Bilateral Total Knee Replacement Surgery And Aftercare


 

| Home Page | Contents | Index | Comments? |

| Chapter — Adventure |

| Next — Chapter - Curmudgeon's Corner |

| Back — A Simple Act of Heroism |


 

Prologue

After 71 years that included Marine Corps infantry, climbing high mountains, shoeing horses, mapping such remote areas as the Solitario, and some years at sea among other adventures and tribulations, my knees had exceeded their million-mile warranty.

I had taken cortisone shots to both knees for a year until the shots were no longer effective. By the summer of 2009 palliative measures were wearing thin and I began looking for an orthopedic surgeon.

By this time I was finding it very difficult to walk, particularly on asphalt or concrete, and usually could not make it 100 yards without difficulty. My wife suggested we look at special footwear and on July 1, 2009, we went to Foot Solutions and ordered custom-fitted inserts for my shoes ($322). They also offered specialized Spira shoes with springs in the soles that also offered great relief. However, Marine infantry had widened my feet from a C width to an FF width. While I now get by with EEEE-width shoes, they didn't have them in the store. Fortunately, the shoes I needed in the required width are available directly from Spira ($145). Those shoes and inserts kept me walking for the next six months.

Knee replacement surgery is now a common operation and the problem isn't finding a surgeon so much as trusting their abilities. Horror stories about botched knee operations are common, often due to both surgical procedures and failure of patients to follow through on post-operative therapy. And it is often difficult to determine whether the surgeon was the problem or whether the patient simply failed to complete the very painful post-operative physical therapy.

So a round of recommendations from friends and relatives and an Internet investigation was begun to narrow the field. Beginning in August 2009 we visited with and sought opinions from three separate orthopedic surgeons. One of my criteria was whether both knees could be replaced at the same time, not a common practice. Another question was whether any other palliative measures, e.g., SynVisc injections, might be taken to delay the operation.


 

Bilateral knee surgery

Top

On October 1, 2009, we settled on Dr. Theodore Stringer with the Colorado Springs Orthopedic Group. Several factors entered the decision. One, he was not content with the previous conventional X-rays, and uses computer-aided surgical navigation, advanced techniques the others didn't offer. Also, he made it clear that my knees had deteriorated beyond the point where SynVisc injections or other palliative measures might help. Given my excellent physical condition he was willing to do total knee replacement surgery on both knees at once, something he usually doesn't do. He was also quite upfront about the difficulties with recovery and the fact that I would be totally disabled for four to six weeks after the operation.

But deciding on the surgeon is only the first step. Once agreement was reached that he would do the surgery then it was necessary to schedule it. Good orthopedic surgeons are not scouring the woods for patients, particularly in a place like Colorado Springs with its immense veteran population. As a result the first available date for my surgery was December 23, 2009, a great way to spend the Christmas holidays, but little choice.

The operation was performed at Penrose-St. Francis Hospital, a new facility on the northeast side of Colorado Springs. I began to have my doubts about the hospital during the pre-operative review when the flyer in the foyer described in rapturous detail all the wondrous features the hospital had for women but not a damn thing about male patients. I brought this to the attention of the nurse doing the medical history review and was told that hospitals make the majority of their profit in obstetrics and gynecology cases, hardly male issues. At the time I was reassured.

As scheduled, in the early morning of December 23, 2009, my wife delivered me to the hospital and Dr. Stringer performed his computer-aided magic. So for Christmas I got two new knees of steel and plastic.

I am told the surgery went well and the computer tomography we were later shown, and rapid recovery, confirms the excellent job. As I snore and there is some evidence of sleep apnea, apparently I was kept in the recovery room for an extended period following the operation. But of that I have no memory.


 

Aftercare

Top

This was my first real experience with Medicare and government health insurance. So I've added comments about incidents that those facing such care for themselves, or friends or relatives, might find useful or informative.

Penrose-St. Francis Hospital

Top

Apparently a combination of sleep apnea and possible reaction to the anesthesia had my blood oxygen level down around 75% from my more normal 95%. So after leaving recovery I was still on an oxygen mask and the back of the bed was tilted up roughly 45° to aid my breathing, or at least that is my drug-muddled understanding.

Many, if not most orthopedic surgeons now use continuous passive motion (CPM) machines to exercise the joints after knee replacement surgery. Dr. Stringer's practice is to begin CPM therapy shortly after surgery with a range of 0° to 90° on the machine. With both knees replaced the practice was to exercise one leg for two hours and then switch the machine to the other leg as there simply wasn't room for two machines to be used simultaneously.

With my being in a reclining position of about 45° and the CPM coming up 90°, and being regularly changed from leg to leg, at some point early Christmas day the CPM was positioned improperly and impacted my testicles. As a result my balls became swollen to a size exceeding a large grapefruit and my penis was completely enveloped in the swelling. The catheter had been removed, they had pumped me full of IV fluids during and following surgery, and I was on delayed-release morphine. As a result I found myself laying in a pool of my own urine for several hours before a nurse or assistant noticed and changed the bedding. That obviously caused a rash to form on my buttocks, back, and thighs.

