6 minute read
Associate Editorial
from ACMS Bulletin August 2022
by TEAM
anDRea G. Witlin, DO, PhD
As of this writing, I am a newly minted member of the “senior knee replacement club,” three months in and well on the road to complete recovery. I escaped any major perioperative complications despite all my numerous doctors’ trepidations. I likely set a record for the number of diverse, requisite pre-op clearances. It would be easy to blame my onerous journey on my complicated medical history. Unfortunately, my unscientific survey of other “club” members yielded similar narratives.
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My journey traversed 5 years and included 4 visits to 3 different knee replacement surgeons, an arthroscopy for a torn meniscus, 10 intraarticular steroid injections, 4 SYNVISC-type injections, and 4 PRP injections. I exhausted my yearly PT benefits, and paid cash for personal trainers, massage therapy, and weekly acupuncture therapy. Had I merited acceptance to the “club” yet?
Knee replacements are considered “elective.” Thus, the excessive standard of care to clear a candidate for surgical risk. But should it be? I regarded PT as my most important life chore. Conceivably that conveyed the wrong impression to my docs that my quality of life was better than it appeared. But I only “came out to play”
The Sweet Spot
at limited, carefully chosen times. I hibernated for far too many hours when I was consumed by pain or physical exhaustion. My quality of life was likely misconstrued by others.
In my heart of hearts, I felt like I was only delaying the inevitable. How much more suffering did I need to endure? I relentlessly calculated my presumed life expectancy versus my surgical risk versus my quality of life. I was afraid to share my deliberations with my husband. The possibility of yet another surgery stressed him immensely although he tacitly understood my suffering and intensifying limitations. Correspondingly, I recalled friends and family who procrastinated and never joined the “club”. I didn’t want to experience similar decline at the end of my life with increasingly substantial knee limitations as I observed with countless elderly relatives and friends. I continued my search for that sweet spot.
The surgeons proclaimed that “I wasn’t ready yet,” that the procedure and rehab were too demanding, that I was too young, and/or I had too many co-morbidities. My tribulations were complicated by the emergence of Covid over two years ago. I was fearful of in-person care. I attempted to continue my rehab in our home gym. It became obvious that I backtracked as my time in isolation progressed. Eventually, I relented and returned for additional intraarticular injections and physical therapy.
My mind was in overdrive. I was confused by the narrative regarding risk because most of the patients that I knew undergoing knee replacement weren’t young and healthy. Many were far older than I. They were in their 80s, usually overweight, likely hadn’t exercised since high school, and likely had other cardio-pulmonary risk factors.
I’d heard that knee replacement surgery and the associated rehab was daunting but everyone in my non-scientific sample was pleased with their decision. In contrast, those who eschewed surgery regretted their choice and were miserable at the end of their life.
By late last year, it was obvious (at least to me) that I had failed my last foray into conservative therapies and required surgery. I spent two months to query all my relevant providers on my surgical risk and lobby them for approval. I was finally at peace with my decision when my “lead” doc who had treated me through many difficult flares and therapy decisions uttered: “You need to find that sweet spot. You will make the right decision. You always do.” That was the “blessing” that I needed.
It was still far from a done deal. I needed to share my decision with my husband and find a surgeon. My first surgical consultation was a relative disaster. That surgeon had no intention of ever operating on me solely based upon the information in my EPIC chart.
My husband joined me for my next and final surgical consultation. I finally had a date for surgery. It was my first surgical consultation where we candidly reviewed quality of life issues, our previous experience with orthopedic surgical procedures, and the role of my husband as caretaker. I emphasized my husband’s ability to care for me in the present tense. Just as I would get older and amass additional comorbidities, so would my husband. Thus, his ability and stamina to provide post-op assistance would decline over time. That must have struck a chord that many other patients didn’t discuss.
We realized that an issue given short shrift during those pre-op consultations was an honest dialogue of the patient’s home environment and presence, health, and skill set of their respective caretaker. A standard pre-op question and requirement is that “someone” must be available to drive the patient home. I don’t ever recall asking or being asked about the availability or skill of a caretaker during the post operative home recovery period. Each orthopedic surgery is unique. All to some degree require assistance with meal prep and clean up, showering and personal hygiene related issues, maneuvering in one’s residence with regard to stairs, doorways, fall hazards.
The most important and least spoken about phase of surgery is the transition from hospital to home. As rough as the immediate post-op period in the hospital is…replete with the uncomfortable hospital room, lousy hospital food, the seemingly forever time for the nurse to answer your call button…It’s actually relatively easy compared to those first few days or weeks at home.
Regrettably, the typical surgeon doesn’t have sufficient time during their brief preoperative consultation to explore these quality of life issues. Occasionally their nurses or advance practice practitioners will review post operative instructions as related to driving, showering (keeping surgical site clean), return to work, etc. PCPs occasionally pursue these discussions at pre-op consultation visits. However, I’ve found those venues fall short with regards to what home life and post operative home care really entails. It’s easy for the caretaker to get overwhelmed and exhausted with a new set of chores and responsibilities added to their daily home and/or work routine.
As for the nitty gritty of ADLs postop…I was sent a bedside commode prior to surgery. It was a rude awakening (literally multiple times each night) for my husband when he had to assist me with its use followed by the requisite cleaning each morning. During the day, we modified the commode for use as a shower chair. Bathing was an ordeal for both of us – it’s hard to know who got sprayed with more water. Dressing was an exhausting ordeal, especially when one knee wouldn’t bend. Then came meal time with food preparation and clean up, washing clothes, taking out the dog…I was sent home with a walker and fortunately was fairly adept with its use from previous experience. But you can’t safely carry anything using a walker. I needed large pockets to carry “stuff” or alternatively as we joked, use our dog’s leash for my husband. Lastly, my husband was the drill sergeant admonishing me to do my exercises!
My peri- and post-operative experience may have been a little rougher than average because of my numerous medical co-morbidities. My surgeon acknowledged that he needed to adjust his surgical technique as my knee pathology was worse than he anticipated. As time progressed, he was both amazed and pleased with my post operative recovery and progress. We first credited his skill and the responsiveness of his team. Additionally, we emphasized the seldom discussed importance of my husband as caretaker and surrogate. We successfully navigated the sweet spot.
