June, 2039. Two Princeton University seniors, killing time between their last finals and graduation day, decide to play some one-on-one basketball in Dillon Gym. Neither one has exercised since high school and the game ends when one of them wrenches a knee — the sound of cartilage tearing can literally be heard.
A few days later, when he is still hobbling around and the joint shows no sign of getting better, the would-be athlete schedules an appointment with Dr. W. Thomas Gutowski of the Princeton Orthopedic Group and a longtime surgeon affiliated with the University Medical Center of Princeton. Well into his 80s, Gutowski is past the days when he would sometimes be on his feet 10 or 12 hours a day, performing what were then state-of-the-art total knee and hip replacements at the hospital’s Jim Craigie Center for Joint Replacement.
But these days surgical repairs of torn knees are rare. Instead Gutowski uses advanced imaging techniques to precisely locate the torn areas and then makes a few strategically located injections of a new biologically formulated material that promotes the growth of brand new cartilage that bonds to the remaining cartilage. Give the material some time to grow and integrate into your own joint structure, Gutowski advises the young patient. Then follow a modest exercise regimen, and in six to eight weeks you should be as good as new.
That’s a vision of 2039. But, sadly for me, I tore my knee in a pick-up basketball game on the Princeton campus way back in June, 1969. Then the appointment was with an orthopedic surgeon whose only option was to surgically remove the torn pieces, sew me back up, and send me on my way. Physical therapy was an after-thought. Sit on the edge of a desk, the surgeon told me, put a few cans of soup in your mother’s purse, and then lift that with your leg a couple of times a day. In six weeks you’ll be good enough to dig a ditch. It was the height of the Vietnam War; the surgeon was a hawk.
Needless to say my right knee never did return to full strength. Over the years I reinjured it several times. In the 1970s I saw an orthopedist who said that before he would consider another operation he would first like to see me pursue a rigorous exercise program to strengthen the muscles above and below the knee. I bought a weight bench that enabled me to do a lot more conditioning than I ever could do with my mother’s purse.
I bought some time — a good thing. In 2002, when a 90 percent blockage in my left anterior descending artery (the widow maker) was discovered, I was able to begin a modest but essential exercise program consisting of a brisk, 30-minute walk most every day. I loved my walk, varied it often, and never wore headphones or ear buds, choosing instead to absorb the sights and sounds of my surroundings.
But then in 2008 I was rearranging some flagstone outside the house. The next day at work, when I got up from my desk, my knee couldn’t support the weight. I hobbled around, and it got a little better, but my 30-minute outdoor walks had to be replaced by 30 minutes on an elliptical machine in the basement. The only relief from boredom was a large screen television and the remote control.
I consulted with the orthopedic surgeon who had successfully repaired my torn rotator cuff back in 1997. He told me my cartilage was shot, but there were some injections on the market that could provide some relief. The trouble was that the relief might last a few months or less, and then more injections would be needed. He did not recommend it. The only true remedy, he believed, was a total knee replacement.
By then I already knew people who had gone through the process. When I first started hearing about knee replacements the advice was that you should wait as long as possible to have it done because you didn’t want the artificial knee to wear out and then go through the process again sometime in your 70s or 80s. Later (and after the longevity of a replacement knee was talked about in the range of 20 years instead of 10 or so), the advice was the exact opposite: you didn’t want to wait too long because then you might not be fit enough to endure the physical therapy required to fully rehabilitate the joint.
But no matter who gave the advice or what side of the timing issue they were on, the artificial knee recipients in my informal and very limited survey group were all happy with the results. For those who received the new knees most recently the discussion usually went something like this. “Oh, the new knee. It’s great. I was walking on it three or four hours after the operation. I was back at work two weeks later. Now I’m playing tennis again (or substitute whatever other physical activity you can imagine) better than ever.”
Since it sounded almost too good to be true, I decided that — when my time came — I would keep a diary:
Fall, 2013. My time has come. I am sitting in meetings at work and when they are over I find myself hobbling up from my chair and limping out of the room. I climb stairs only with difficulty. When I reach the last step I need to take an extra half step to get to the top landing.
