothes for a fabulously simple, open-backed smock. “All the better to allow the medical wizards access to all my parts,” I think, more sardonically than morbidly. The smock’s bright yellow and red plaid seems intentionally calculated to mark this person as not a medical professional while confirming for me and any observer that my conversion to submissive patient status is complete. Jan and Molly assume (correctly) they how have the go-ahead to mother-hen me. Jan takes charge of my “effects” while Molly directs me to the fully computerized bed-on-wheels that will also serve as my ride to the operating room. I am just making myself comfortable, a truly relative term, when my epidermis receives the first of numerous piercings to come. In a flash I’m hooked up to an intravenous drip taped to the back of my right hand. Molly then clips a pulse oximeter to an index finger and a blood pressure cuff on my arm. Then, after confirming the most basic fact with me, she uses a permanent marker to write “THIS LEG” above the correct knee. My surgical look is complete. I’m confident my left leg will be unmolested. I’m committed. I’m ready.
The curtain opens and the anesthesiologist appears. Tall and slim, he introduces himself in a sanguine tone while discomforting me with his shifty eyes. He injects an unnamed calming agent into the I.V. access port and I begin slipping into something like mental quicksand…
Jan is, as always, my soothing goddess, but it seems like they’re asking her to step out. A group of people in scrubs crowd into the small space, surrounding me. They all seem fully versed in my reason for being there and they engage in an abundance of overly cheerful banter intended, I suspect, to put me at ease… as if the drug in the I.V. needs any help. Apparently some signal goes off because all at once brakes are released and I’m rolling out of pre-op. From behind me I hear Jan’s adieus until a bevy of bodies eclipses her voice. Where did all these folks come from? It seems it also takes a village to transport a patient to surgery but I feel more like a movie star with my entourage. I’m aware of other unidentified people watching me as I roll by in my electronically-enhanced bed on the way down a hall towards, presumably, a bright and dramatic operating room with my name on it.
Voices echo. New faces appear and disappear. I suspect the contents of the I.V. have been altered and I’m hallucinating a little. A nurse (or maybe an assistant or orderly, who knows?) is staring at me and we lock eyes. There’s a peculiar expression on her face and I notice she’s not wearing a mask. Even in my altered state I wonder how that can be. The thought fades as other people appear, all in masks, and I swing my gaze around to see who else is here as my flying bed moves through swinging doors. My deranged thoughts return to the no-mask woman who was looking so intently at me and I compulsively look around for her. There she is, still staring at me with what I now take to be a mocking sneer. Though I’m already chemically influenced, I sense I should be concerned about her expression. Later in an opioid trance I’ll become convinced she wants to hurt me or at the very least she gets a perverse pleasure from watching patients go under.
Apparently I am now in the operating room. It appears I’m viewing the world through a lens smeared with Vaseline but it might just be they’ve upped the mystery drugs. The scrubbed and visored surgeon I’ve only seen in his office garb materializes, says some things in a foreign language. Several other people I don’t recognize appear in the gathering mist. They’re all occupied with their specific tasks and seem to be oblivious to me until several of them start transferring me from my flying bed to a plank that apparently doubles as an operating table far too narrow for me. I feel like a giant Gumby as they bend me in half so the shifty-eyed anesthesiologist can start sticking a tiny needle into my lower back to administer a spinal block. He mumbles apologies into the echoing well of my half-consciousness as he takes three attempts to get the block started. While Mister Anesthesiology bumbles beyond my peripheral vision, a young woman magically appears before me. I determine with a low probability of correctness she is there to hold me up lest I fall off that narrow board where blood will soon be spilled. Her face is three inches from my face and she looks like a sympathetic, surreally beautiful, fourteen-year-old angel in a surgical mask. Right around that point I disappear.
And then a few seconds later, it seems, I’m once again aboard the electronic bed rolling through endless halls. I’m maybe two thirds conscious and feeling no pain as the person pushing the bed informs me we’re on our way to post-recovery. I see another patient, a man who looks punch-drunk as well as middle-eastern, as he’s rolled head-first into a nook. He’s awake. He sees me, and at the same instant we flash thumbs-up to each other. I can’t feel my legs yet but at least I’m out of surgery.