But with my penis lost in my swollen testicles I couldn't effectively use the bedside urinal and my bedding repeatedly became soaked in urine. However, I was now aware of the problem and could usually get someone to change the sheets and pad though my rash continued to worsen,

It is also their standard practice to begin physical therapy a day after surgery. So that painful process began the day before Christmas and continued until I left the hospital. I would comment that throughout my recovery I found the physical and occupational therapists uniformly professional and competent. Painful, yes, but every session has resulted in some progress toward recovery.

Center at Centennial

Top

We had naively assumed that, with the available home health care, I would not need inpatient rehabilitation and therapy and that, following the surgery, I would be free to go home and that my wife would be able to take care of me. The severity of having both knees done and the subsequent problems with swollen testicles, etc., very quickly made it evident to both my wife and I that a transfer to a rehabilitation facility with inpatient care was an absolute necessity.

Because of its proximity to our residence, and recommendations from friends, we had assumed I would be doing my outpatient therapy at Village at Skyline. However, on Saturday, December 26 th , the hospital coerced us into going to the Center at Centennial, 3490 Centennial Boulevard, Colorado Springs, CO 80907-4087, telephone (719) 685-8888. Both my wife and I protested but were told by the hospital social worker that Village at Skyline was closed on weekends (a lie) and no one answered the telephone there. We also found out later that Center at Centennial is owned by a consortium of doctors and there is considerable pressure to put patients requiring rehabilitation at that facility.

Despite protests, the day after Christmas I was transferred to the Center at Centennial. In fairness, I should mention that this is a relatively new, about 2-years-old facility, and puts forth quite an attractive facade.

Once there I was placed on a bed covered with a thick sheet of plastic over which a sheet(?) of very thin muslim had been placed. Under my midsection a pad of some sort, possibly a towel, was placed. Nothing was done, e.g., ice pack, about my swollen testicles or my inability to use a bedside urinal. So the pad quickly became soaked and I was laying in my urine. In addition, my upper body was now laying in a pool of sweat on top of the plastic sheet and I was virtually totally immobilized from the bilateral knee operation. I was also apparently on delayed-release oral morphine tablets so initially I was quite unaware of what was happening.

Sometime in the night I became aware of my situation and pressed the call button for assistance. A very kind nurse's assistant repeatedly changed the urine-soaked pad under my midsection that night but could do nothing about the pool of sweat under my back from laying on a plastic sheet. And pain limited my feeble attempts to even roll on to one side to dry out. Needless to say, the rash that first developed in the hospital got worse and spread.

On Sunday I asked for adult diapers as the swelling in my testicles had not abated or been treated. One might reasonably ask why a patient has to request such an obvious step from what is billed as a skilled nursing facility?

While the diapers did help in preventing the pad under my midsection from becoming quickly urine-soaked the staff made no effort to change, or check the diapers which, of course, became soaked regularly. So to get a dry diaper I had to repeatedly press the call button. And one of the nurses seemed to have emigrated here from Germany after taking her medical training at Buchenwald or a similar facility and she regarded Herr Doktor Professor as simply one more Juden schwein to be disposed of.

Diaper changes were not a minor issue. I repeatedly sampled both types of adult diapers they had although I can't remember the brand that worked best. Of course nothing was done to alleviate the rash in my groin and on my back from laying on a sheet of plastic.

Realizing that in another day or two I would be faced with bed sores, that my overall condition was deteriorating, and appalled at both the food and treatment, I called my wife on Sunday evening and asked her if she would arrange for my transfer out of the Center at Centennial as early as possible on Monday morning.

Having been told by the St. Francis-Penrose Hospital social worker that Village at Skyline was closed on weekends, my wife called them at 8 AM on Monday. While arranging for my transfer there she also found out that Skyline is available 24/7 for the type of care I required and we had simply been lied to on Saturday at the hospital.

On Monday, December 28, 2009, my wife called Village at Skyline and quickly made arrangements for my transfer to their inpatient rehabilitation facility. However, formal arrangements and transportation took most of the day and it wasn't until about 5 PM that the bus to move me actually picked me up for the trip.

When Center at Centennial was told I was leaving basically all services stopped. Unfortunately, I had not had a bowel movement since the morning of December 23 rd before surgery. That is common after surgery where opiates are used to control pain. While waiting for the transfer, after five days nature caught up to me. Fortunately, I had the upper body strength to lift myself into a wheel chair, and with my wife's help with my legs, on to the toilet. Then things got stuck. Calls for a nurse and an enema were not answered. After a half-hour or so of pain I recalled an old lesson from the Marines about prying feces out with one's fingers. So for some time I sat there and pried shit out of my anus with two fingers, which successfully cleared the blockage.