Where to go? What doctor should do it? With baby boomers’ hips and knees growing creaky as they age (and even creakier as a result of some boomers’ obsession with sports activities), joint replacements are a big business. Nationally some 700,000 knees are replaced each year — the number is expected to soar to more than 3 million a year as baby boomers age. The major Princeton-area hospitals have all geared up with special centers to serve those patients.
Robert Wood Johnson University Hospital Hamilton has established its Center for Orthopedic & Spine Health, and has received certification for knee and hip replacements and spinal surgery from the national Joint Commission.
The “joint” in Joint Commission has nothing to do with body parts, but rather represents the joining of several medical associations in 1951 to establish one large independent nonprofit commission to review the performance of more than 20,500 health care organizations in a wide variety of services against a set of standard benchmarks. It was originally called the Joint Commission on Accreditation of Hospitals (JCAH). The name was changed to the Joint Commission in 2007. Now hospitals proudly display the “gold seal” of the Joint Commission at every opportunity.
Capital Health Medical Center-Hopewell boasts its Marjorie G. Ernest Joint Replacement Center of Excellence (the donor is the daughter of an orthopedic surgeon who practiced for many years at Mercer Medical Center in Trenton, the predecessor of the new hospital). The Joint Commission has certified its hip replacement program.
And the University Medical Center of Princeton at Plainsboro created its Jim Craigie Center for Joint Replacement along with the construction of its new campus on Route 1 at Plainsboro Road (made possible by a donation from Craigie, the CEO of Church & Dwight, who had both hips replaced by Dr. Thomas Gutowski). The Craigie Center has been certified for knee and hip replacements by the Joint Commission. Craigie himself, in publicity materials for the Princeton center, acknowledged that people in Princeton sometimes felt they had to go to New York or Philadelphia for specialized care. That was no longer the case, he firmly believed.
Certifications, accreditations, gold seal centers, and CEO endorsements all sound like sales talk to me, a jaded baby boomer. More important at this point in my life, the new Princeton hospital is just minutes from home, and getting there would be easy for family and friends, as well as for me.
So I lean toward Princeton hospital. To get a second opinion I look no further than the house next door to mine in downtown Princeton, and my relatively new neighbor, Anna Westrick, who happens to be an anesthesiologist at the hospital. In my best “just between you and me” (and now another 19,000 or so readers of this newspaper) voice, I ask if she would recommend Princeton for a knee replacement. She would, and she mentions the Joint Replacement Center. She adds that she might even be assigned to my case if I went there, and that she would make a point of taking my case if I want her to.
At this point I figure one anesthesiologist is the same as any other. But, thinking that it’s better to be known than unknown in the operating room, I seize the opportunity.
Committed to the Jim Craigie Center for Joint Replacement, I figure I might as well try to get the center’s medical director, Thomas Gutowski, to perform the surgery. A phone call to his office encourages callers to leave a message, but only if they are candidates for knee or hip replacements.
That would be me. We soon fix a date: Tuesday, January 14.
December, 2013. The process begins with “joint class.” I figure that a lot of the demand for new knees and hips comes from aging baby boomers who have pounded their joints through jogging, tennis, skiing, etc. But at the class I am struck by how many participants arrive with canes or walkers. A substantial portion are overweight.
The instructors pass around models of the knee and the hip and describe the procedures. There’s a hand-out, a 54-page booklet that details pre-operative activities and exercises that should be done before the operation to get your leg in shape for the physical therapy afterward. One of the exercises is called a heel slide. You lie down on your back, and slide your leg back toward your butt, so that the knee bends and rises into the air. Do 10 repetitions, the book says. I can’t do even one with my “bad” knee.
At the end of the “joint class” the instructors say they welcome feedback on how to make the class better. My advice, offered now with my 20-20 hindsight: Don’t try to put knee and hip replacement patients in the same room. For those of us whose anatomy knowledge is limited to the nursery school song, “the knee bone’s connected to the shin bone,” etc., the simpler the better.
