Lessons from the Other Side of the Knife

By Thomas H. Mallory, MD

Note: This article appeared in The Journal of Arthroplasty, Vol. 18, No. 3, Suppl 1 (April 2003) and is reprinted with permission from Elsevier Science Inc. © 2003 Elsevier Inc. All rights reserved.

What is it like to be on the other side of the knife? Anticipating a total knee arthroplasty, I pondered this question. The complications that I have observed and managed in my own patients over the past 30 years leapt to mind. Although serious complications are rare, the surgical event and acute period can be fraught with danger, pain and suffering, and occasionally even demise. I began to experience a heightened sense of loss of autonomy [1, 2]. Obviously, the rigid routine of the hospital would prevail, but the medical personnel would be watching how I handled the pain. Would I dare to complain? How about anxiety and apprehension? How would I manage? Other question came to mind: should I go with the flow and mix with other patients or have a private room and isolate myself? How quickly would I regain control [3, 4]? How rapidly would I be back in the position of calling all the shots even with my own knee? I was soon to find out what it means to be a patient.

Personal History

Playing football in high school resulted in an injury to my right knee involving the lateral meniscus and anterior cruciate ligament (ACL). In 1995, the state of the art in orthopaedics for meniscal injuries was arthrotomy and complete removal of the meniscus. Anterior cruciate repairs were not attempted. Eventually, I returned to playing football; however I had gross knee instability. I wore a derotation brace that was bulky and cumbersome, but it did provide knee stability. After medical school and residency, I became athletically active again. I participated in long distance running and completed 5 marathons. My right knee would be bothersome occasionally, but for the most part it was relatively pain free.

However, over time I developed a valgus deformity; eventually running became too painful. I then began to bike and swim. Moreover, I increased my equestrian activities to include playing polo. There were occasions when I would have exacerbation of pain, sometimes insidious and not always related to activity. My valgus deformity increased and became quite noticeable. Because I promoted total knee arthroplasty as a treatment for my patients’ knee conditions, they would often ask me, “when are you going to have your knee treated?” Finally, deformity, dysfunction, and progressive pain underscored my decision to undergo total knee arthroplasty.

The Event

In 30 years of performing joint arthroplasty, I have aspired to give my patients the environment that I was now seeking. These elements include surgeon, hospital, anesthesiologist, internist, and support system. I wanted a surgeon who was experienced and technically competent. I wanted a hospital system with tertiary support. I preferred regional anesthesia with a pre-emptive analgesia program for pain management. I wanted competent medical coverage with particular attention to the prophylaxis of thrombophlebitis. I preferred a community close to home so that I would have the support of friends and family. The program was laid out and I proceeded.

The surgery was uneventful; however, the recollection of events the day of surgery are somewhat blurred. I was scheduled to get out of bed that afternoon, but it was not feasible due to the somnolent effects of anesthesia and analgesia. The following morning, getting out of bed proved to be no easy task and in fact was quite painful. Gradually I began to take hold of the situation and later that afternoon I had improved significantly. The pre-emptive analgesia program required modification due to associated nausea, which limited oral medication. Meanwhile I was kept comfortable using intravenous, patient controlled analgesics. My nausea persisted and was associated with disrupted gastrointestinal function. My knee became swollen in part due to the lateral release necessary to correct my valgus deformity. The swelling and subsequent hemotoma limited my flexion activities. The exercise sessions were painful; however, the swelling gradually subsided as flexion increased with the use of a stationary recumbent bicycle. The knee finally began to loosen and I was able to flex comfortably.

Complications

Shortly after my knee arthroplasty, I developed persistent dysentery. My medical consultants diagnosed antibiotic-induced colitis and suspected Clostridium difficile. Although I was in reasonably good health at the time of surgery, I had been exposed previously to clostridium difficile through patient encounters. The diarrhea continued for an extended period of time. I lost 20 pounds and remained weak and inactive despite antibiotic treatment. Finally, after 3 months, the gastrointestinal symptoms of nausea and diarrhea abated. I returned to practice, albeit changed with feelings of fragility and weakness. My first days in the operating room were stressful. However, with the passing of time, confidence returned, strength was regained, and I returned to my usual busy schedule.