Following that memorable experience my wife helped me back into bed and within an hour or so the assistant from Skyline arrived to transport me there.

If one treated a dog the way I was treated at Center at Centennial they would be arrested.

Village at Skyline

Top

The treatment at Village at Skyline was as day is to night. They made sure my bed had some padding so that I did not lay in my own sweat. A meal was provided even though it was past meal time, and I was treated as a welcome guest.

But lets not get carried away with the praise just yet! For the first time in three days I was able to go to sleep comfortably around 8 PM. However, at about 10 PM the lights came on and three grinning idiots were introducing themselves as the night staff. Now they turned out to be nice people and did their best to help me but I was desperate for sleep.

Finally they told me that if I needed anything to just press the call button and they'd be right in. But Murphy wasn't done with me. Sometime around 2:30 AM Tuesday morning my pad got soaked in urine again and I needed it changed. Pressed the call button and waited. Nothing happened. Press it again. Nothing happened. It simply wasn't working.

Recall that I was in such poor condition that I was unable to even roll on my side at this point.

Around 3:30 AM I tried calling for help. Repeated calls every time I thought I heard someone outside the room for about an hour. No response and I needed help!

Finally, about 4:30 AM I called my wife and overrode the night block we have on the home phone by declaring an emergency. The phone finally woke her, as she was as exhausted as I by the week's events. As soon as she could understand me I explained the situation to her and asked her to see if she could reach someone at Village at Skyline who could come and help me. Eventually she reached someone at Skyline and about 5 AM a nurse finally came in to help me.

Of course, this being a government-controlled Medicare facility it was necessary for one to fill out a form and notify maintenance about the malfunctioning call light. About 9 AM a maintenance man showed up and fiddled with the light. It worked while he was there but stopped working about 15 minutes later. Repeated requests for repairs over several days and reliability improved somewhat. But during my entire stay that call light could not be depended on to work when the button was pressed. After a couple of days I did learn to jigger it by repeatedly pressing the reset button until it started flashing so my discomfort and danger diminished. But I worry about subsequent occupants who may need help and not have my technical skills? What is more basic to a nursing facility than a reliable call signal for the nursing staff from patients in need of succor?

Then on Tuesday a somewhat amusing incident happened. Now that my bowels had started to work they decided to complete the job and rather completely remove the backup. That plugged the toilet. More forms and calls to maintenance when what was needed was a toilet plunger. But nurses, CMA's, therapists, etc., are not allowed access to toilet plungers and they are kept locked up. It took over 24 hours to get someone to use a plunger on the toilet! Fortunately, my bowels held off until a plunger could be located and employed.

Through all this the staff was as helpful as one might wish but these facilities all have many similarities to a prison hospital. You are not allowed to have any medications not provided by the nurse and prescribed by either your doctor or the staff doctor. And you must take the pills while the nurse watches. There are comic side effects to this. For example, to circumvent the virtually inevitable constipation that results from narcotic pain medications I was prescribed a stool softener. That continued until I developed diarrhea. After that I told the nurse to stop that medication but the rules forbade such arbitrary stoppage. So for over a week, each time I was presented with my pills I had to pull out the stool softener and refuse to take it.

A not so comic side to the rules on medication involved a prescription ordered by my surgeon. To avoid possible blood clots following my surgery I was placed on Coumadin (warfarin sodium), a blood thinner. To reduce the pain in my legs I asked for a muscle relaxant and normally would have used aspirin. But aspirin was contra indicated in conjunctions with Coumadin. So he prescribed 2 mg Valium (diazepam) tablets to ease the spasms in my legs. Now I don't know what happened but, despite repeated requests to investigate, I never received that drug while I remained at Skyline, a source of considerable discomfort to me while enduring quite painful physical therapy.

While the swelling in my testicles did finally recede, and I was able to use a bedside urinal again, little was done for the rash in my groin and on my back as nothing was prescribed. Rather than wait the days for an official visit and prescription, my wife brought in some 1% hydrocortisone cream in her purse. After a sponge bath she applied the cream once a day for several days until the rash receded. But what would I have done without her? And when they changed my bedding after the first week they removed the pad from the waterproof mattress and I found myself laying in my own sweat again. A chat with the Director of Nursing fixed that but what do other patients do?

Another source of discomfort common to such facilities is the corncob-on-a-roll single-ply toilet paper provided. Let me here extol the blessings of modern double-ply soft toilet paper and again bless my wife for smuggling some in.

But all these are minor discomforts likely to be found in any skilled nursing/rehabilitation facility that accepts Medicare patients. Welcome to government health care!