Monday, January 6. My first meeting with Dr. Gutowski. I bring along X-rays and other information from my visits three or four years before with my other orthopedist. He looks over my X-rays, checks some new X-rays just taken by his staff, and says that he concurs with every bit of advice offered by the prior orthopedist. The bottom line is the same: The knee has to be replaced.
I am surprised that there is no MRI, no complex imaging to take an exact measure of my knee. I ask Gutowski about that and he explains that the determination of which size artificial knee to install will be made at the time of the operation. A simple incision down the center of the knee will allow him to expose the knee, slide the kneecap out of the way, move the muscles, tendons, and blood vessels out of the way, and then trim the femur (or thigh bone) and tibia (or shin bone) to accommodate the installation of the two parts of the new metal knee and the plastic material that serves as the equivalent of cartilage.
At that point he will take a few measurements and pluck the right-sized parts from the extensive inventory maintained by the Joint Replacement Center. There are literally hundreds of different models to choose from, including designs for right side and left side, some that are gender specific, and some “high flex” models.
The Zimmer knee that I receive is made of two different kinds of metal. The part attached to the femur is chromium cobalt; the part installed on the tibia is made of titanium. One metal is especially good for handling the forces of compression. The other is better at withstanding rotation. In between them is polyethylene — plastic. That part, I gather from some Internet research, will eventually wear down — 20 years is a reasonable life expectancy. But it can be replaced separately in a follow up operation that is much less complicated than the original.
Rehabilitation will take time, he warns. Not only does the body have to recover from some pretty substantial alteration to two major bones, but the ligaments and tendons that support the knee have to get used to working around a new and different joint — not the one that evolved by various accidents over 45 years.
About the Craigie Center. Months later, in preparation for this article, I interview Gutowski to find out more about the Joint Replacement Center. While the certifications may sound like fodder for the marketing department, Gutowski, the medical director, firmly believes it leads to better medicine.
The knee replacement business has changed dramatically from the days in the 1980s when Gutowski performed his first knee replacement. Then there were three sizes: small, medium. and large. There were no gender specific or even left-right variations. Now there are multiple brands and types, with customization possible for people with extraordinary flexibility requirements. Gutowski, for example, has replaced the knees of a yoga instructor and a wrestling coach.
With so many different possibilities and so many surgeons approaching the procedures in their own unique way, Gutowski and others have seen the virtues of defining a set of best practices and making sure they are followed by the many different providers who interact with the patient — from anesthesiologists to surgeons to nurses to physical therapists. One advantage of this approach: It prevents patients from hearing one piece of advice from one caregiver, and then a conflicting piece from another.
Setting up the Craigie Center was a challenge from a financial point of view (helped by the Church & Dwight CEO and namesake) and from a physical standpoint (there wasn’t room at the old hospital, but the new facility provided a great opportunity).
Then there were problems that money couldn’t solve. Some other departments at the hospital looked at it as “elitist,” Gutowski says. “There was a little jealously. It was not universally endorsed.”
Getting the MDs on the same page was another challenge. “On the professional side we have seven surgeons at the center,” Gutowski says. “Some of us are very divergent. Each trained at a different institution. And each one was probably thinking their way was better than the way the other six guys did it. We needed to sit down and settle on our best practices. We had to look at the discipline, study it carefully, and then agree on a common approach.” He adds, “We had a lot of meetings.”
Gutowski says the approach even extends to the anesthesiology. The multi-modal approach refined by the team of anesthesiologists dedicated to working with the Craigie Center, Gutowski tells me, is critical in the overall patient experience, getting them on their feet more quickly, minimizing the risk of blood clots, and enabling them to begin exercising their newly reconstructed knee or hip from day one.
The Princeton anesthesiologists’ work has caught the attention of other hospitals, Gutowski says. It’s a big part of the unified approach that is being promoted at the Jim Craigie Center.
