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A New Set of Knees Comes at a Price: A Whole Lot of Pain

Jane Brody; New York Times; Section F, Column 1; Personal Health; page 7; 2/8/2005. Posted: 2/9/2005; Modified: 2005-12-17
[Identifier = http://www.doctordeluca.com/Library/WOD/NewKneesLotOfPain05.htm]
 
See also:
When It Comes to Severe Pain, Doctors Still Have Much to Learn; Jane Brody; NYT; 2005-02-15
 
A Fight for Full Disclosure of the Possible Pain; Jane Brody; NYT; 2005-03-08
 
Major Media on the War on Doctors and the Pain Crisis, 2005; compiled by Alexander DeLuca; 2005-12-12
 

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Total knee replacement is now one of the nation's leading orthopedic operations, and it promises to become even more popular as the population ages (and grows heavier) and the body's most vulnerable joints fail to withstand the punishment of decades of use and abuse.

Debilitating wear-and-tear arthritis is the major reason that knee bones are being replaced by two-pound pieces of metal in people who wish to remain mobile, pain-free and physically active in their later years.

Dozens of people I know who've endured the surgery say it has changed their lives very much for the better. They can walk again with comfort, even play tennis and ski, after years of sitting on the sidelines.

The Time Was Right
 
And so, at age 63, I decided to have both knees replaced. I had been nursing my increasingly arthritic knees and bowed legs for two decades -- at first with ice packs and ibuprofen whenever I did strenuous activity, graduating to daily Vioxx and Tylenol with growing limits on what I could do without life-limiting discomfort.

The last straw (after giving up tennis, ice skating and cross-country skiing) was my inability to hike or even join my friends on our morning fitness walk around the park. Even Vioxx (before it was withdrawn from the market) was not keeping me comfortably on my feet.

I consulted one of the world's leading orthopedic surgeons, a man who had done thousands of knee and hip replacements, including 500 double knees. He was very reassuring.

With the aid of physical therapy, he said, I could expect to be driving again in four weeks and well on the way to full recovery in six. Even the reputedly horrific postoperative pain associated with this surgery, he added, is now fully controlled with morphine through epidural anesthesia supplemented by extra doses that the patients can administer.

A neighbor who had one knee replaced last summer had warned me, ''The first four weeks are hell,'' but I discounted her prediction, given that I was in good health, top physical condition and slender going into the surgery.

A preoperative education session at the hospital emphasized the importance of good pain control because without it patients cannot do the physical therapy essential to a good recovery.

I gave two preoperative blood donations (one for each knee), arranged for inpatient rehabilitation after leaving the hospital and thought I was fully prepared for what lay ahead.

Facing Reality
 
I was not prepared for the swelling. When I arrived at the rehab center on the fourth postoperative day, I weighed in at 120, 15 pounds more than I weighed at surgery.

My legs were filled with fluid, hard as rocks, with no visible bones, veins or tendons. In four days I was down to 103, but my legs continued to swell and stiffen for more than two months.

As for pain, the surgeon was right on one count: the morphine was bliss -- not a bit of pain the first two days after the operation. Then it was withdrawn and replaced by two narcotic oral pain medications, which worked pretty well for about five days.

But as the various tissues in my knees began to heal and physical therapy got more demanding, the pain grew worse and worse, until at three weeks I found myself moaning, then crying for much of the day despite the narcotics and repeated icing of my swollen knees. Sleep was my only relief, but one can't do that 24/7.

Thinking something must be radically wrong, I returned to the surgeon 26 days after the operation, only to be told my knees looked perfect on X-rays and that my mobility placed me in the top 2 percent on the recovery scale: I could walk and go up and down stairs, albeit slowly, and I could fully extend my knees and bend them 90 degrees.

As reassuring as this assessment was, it did nothing to control my pain. So he changed my medication to a potent anti-inflammatory drug and suggested that I gradually cut back on the narcotics. That proved to be something of a pipe dream, at least for the next several weeks. And there was no sleeping without a nightly dose of Ambien.

I learned much later that I could have been prescribed a much higher dose of narcotics with no ill effect and much better pain control. No doctor I reported to, however, including the surgeon, even considered that.

The fact is, This operation, which involved cutting my leg bones to straighten my bowed legs, hurts like hell. To the few patients I spoke with who had relatively little postoperative pain, I say, ''Count your blessings.''

My biggest complaint was not that I was suffering. (The pain at five weeks after the operation had definitely eased on most days, although my right knee hurt much more than the left. So much for driving!) My biggest complaint was that I hadn't been warned. I was presented only with the best-case result, not the worst.

Too Sore to Knit
 
I complained to my internist that in the first three postoperative weeks all I had been able to do was read three simple novels. Even knitting and crocheting seemed too much for me, let alone the many projects I'd hoped to tackle during my self-assigned six-week recovery period.

My doctor explained why: ''Intense pain is all-consuming. It takes over your life, and it's impossible to focus on much else.'' In fact, it changes your personality, and now I understand far better why patients with chronic pain can be so difficult to live with. It's hard to be pleasant when all you want to do is chop off the part of your body that hurts so much.

Continuing physical therapy is critical to a full recovery, but at first I overdid it by going three times a week. I have since cut back to twice a week to give my body more time to recover between sessions. It seems to be helping.

Insurance Madness
 
Compounding my physical discomfort was the emotional turmoil caused by insane insurance policies. My plan from the outset was to go from the hospital to an inpatient rehabilitation facility, which my policy covers for patients with double-knee replacements.

The insurer, however, wanted me to leave the hospital on the third day after surgery, when I was still restricted to using a bedpan. My hospital-provided case manager (every hospital must have them these days to negotiate with insurance companies) argued for an extra day, but that was covered only because I experienced severe chest pains (due to indigestion, it turned out) on the fourth day, not because my walking was limited to a few steps.

Then the insurer limited me to four days of inpatient rehabilitation, not nearly enough in my view, especially since I was going home to a four-story house. After six weeks of post-op, I still could descend stairs by bending only one knee.

But the most irritating insanity was the limit placed on my sleep medication: 14 tablets every 23 days. Was I supposed to sleep only every other night? Who came up with such a formula? Certainly not anyone who has ever had major surgery. Although my husband asked, the pharmacy failed to tell him that I could pay for the drug myself, about $4 a pill, far preferable to lying awake in pain all night.

I'm still waiting for that blissful day when I can walk better than I did before the surgery, get through the day without multiple pain pills and sleep without medication. I'm reasonably sure that day will come in the next few months, but I must admit I'm fast losing patience.

People ask, ''Are you sorry you did two knees at once?'' Not at all. In fact, I can't imagine going through this twice, and both knees were in horrible shape and needed to be replaced.

I've met several people in rehab who had one knee done and need to replace the other. But having endured the first replacement, they say they are now very hesitant to do it again.

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