The real measure of such facilities, particularly as associated with knee surgeries, is the physical therapy staff. The pain sisters at Village at Skyline are real standouts and, despite my continued comments about their fiendish torture, every session with them resulted in noticeable improvement. They had me up and walking (with a walker) in less than two weeks after the surgery. By January 8, 2010, I had completed inpatient therapy and was discharged on January 9th without the need for any extended home health care visits.

On January 11th I began outpatient therapy (aka, torture) and one of the outstanding features for therapy at Skyline is their pool. So hydrotherapy began twice a week as of January 12th. And by January 26th, just a month after bilateral knee replacement surgery I was able to begin pedaling a stationery bike, a therapeutic landmark for flexibility in such cases as mine.

While physical therapy will, of necessity, need to continue for some months, a successful outcome is highly probable thanks to the dedication and training of Skylines's therapists.


 

Costs

Top

My operation occurred during the middle of intense debate in the Congress about health care reform. Also doctors and hospitals are screaming about the amount of payment they are receiving from Medicare.

Since knee replacement surgery is a growing business as the population ages it is reasonable to take a moment to review what Medicare does pay versus what the surgeon and hospital claimed their costs were. Bear in mind that Penrose-St. Francis is a brand new hospital with all the latest facilities and that the surgeon was chosen because he had the latest equipment and skills. So the surgeon and hospital are not the cheapest one might find. But they are probably not the most expensive in the country either.

Table 2 provides a comparison between what Medicare paid and what the hospital and doctors charged. Given the years of training for a surgeon and an anesthesiologist I am loathe to second guess their reasonable costs. It seems obvious that Medicare is grossly under compensating them for their time and skills. However, the cost to taxpayers of fully compensating them for these very common operations is enormous as a large percentage of such operations are, and will be done under Medicare or Medicaid coverage.

    Table 2: Cost comparison between hospital and doctors charges and what Medicare paid in 2010.

Facility

Facility

charge

Medicare

paid

Difference

(loss to facility)

Percent paid

by Medicare

Hospital

$112,579

$18,779

$93.780

17%

Surgeon

$10,154

$3,045

$7,109

30%

Anesthesiologist

$2,835

$992

$1,843

35%

Since participation in Medicare is voluntary for a doctor, Medicare is forced to pay a little higher percentage of their billed rates as shown in Table 2. However, apparently many doctors are opting out already as they can earn more dealing only with private insurance companies. That trend is likely to continue as government interference grows, to the detriment of the nation's elderly.

The hospital costs are an even more complex issue due to many existing government mandates and regulations. For example, the hospital must provide emergence services to everyone, whether they can pay or not. So the poor, who cannot afford a doctor visit for some relatively minor problem, often end up in the hospital emergency room adding immeasurably to the hospital's uncompensated expenses. But hospitals are fixed facilities and they generally can't simply opt out of Medicare the way an individual doctor can. So Medicare has found it convenient to pay even less of the hospital costs.

This is a sample of one operation so it can't be extrapolated very far. But it does serve to illustrate the enormous cost to the public of such programs as Medicare. Since the majority of medical expenses typically occur toward the end of life many ethical questions about the level of care are raised, both here in the treatment by such facilities as Center at Centennial, and in general. Should a rich society such as ours care for the elderly? Absolutely! Can the present system be improved? Unquestionably! Is the Congress likely to improve health care through more legislation? Absolutely not!

So some tough problems are raised that our society has not learned to deal with as life spans have increased and medical technology has constantly improved.


 

Lessons learned

Top

• Good physical conditioning is essential to your recovery.

• If surgery is pending, or you have the chance, investigate potential medical facilities as closely, or more closely than the surgeon. You'll be spending more time in the facility than with the doctor.

• Just because doctors own a facility does not mean it is well run. Few good doctors are also good managers.

• Social workers across the board either lie or are too stupid to know the truth. Take their word for nothing you haven't personally verified.

• Be sure you have a trusted family member, or very close friend, to help you after surgery or through your illness with everything from finances and bills to bringing you toothpaste and toilet paper.

• Few things in life will make the importance of family and marriage more evident than a serious illness or surgery. Treasure those closest to you!

• Assisted living and rehabilitation facilities don't usually attract the cream of the medical profession. Make allowances and have your family seek second opinions or transfer you to another facility.

• The difference in any medical facility is often based on how friendly and helpful the staff are in difficult situations. Typically their attitude towards patients depends on how good the management is and how their boss treats them. Unhappy, uncooperative staff, get the hell out ASAP.

• Vicodin can become addictive within seven (7) days and withdrawal causes terrible chills.

• After the incisions heal you may find that BenGay, or equivalent topical cream, is a great help in relieving the stiffness and cramps.

Top


 

| Home Page | Contents | Index | Comments? |

| Chapter — Adventure |

| Next — Chapter - Curmudgeon's Corner |

| Back — A Simple Act of Heroism |


 

Added January 30, 2010

Last modified 2/15/14