A decade ago TKA surgery required a two day stay in the hospital. It’s 2021 now and the preadmission nurse verified what the surgeon had told me weeks earlier: this would most likely be a same-day procedure as long as there were no complications and I met certain requirements like being able to transfer from bed to walker, walk up and down the ward, eat something and keep it down, and use the bathroom. An hour or so later I somehow manage to pass the tests and at 3:30 P.M. I’m in a lobby, wheelchair-ensconced with a nurse in close attendance, waiting for Jan to pull up beyond the glass. She pulls up, I awkwardly squeeze into the passenger seat, and then I’m on my way home.
The first three or four days are vexing and weird as can be: blocks wearing off, opiates rampant, swelling, constipation, no appetite, and every movement a royal pain. I cannot imagine getting about, bed to recliner, recliner to bed, without that thrift store walker. Blood clots are a big concern at this stage and I’ve been ordered to wear compression hose. My new scar is eight inches long and though I’m told it’s edge-glued, it seems a broad piece of reinforced transparent tape is what actually holds the wound closed. During those first days I was a helpless mess and I probably would have died if not for Jan’s attentive kindness. I cannot imagine how a person could get through this without a great partner.
Two weeks have passed and it’s time to commence physical therapy. I understand how important this is for rehabilitation of a leg that has atrophied and been brutalized on the operating table. Therapy stretches surgery-impacted tendons and ligaments, strengthens atrophied muscles, and keeps scars from forming into stiff gait-limiting seams. I do not look askance at physical therapy, mind you, but during those two first weeks I could not face going to therapy. It wasn’t until half-way into the third week following surgery — weaned off the big painkillers and still icing my new knee — that I finally trundled off to my first appointment with the therapist. Jan drove.
By the time I’ve had ten physical therapy sessions, I know my two therapists pretty well. They’ve been attentive, sincere and, for the most part, well-trained, but for several reasons (like each session costing a thirty dollar co-pay) I’m about to start doing the same exercises at home and at the gym.
Completing rehab on my own is not a path for everyone, I did my own prehabilitation at home for two months before the surgery with the doctor’s support and years ago I managed a physical therapy clinic for a decade, so I’m probably qualified. If I find I lack the discipline or techniques, I can always go back to the P.T. clinic.
That I elect to self-guide the remainder of my rehabilitation does not reflect negatively on professional physical therapy. I have found most physical therapists are smart, committed caregivers who sincerely want to help patients attain their goals, but not all PTs possess equal skills. Completion of the rigorous Doctor of Physical Therapy endows most of these practitioners with excellent training but the degree reaches its goals only after years of experience. It is an intense profession and burn-out is a very real danger, so I followed my own recommendation and searched for a practitioner with at least a few years of experience but not the decades that might suggest professional fatigue. With the number of total knee replacements approaching a million a year in the United States alone, experienced rehab experts are not hard to find.
Total knee arthroplasty (TKA) has become the best and, in most cases, the only way to fix a painful, osteoarthritic, non-functional knee. When it is bone-on-bone and exercises, steroid shots and nutritional changes no longer work, the proven solution for over thirty years is the TKA, and that’s because it works 95% of the time. TKAs are now the most frequently performed inpatient surgical procedure in the country. My orthopedic surgeon has done over a thousand knee replacements himself.
There are many varieties of knee replacement hardware with different configurations designed for every need from elite athletes to older folks like me. The installed hardware, which weighs less than a pound, relies on proven bio-compatible prosthetic materials, usually cobalt-chromium alloy for the metal parts and high-density polyethylene for the bearing surfaces. Although the methods and materials have continued to improve over the years, a handful of potential complications remain. These include infection, joint instability and enduring stiffness, any of which can lead to resection (another surgery). These are all low-probability. At just six weeks out from surgery I am walking the dog and when the Pandemic allows, Jan and I will scuba dive in the Caribbean again. Total knee arthroplasty is a tried and proven elective procedure and I’m glad I did it.
So am I now a bionic cyborg? I must confess some perverse part of me is looking forward to setting off alarms at security checkpoints.