|Ira H. Kirschenbaum MD, chairman of the Department of Orthopedics at Bronx-Lebanon Hospital Center, Bronx, New York, has performed over 3500 total knee replacements. When Dr Kirschenbaum needed a new knee himself, he kept a diary from a perspective he had taken for granted that he understood: that of his patients.
Despite being an expert on the procedure he was about to undergo, much about the experience leading up to the surgery was unexpected, which Dr Kirschenbaum recorded in his diary. Part 1, presented here, offers his thoughts before and immediately after the procedure. Part 2, coming soon, includes his reflections on postoperative pain management.
Ira H. Kirschenbaum MD, Medscape Orthopedics September 07, 2016
|My Knee Is Now Your Knee|
|August 17, 2016|
|I have always had a certain amount of knee pain, but at age 59, I am scheduled to have a left total knee replacement next Monday, 6 days from now. I am used to being the surgeon. This time I am someone else’s patient.
Since venturing from my fellowship in joint replacement surgery at the Rothman Institute in Philadelphia in 1991, I have performed over 3500 knee replacements without a sense that one day this might be my fate too. Performing a knee replacement is a surgical religious experience. It is thoughtful, elegant surgery coupled with a massively positive intervention in the quality of life of the patient.
In good hands, a knee replacement takes about 45 minutes to an hour to perform. The results are so good that when a less-than-optimal result happens, we surgeons experience a great sadness for our patients because we feel that we do the operation the same way each time—and, as such, we expect consistently good results.
When the results are just not good, it’s frustrating. Even if this only happens 3% of the time, all you have to do is crunch the numbers. If a surgeon does 200 knee replacements a year and 3% of patients are not happy with the result, that means that six people a year—a lot of people—are not pleased with the surgeon’s attempt to make them feel better. This sometimes makes for a tough job.
Now that I am about to be at the other end of the scalpel, I have two fears. The smaller one is the pain after surgery. That will be temporary. Considering that my surgeon uses a multimodal approach to pain—with many medications and modalities, as well as the use of a long-acting local anesthetic—I think the pain will be manageable enough. We shall see.
The bigger concern is whether, despite the skill of my surgeon, I will be in that 3% of patients who have a less-than-optimal result. This is the group in which everything went well in the operating room, the x-rays looked great, and by all accounts their results should have been home runs, and yet they weren’t. In my past 25 years in surgical practice, I have seen too many patients who were in that 3% to know that it is impossible to predict whether I will be one of them.
Dr. Ira Kirschenbaum on WPIX-11: The Alternatives to Knee Replacement Surgery. Published on YouTube January 19, 2012
|This Is Not Happening to Me!|
|August 17, 2016|
|It is really a strange moment of disbelief—that you will lose a part of your body. When this moment happens, you try to look back to see when it all started. Everyone can go really far back—to Pop Warner football or to a host of other relatively uneventful but memorable knee injuries. Unless you had a major trauma to your knee (which I never did), most knee arthritis—the most common disease that leads to knee replacement—is not easily explained, other than that somehow it was in your body’s master plan for you. Whether this was somehow inherited in your family’s genes or is unique just to you, we really don’t know. The best you can say is that it is fairly common; over 1 million people each year need joint replacements in the United States alone.
I remember the last time I ran, though. It was in the fall of 2012. I thought about that time when it became clear that I was going for a knee replacement. My youngest son and I were coming home from a New York Knicks basketball game and had the chance to take the 10:36 PM train out of Grand Central Station if we moved fast enough. The consequence of missing the train was having to take the 11:05, and considering that the food court in Grand Central was closed by then, there was no intelligent reason to be waiting around. We had to start running.
Having run track in junior high school and played football in high school, running was simply running. No biggie. Bolting to the S train, the shuttle to Grand Central, I heard a pop in my knee, and it buckled with the simple clarity of PAIN! For the rest of the successful journey to catch the 10:36, I walked fast. No self-respecting New Yorker misses a train, even if it means hopping on one leg. I never ran again after that day.
Fast forward to September 2015. I was increasing my exercise regimen—nothing crazy, mind you: about a half hour of weights and the same amount of time doing cardio. I did a particularly vigorous quads set on a machine, and the next morning the pain in both knees was incredible. I fully expected that with a little rest, ice, Aleve® (naproxen), and time, I would be back to baseline. The right knee rapidly improved. The pain never stopped in the left knee, however, and a cascade of events had begun that caused the further demise of that joint. When I eventually got an x-ray and saw bone on bone, I have to admit that I sensed the left was doomed. I was not going to let this happen—a knee surgeon needing a knee replacement so young—so I embarked on an aggressive but conservative treatment journey.
|Anything But Surgery!|
|August 17, 2016|
|Once you truly need a knee replacement, there really isn’t a lot you can do to avoid it. The only people, in my experience, who can avoid a knee replacement by trying a particular exercise regimen or injection product don’t really need a knee replacement in the first place. Once the bone on one side of the joint touches the bone on the other side and you begin that terrible painful slide down into arthritis pain, it is unlikely that you can avoid surgery. You can definitely do some maneuvers to temporarily relieve the pain, and as long as you continue to do these things, you can postpone the inevitable for a few months or maybe a year.