“It’s really a hospital within a hospital,” he says. “And we mean it passionately. We have a ‘dashboard’ that reports on everything we do — a hundred specific metrics that we look at. At the beginning of every operation the room goes quiet and we run through a checklist.” It’s a chance for anyone to speak up if something is not right. “We can’t afford to be less than 100 percent.”
Saturday, January 11. Three days before surgery. The brochure from joint class says to begin three straight days of showering with a special anti-bacterial soap, as well as abstaining from alcohol. This operation might begin with just a simple little incision, but the adverse effects could include the usual fatal blood clots and also infection of the new knee, requiring a replacement of the replacement. Ouch. I swear off booze and scrub up like Dr. Kildaire.
Tuesday, January 14. Operation day. After the normal pre-operative intravenous feeds are installed, my neighbor arrives in the hospital room — one of 20 in a separate Craigie Center wing on the second floor. As she had told me a few days earlier, it will be all business today. Anna the neighbor turns into Dr. Westrick, who determines that I am indeed who I say I am, my date of birth is confirmed, and then she asks me to confirm that the right knee is the one being replaced. I confirm and she then initials the knee with a marker.
Amazingly, 17 years earlier, I had a torn rotator cuff repaired, and I joked with the surgeon that I might put an arrow on my right shoulder to let everyone know that was the one to operate on. His response surprised me: He didn’t believe it was necessary because he was confident that his procedures were sufficient, but — if I did it — he would not be offended. Better safe than sorry. Today it’s standard practice at the Craigie Center for Joint Replacement for the patient and anesthesiologist to sign off — literally — on the location of the work. (Gutowski tells me in our later interview that there are still several hundred “wrong site” operations every year in the United States.
The Role of Anesthesiology. As Westrick wheels me down the hall to the area near the operating room, I think back to my first knee operation in 1969. After I was back in my room, a high school classmate of mine, then working as a volunteer before moving on to her next academic gig, walked in to cheer me up. I raised my head and promptly vomited in her direction. In 2014 would my neighbor be agile enough to duck?
But the fact is that it’s not just a good neighbor policy that has Westrick handling the anesthesia for my operation. Anesthesia practices have changed greatly since 1969, and in fact, even in the last few years. Gutowski tells me that the two anesthesiologists who work closely with him, Westrick and her colleague at the Princeton Anesthesiology Services, Bridget Ruscito, have both made it their business to study the latest techniques in anesthesia for joint replacement operations. The surgeon says that to understand the approach of the Craigie Center I should not just interview him; I should also talk to the anesthesiologists.
Later I meet Westrick and Ruscito to gather information for this article. They tell me that, as much as surgical techniques have changed, anesthesia practices have changed just as much. My 1969 “greeting” to my high school classmate visiting me after my first knee operation was not unusual. “In the old days you were knocked out with a general anesthesia, then you got slammed with morphine” to combat the pain, says Westrick.
Today at the Craigie Center general anesthesia is rarely used for joint replacements. Instead the center’s procedure is to use a multi-modal approach for pain management before, during, and after the operation. A spinal injection is used to numb the legs. And a nerve block is administered to help control the pain after the operation. In addition, at the very end of the operation, just prior to stapling up the incision, the surgeon injects a local anesthetic — Exparel, similar to novocaine — that will provide additional pain relief inside the knee for two or three days.
The type of nerve block used has been refined in recent years. At first anesthesiologists used a femoral nerve block. But, says Westrick, “that numbed up the quad muscle so you weren’t able to get up and rehab right away — the muscle was weak.”
The femoral block has been replaced by an adductor canal block, also known as a saphenous nerve block, which targets the pain relief even more directly to the knee, and does not numb the quad muscle — making it even easier for the patient to get the new joint moving (along with those old tendons and ligaments) just several hours after the operation.
A breakthrough in anesthesia for knee replacement came with the ability to use ultra sound imaging to precisely locate the nerve block. Says Ruscito: “Ultra sound has transformed regional anesthesia.” Before ultra sound anesthesiologists essentially had to poke around the body externally to determine the correct place to make the injection. The fact that every patient is different made the challenge even greater. Adds Westrick: “Formerly nerve blocks were done by measuring and estimating using anatomical landmarks to determine where the injection should go. Now we have direct visualization.”