New Direction

As so often happens, 8 to 10 months after my right knee arthroplasty, my left knee became problematic. I had injured my left knee years earlier while involved in long distance running. At the time of the injury I denied the symptoms; however, within a short period a large Baker’s cyst developed and I underwent arthroscopy with chondroplasty. At the time of arthroscopy, degenerative changes of the medial meniscus and articular damage were identified. The left knee had progressive degeneration of the medial compartment over the ensuing years. The patellofemoral joint space was preserved and the lateral compartment appeared to be uninvolved. I decided to pursue a unicompartmental knee arthroplasty. I experienced entirely different surgical and hospital events. The surgery was brief, and recovery was rapid and convenient. I was walking the same afternoon after surgery and was discharged the following morning. Two weeks later, I had full range of motion. Pain and swelling were minimal compared with what I had experienced in total knee arthroplasty. I regained an active lifestyle with little interference or persistent complaints. I was certainly amazed at the difference between these 2 procedures. I can understand the enthusiasm for unicompartmental knee arthroplasty when indicated.

Personal Perspective and Observations

As I reflect on my experience with knee surgeries, I am reminded of how far we have come in orthopaedics. Especially in the practice of sports medicine, there has been great advancement. I am certain that my total knee arthroplasty would have been delayed, if not actually avoided, had I undergone a right partial meniscectomy and ACL repair at the time of initial injury. Wise consultation would have directed me away from contact sports such as football. As a practicing orthopaedic surgeon I am amazed at how insensitive I was to my own knee condition. I should not have run marathons; I would have tolerated the activities of biking, swimming and equestrian activities in moderation. But that was a time in my life of “can do”. I was experiencing life without considering the long-term consequences. Meanwhile, I was advising my patients to practice caution, consideration and restraint. Although I have undergone 2 successful knee arthroplasties, to be honest, I would rather have my natural knees. We certainly are “old quick and slow smart”

I have also gained several other insights that my have been helpful. As a physician and patient, I believe that we are at risk [5]. Potential issues include overdoctoring, overmedicating, and indecisiveness as to who is in charge. In my case, I developed dysentery. Consultants were many in number with multiple suggestions and advice, all of which was discussed with me with the sense of peer equality. I was treated as a physician with a colon infection rather than as patient with this condition. However, I was too sick, exhausted, irritable, and depressed to make wise choices regarding my treatment and recovery. Others have voiced the same observations regarding the loss of leadership in a doctor-patient relationship when the patient is a physician [6]. Treatment protocols can be altered because of the persistent skepticism. As a patient, one is a patient, no physician. Conversely, when the patient is a physician, the physician must be the physician. [7, 8].

These experiences have also taught me the importance of pain management, wound care, physical therapy, and finally conceding to the prosthetic lifestyle. Anyone who has undergone knee arthroplasty must understand the importance of coping. The patient must understand that the device can wear out, periarticular fractures can occur, and infections are an ever-present danger. The individual must set boundaries on activities, be attentive to general health, and use constant surveillance of the status of the joint replacement.

I realize, now from a patient perspective as well as the physician perspective, what a serious proposition it is to recommend a surgical procedure of this magnitude. When comparing total knee arthroplasty to unicompartmental arthroplasty, the emphasis is on offering patients the least invasive procedure necessary to relieve pain and restore function. Responsibilities extend not only to the technical execution of the procedure but also to being aware of the physical and emotional stress this surgery produces in any given individual. This experience has led me to a greater awareness of how important the patient is in the accomplishment of a satisfactory knee arthroplasty outcome. Was I a good patient? Not really, but it didn’t matter because the benevolence that was offered me was entirely unconditional.

Acknowledgment

The author expresses his sincere appreciation to Adolph V. Lombardi, Jr., MD, and John A. Repicci, DDS, MD, for their superb knowledge and surgical skills, their patience and encouragement, and for the excellent care they provided to him. The author also wishes to acknowledge Joanne B. Adams, BFA, and Kathleen L. Dodds, RN, BS for their editorial assistance.

References

1. Oddi LF: Enhancing patients; autonomy. Dimens Crit Care Nurs 13:60, 1994

2. Beauchamp TL: Principles of biomedical ethics. Oxford University Press, New York, 1989

3. Bachmann MO: Ought patients to follow professional advice? Health Expect 4:141, 2002

4. Farthmann EH: Surgically relevant comorbidity: ability to cooperate. Kongressbd Dtsch Ges Chir Kongr 118:674, 2001

5. Gillick MR: Talking with patients about risk. J Gen Int Med 3:166, 1998

6. Mainmore M: Fitness profile. South Florida Sun-Sentinel, E3, December 14, 1997

7. Bottles K: Patients and doctors: some thoughts on an evolving relationship amid

unprecedented change. Manag Care Q 8:34, 2000

8. Davis JM: Keeping the ill at ease. Postgrad Med 88:44, 1990

Go back to main Questions page