As in any situation, there are some exceptions, and everyone has a unique story. Some people say that they derive pain relief from Synvisc-One® (hylan-G-F 20) or glucosamine, even though such results are not based on hard science, but these products do nothing to lubricate the joint or build cartilage. Nevertheless, I tried them.
I did physical therapy focused on strengthening my knees. I took glucosamine. I did Synvisc-One injections. I did cortisone injections and took 600-1200 mg of Aleve liquid gels daily. The Aleve worked in bringing the pain down from a high of 8 to a low of 5 on the visual analog scale. Everything else was no-go. I still intend to recommend to my patients all of the modalities that failed for me. Even if a small percentage of patients do well, these modalities are so minimally invasive that there is no harm in trying. So go for it. But if your x-rays show that your knees are done, then they are probably done.
Denial works, though. “Who needs to run or even walk quickly anymore?” I thought. “There are more than enough Netflix and Amazon TV series to avoid ever needing to leave the couch.” So what if it takes me 15 minutes to walk across the street.
This line of thinking begins to run thin. Life is motion, and motion is life. But being in denial helped me hold out for 4-6 months, until nearly everyone I knew was saying, “When are you finally going to do something about that knee?”
“All right, already,” I replied. “I’ll go get major surgery so you don’t have to feel so much pain when you watch me walk!”
|August 17, 2016|
|No matter how many patients I prepared for surgery as a surgeon, from a patient’s perspective, I see how complex it is. There are so many pieces to the puzzle. The major issue: Everyone who has to prepare for surgery had a life before having to prepare for surgery. Now you need to take time out for the preparation.
No matter how many patients I prepared for surgery as a surgeon, from a patient’s perspective, I see how complex it is. There are so many pieces to the puzzle.
It’s not as easy as it looks. A whole bunch of people have to do a whole bunch of things separately and distinctly from each other to make everything come together on a particular day so that afterward the patient can feel a whole bunch better.
It starts with preparing your mindset. I needed to wrap my brain around the enormity of the concept of having surgery—the pain, the time off from work, and the change in my daily lifestyle, just to mention a few things. Early on, this knee surgery needed to be placed high on my priority list.
Organizing my professional life was no small feat. Patients who have surgery when they are younger are typically working, and I was no different. When you are going to be out of work for 6-12 weeks, figuring out how to turn work down is a challenge. I decided it would take 3 months to get things in order, so I scheduled my surgery appropriately.
Truth be told, a week before my surgery, I was still scrambling around. So much for a plan. I was glad that I told a lot of people at the hospital that I was having surgery so that my preparations were not seen as being out of context. I needed a plan for leaving and a plan for returning. I planned to recuperate for all of September, have office hours only in October, return to 50%-75% of my normal surgery schedule in November, and then return to work full time in December.
I was curious to see if I could stay on course.
You never really know how sick you are until your primary care doctor prepares you for surgery. As a surgeon, I always thought that I saved people’s lives just by sending them to a primary care doctor for preoperative preparation. At that meeting, the primary care doctor would often find a host of illnesses unrelated to their surgeries and put the patients on a treatment plan. Fortunately, in my surgical pre-op visit, there were no surprises. My internist recommended some cardiac testing, and the chairman of medicine at my hospital reviewed my excruciatingly normal tests. My medical life was in order.
Health finances are harder to understand than an algebra question. There are a million deductibles and fine-print rules; none are really advantageous to patients. For me, there was an interesting twist: Financially, my surgery was being performed under one of the first commercial bundled (ie, a global flat fee) payment programs for outpatient joint replacement. By having the surgery done as a bundle, there are no billing surprises.
I had more than enough sick leave, short-term disability, and a plan to return to work within a reasonable time, so personal finances would not be a problem. Still, this was something I needed to calculate.
My personal life, however—from my mobility to how I would spend my time—would be upended by the surgery. At this point, I am not even close to anticipating how much time I will need to devote to healing. This is likely to be a challenge.
I have an advantage over most patients when it comes to surgery education. But even for an orthopedic surgeon, there is a lot to learn. My operation is taking place in an unfamiliar hospital, and the protocols to be used are also a bit unfamiliar. I want to try my best to be a good patient through the process.
|Pre-op Physical Therapy|
|August 18, 2016|
|I finished my preoperative physical therapy this morning. For many years, I ordered pre-op PT for my patients but was never really sure of its value. Now I am sure. It’s really great. It lowers the fear of what to expect. In a controlled setting, my therapists reviewed all of the exercises in my regimen before I experienced postoperative pain. They were caring and comprehensive. It’s amazing how every little thing—from which foot to put first to how to position your leg—has a science behind it. I really valued this appointment. We discussed exercises, equipment, and modalities to decrease the pain. Pre-op PT: Don’t go into the OR without it!|
|The Pain Epiphany|
|August 19, 2016|
|I woke up this morning with a remarkable amount of pain in my knee. This should be no surprise. In 3 days, I am getting my left knee joint surgically replaced because of the pain. As I limped across the room, I realized that this is how I had woken up for many days over the past few months, and in a strange way, I had gotten used to this pain as part of my life. I did fewer errands, walked up and down the stairs at home fewer times, and avoided doing many things that I used to do.
