Saturday, July 19, 2008

1. How Intuition Led to the Less Invasive TKR

A few months ago I had a total knee replacement (TKR) by the “less invasive surgery”. The “less invasive” procedure is a break-through trend in different areas of surgery, beside joint replacement. It brings substantial advantages: shorter surgery (anesthesia) time, less pain and less painful recovery. This blog documents my unusual journey toward this procedure, preventive measures, surgery and the post-surgery rehabilitation.* It would please me, if my experience served prospective TKR patients in their decisions.

In two years of seeing my orthopedic surgeon, I had tried injections in the knees, the painkiller “Aleve” , coral calcium and other joint strengthening supplements–without success. The last resource, SURGERY, was looming large over me. I scheduled a date, a month and a half away. As I was being "processed" for the surgery, I started feeling like moving on a conveyor belt toward a narrow and inescapable opening–the operating table. At once I felt depression enveloping me like a thick fog, I became extremely sensitive, tears coming on without provocation. My friend suggested seeking a second opinion. As soon as I started searching for an orthopedist, my depression lifted; I was my normal self again. The second opinion was unequivocally “total knee replacement”. I was to go on with my scheduled surgery date with my primary surgeon. Then a primordial fear seized me, as if my body panicked, its very survival endangered. My surgeon was most reassuring.

I sought an advice from an
acquaintance radiologist. He recommended less invasive TKR.

The less invasive TKR employs special tools and techniques, which enable a surgeon to access the knee joint with fewer cuts into the surrounding muscle tissue, thus affecting a shorter operating (under an hour) faster mobility and an "easier" recovery time.

Even though I had a two year interaction, and a very good rapport with my primary orthopedist, I canceled my surgery there and made an appointment to see a less invasive TKR practitioner.

*Physical therapy is covered in the video part of my "New, totally revised TKR" blog after my second TKR.

2. Overview

Information and its sources
Nowadays patients have to inform themselves about every aspect of their condition, starting with the basics – p.e., that arthritis is an inflammation of the joints. Sources of information abound: many TV programs have health segments, every health clinic has a website with specific topics, bookstores, health food stores. I especially recommend the extensive, just launched "" website, aimed at educating us about our health issues; finally asking doctors themselves. For the most part doctors appreciate patients taking an active part in their health and procedures, because involved patients heal better.

Early symptoms and prevention of arthritis
The earliest sign of arthritis is the joint swelling. Few months back I had developed a “trigger thumb”, i.e. I could not straighten it in a smooth motion without a jerk; the thumb joint to the hand was slightly swollen and sensitive to pressure. I asked an orthopedist for a cortisone injection; indeed two of them cured the swelling and the “trigger effect”.

Another preventive measure at an early stage, I discovered, is a “yucca” supplement. Knowing that arthritis is an inflammation, and that acids in the body promote it, yucca works by neutralizing the acids through its alkaloid property. In 1992 I have managed to stop a rampant spread of swelling in my fingers by taking yucca* capsules.

Intake of glucosamine with condroitin is also widely advertised as a joint health guardian. I cannot attest to that, because I am allergic to glucosamine. Another supplement for strengthening bones is coral calcium. These are all effective, preventive agents.

Intuition & listening to the body

In my own case intuition and my heeding its messages played a decisive role in the foremost and crucial aspect of the surgery:

Choice of the procedure and the surgeon
Even after scheduling my less invasive TKR surgery, I was still ambivalent about it. On the assistant’s advice I canceled, until I was fully ready. Three months later the voice to have a surgery came to me clear from within. Now the process accelerated. Instead of waiting another eight weeks, I jumped in on someone else’s cancellation and went into surgery on a four days’ notice.

The SURGERY passed without a hitch, or a hint of pain. Strangely, as it may sound, it was a pleasant experience: from the pre-op stay in the “holding area” – my next post – to the two-day hospital stay afterwards. Into my quiet room, a stream of staff flowed at frequent intervals, attending to the attachments on my body, feeding me "cocktails" of pills as my epidural was wound down and disengaged, the wound drained, catheter removed. Through it all I stayed unperturbed, feeling safe and coddled in the staff's care, sleeping and resting peacefully. I would have gladly stayed longer in that supportive environment.

*Yucca is a native plant known to native American tribes. The root is used in cooking. In a form of
"Nature's Way" (brand) capsules, it is a supplement available in health food stores.

3. "The Holding Area"

Finally I am being wheeled through barren, like out of Saramago's* "Blindness" corridors set, bluish neon-lit, zigzagging into the general holding area before the surgery. The same blue light reveals a comfortably large room, and thank god, life in it. Several nurses with “shower caps” on, are busy preparing patients for their surgeries. I observe everything with wonderment. It is my first time and I cannot imagine what will happen to me. There is no time for the primordial fear of the body to seize me. When my surgeon comes in to see me, I joke: ”No time for cancellation now!” Unsure how to take it, he maintains, whether in jest or seriously, I can always cancel. Meanwhile, a nurse is attaching me to various tubes ending in dangling plastic bags attached to the bed. Everything is named, explained, sounding sensible and indispensable. In comes anesthesiologist, a pleasant, jovial person, rubbing his hands, complaining of the cold in the operating room, as we shake hands. I offer to warm them. He starts fondly reminiscing about a girlfriend from Czechoslovakia. He must have been quite taken by her. I hope someone somewhere in the world moons over me that way. I omit to ask what had happened, not for the lack of interest, but out of discretion. He prepares to give me the epidural in the back of the spine. The needle doesn’t hurt.