So it hit me that, very soon, I would be saying goodbye to this pain. I almost didn’t remember what it was like to be unrestricted in my activity, and it is amazing how insidious pain is as it creeps into your daily routine and attaches like bamboo roots to your brain.
Fortunately for me, daily Aleve was all I really needed to take the edge off the pain, but I know that other people need stronger medications. I am sure that their dependence on these medications happened slowly over time and that not all of these people had a surgical solution to their problem. While I am not looking forward to the pain after the surgery, I am looking forward to no more pain after I heal.
|August 21, 2016|
|Two days before surgery, I just want the surgery to be done. From the surgeon’s point of view, the day before surgery is just a regular day. I would have planned all of the operations I had scheduled a week before so that all I had to do was show up. As the patient, it is a different story.
I am going through a checklist that my surgeon gave me. There seems to be way more stuff to do as a patient than I thought there was. After doing over 3500 knee replacements, I guess that reviewing the list with patients is second nature, but when you’re actually the patient, there is a lot to remember:
I am picking up my wife from the airport today. I can’t even imagine the stress my surgery is putting on her. The caregiver shares in the pain and the process. Fortunately, this is time-limited until I get better.
I just got a text reminder to fill out my preoperative patient-reported outcomes scores. These forms let my surgeon know how I am doing throughout the process. They also allow for comparison with other patients. I am managing a flurry of well-wishers on Facebook, LinkedIn, and email and expect to get really busy today waiting for the surgery. There’s not much else to do.
|August 23, 2016|
|I got to the surgery center at about 6 AM. Everyone there knew the entire protocol, knew what to do, and knew what I needed to do. It is not that I am surprised, but I am pleased it happened that way. After an interview with the intake nurse and then the anesthesiologist, the circulating nurse walked me to the operating room.
The surgery ended at 9:30 AM. I am recuperating at the home of my surgeon, a personal friend. I was in his house before noon. It is now 5 PM. I have no pain. I received a long-acting local anesthetic during the procedure. It’s still working. But I know I have a long road ahead of me.
The pain would eventually arrive, and I needed to be ahead of it. I started taking two regular-strength Tylenol® (acetaminophen; 650 mg) every 4 hours while I was awake and two Aleve twice a day. I had some heavier meds in tow just in case. I also needed to be very compliant with my anticoagulation plan. I had started taking Coumadin® (warfarin) 5 mg the previous night and had just taken my second dose. After the third dose, I would be switching to Lovenox® (enoxaparin) for 10 days and then to aspirin for 6 weeks. I also had my portable sequential compression device (SCD) pumps to prevent deep vein thrombosis.
|The Day After Surgery|
|August 24, 2016|
|There is a lot of talk about patient satisfaction in healthcare. I think that we need to do more than talk about it. We need to do something about it. It starts with what patients want. I am fortunate that my surgeon is a huge patient advocate.
It is the second day after surgery. I am laying down now with my knee elevated, with pain a 1 out of 10. I am a satisfied patient.
Multimodal pain-relieving strategies are important. For my surgeon, this means preoperatively starting with nonsteroidal anti-inflammatory drugs (NSAIDs—in my case, Aleve), intravenous Tylenol, injections in the knee that include plain bupivacaine (lasts 12 hours), liposomal bupivacaine (lasts 24-72 hours), and tranexamic acid (for bleeding control). The total cost of these injections, which now leave me with minimal pain on the second day after surgery, is approximately $350. That’s it! Now that’s a value to get patient satisfaction.
Recently I heard of a hospital that is removing the intravenous Tylenol and the liposomal bupivacaine because it cost them too much, and they did not achieve improved length of stay. I have seen this operation from both sides now, and of the things that make patients satisfied, pain control takes precedence. For a $20,000 operation, a hospital or surgeon unwilling to spend $350 of that on pain control just does not care about patient satisfaction.
In the first 2 days after the surgery, I exercised quite a bit and was very sore at night. I had more soreness than I wanted, so I took Tylenol 650 mg and oxycodone 10 mg twice on the second night. That’s all the opioids I took in 48 hours. When I woke up the next morning, I went back to Tylenol and Aleve.
Because of my pre-op physical therapy session, I am on target with the prescribed exercises, using a walker for getting around. I am also using my incentive spirometer to inflate my lungs to prevent pneumonia.
|Day One After Surgery. Ira H. Kirschenbaum MD, My Knee Your Knee|
In part 2 of this diary, I’ll report on my postoperative pain management.
Source Medscape Orthopedics