When I open my eyes again, I am still or again on my bed, in the same place in the holding room, feeling no pain or any different from normal; it is after it has happened, yet I have no sense of how much time passed. I am in a suspended time-space, peaceful amidst activity. The male nurses are scurrying around other patients, monitoring each one’s condition, recording. Every few minutes another nurse comes by and sticks a thermometer in my mouth (just like at the dentist's, I wonder, do they disinfect those things), wraps velcro around my arm for blood pressure, or pricks my veins to check on the blood itself. I play along.

Across from me is a fiftyish man, naked to the waist, salt and pepper hair, a Victor Mature* look-alike in “Samson and Delilah”. Like the chained Samson in the temple, every now and then he raves, wanting to get out of bed, shaking himself free of the attached tubes, while the nurses swarm around him, waiting for the sign from the “super” whether to knock him out or inject him for sedation. He groans like he is in pain, but it is the pain of boredom, when he articulates his groaning. I don’t mind being in this room, although with this raving neighbor, I’m looking forward to my own. The nurses and the anesthesiologists ask me to wiggle my toes. I don’t know where they are, I don’t feel my legs. One of the nurses shows me a plastic container with neatly sawed off bone cubes, supposedly my knee. I wonder whether they show the same container to every patient. Finally the rowdy Samson is wheeled out, but so am I, as soon as I can wiggle my toes.

*Jose Saramago is a contemporary Portuguese writer and a Nobel prize winner for his life's work. Currently a movie is coming out based on the "Blindness".

*Victor Mature was a film star in the 40s and 50s, best known for the Western “My darling Clementine” and the filmed version of the biblical story of “Samson and Delilah.”

4. After the Surgery - What to expect

The surgery having passed so easily and painlessly, I was expecting (unreasonably) the rest of my recovery time to be just as easy and short. To everybody’s amazement, I was walking since day two, and after I was released from the hospital on the third day, I could walk in my apartment and take care of myself as needed. From the start, I never used a walker or a cane. I wouldn't treat my body as if it were an invalid. The second week after the surgery I drove my car.

Regardless of the technique used, TKR is a major surgical procedure. It is a miracle that it can be done and the “less invasive procedure” – not widely known yet or performed, is a major improvement. I propose a further improvement: replacing current chrome prosthesis with a strong, yet lighter material: at present a complete knee joint weighs 1 1/2 to 2 lbs. Also, that there be different sizes knee joints. One size doesn't fit all. My operated knee's circumference measures 1/2 inch more than my other knee's and I wonder how that influences the balance of the whole body and the function of the hip joint on that side. Besides, I am surprised that surgeons and physicians don’t concern themselves with the effect of this extra weight on their patients’ hearts, since TKR is performed mostly on older patients. A lighter joint may contribute to patients‘ greater comfort and artificial joint's
easier "integration" into the living tissues. Surgeons' argument: most people “don’t feel the weight”, “no one complains” and therefore no improvements can be expected! Patients are ignorant about the prosthesis’ weight (I found out by chance), but let’s be informed about it and urge the surgeons' establishment to keep pushing for improved materials. (Limbs’ prosthesis are not made of wood any more either, for a reason!)

According to several TKR patients I had consulted, complete recovery should be a “2 months' affair.” In spite of my overall good health, flexibility, uplifting attitude and good strides in my physical therapy, these were unrealistic prognosis and expectations. According to my therapist, it is a year long process. Let our expectations be realistic. Everybody’s organism is different; mine “kills” the painkillers, or renders them ineffective; so I have been in moderate discomfort ever since the surgery but never in "excruciating" pain. I understand that patients
after the classic TKR surgery go through a great deal of pain.

Concluding, recovery is a slow process. As of this moment, I am five months into this journey. I intend to do everything necessary for the full rehabilitation and expect to have a well-functioning knee by the end of the year. My account should not discourage anyone, but to inform and incite them to actively participate in every aspect of this important life decision. While a successful surgery constitutes the foundation for a well-functioning joint, physical therapy builds on surgeon's mastery, and through care and dedication restores patient's mobility and return to normal life.

Friday, July 18, 2008

5. What this experience has taught me

Throughout my life I have been attuned to my body, listening to its messages. In time I’ve become so aware of the connection between the physical-, emotional- and the mind-body, that whenever I feel a pain or discomfort in any part of the body, I ask myself why and how it relates to my state of mind at the moment. The TKR surgery and recovery procedure have further deepened my connection to and regard for my body. It is an autonomous entity; it clean­ses and regulates itself, maintaining the amazing equilibrium of all its complex systems, most miraculously – it heals itself. Always acute, now my senses are even sharper, my intuition speaks to me in a clearer voice.* I hope that my account and recommendations help someone decide when, where and by whom to have a joint replacement done, while at the same time listening to and respecting their own body’s voice.

*A glacier climber in Peru who survived injured and trapped in a crevasse for 8 days, yet managed to get to his camp, told, that through it all, there was a clear inner voice at every step telling him what to do.