Both Westrick and Ruscito have been surveying what other people in their field have been doing, and have created a policy for anesthesia at the Jim Craigie Center that incorporates the best practices. A consultant who worked with the hospital in creating the Craigie Center was impressed by the Princeton anesthesiologists’ approach and has mentioned it to other medical centers reviewing their joint replacement procedures. Ruscito and Westrick have been approached by other hospitals seeking to improve their care.
On the day of my operation, all the nuances of anesthesiology are lost on me. Westrick whisks me to one room, administers some potion, and announces she will inject the regional nerve block that numbs the area around the knee. At one point she gestures toward a monitor that I now assume is the ultrasound display. I can watch the entire injection procedure, she says. Sure, if I could stay awake.
Ruscito and Westrick tell me later that the anesthesia cocktail not only makes you numb to the pain and puts you to sleep, it also causes amnesia so you may never remember what happened when you are awake. I remind myself not to trust fully any patient’s account (and not even my own) of an OR or ER experience.
My next waking moment is on the operating table, my right leg lifted in the air, and an ace bandage being wrapped around it. It’s over. And I will not be vomiting on anyone.
The operation, I find out later, turns out to be a little out of the ordinary. In the midst of installing the new knee parts, Gutowski discovers a hollowed out area in the back of the femur or thigh bone. The years of wear and tear with little or no cartilage apparently have not been kind to my right knee. The surgeon takes pieces of bone left over from the trimming process, packs them into the crevice, and then installs a screw to hold the patch together. That provides a suitable surface to which he can cement the upper component of the artificial knee.
Gutowski later explains that the screw is similar to a steel reinforcement bar in a piece of concrete in a building foundation. If you have too big a piece of cement patch, it may wear out prematurely. The screw serves as post to anchor the whole patch together.
Later when I see the X-ray that shows the new pieces and the screw I can’t figure out how he did it — there is no incision on the back of my knee.
“There is a targeting device that reaches around back,” he says, and allows him to “navigate” even in places he cannot see.
For all the common practices established by the Joint Center, it appears to me, not everything can be done “by the book.” As Gutowski says, “after doing so many of these you may think you’ve mastered the art. But regardless of how good you are there are always nuances, issues. That’s one good thing about gray hair — over 30 years I’ve seen a lot.”
My two post-operative days at the Jim Craigie Center are marked by two noteworthy events. One is a group physical therapy session, in which six or seven of us stand (our hands gripping our walkers, of course) in a circle under the watchful eyes of several physical therapists, and toss a ball from one to another,. We practice getting out of our chairs and otherwise move around — gingerly.
One woman announces that she will not be able to get up from the chair without assistance. The rest of us cheer her on and — lo and behold — she makes it. I also feel myself making a little progress, in part because the group tends to reinforce its members. Later, when I begin my outpatient rehabilitation at the fitness center affiliated with the medical center, I think of the group session several times. I suspect there would be real value in being in a PT group with other knee replacement patients with whom I could compare notes.
The other group event is a “graduation” ceremony, when a half dozen patients with new hips and knees are ready to be discharged. I think we all feel a little trepidation, just as real graduates might feel as they step out into the real world. As Gutowski has said several times during the stay, the pain medication injected into the knee at the end of the operation will wear off about the same time we are discharged from the hospital.
A representative of a medical supply company has already sold me a walker, a cane, and — this turns out to be important — a folding commode with adjustable leg height so that you can sit comfortably (a relative term) over a regular toilet. The hospital provides two ice packs, so that one can be in the freezer getting ready to use while the other is on your knee — a much appreciated feature. We also have arrangements made for physical therapists to make home visits for a week or so until I am ready to go to a fitness center for continued therapy.
In addition I have a prescription for 19 days worth of a blood thinner called Enoxaparin. The treatment protocol requires some sort of anti-coagulant, and this is Gutowski’s preferred medication. It will be a real adventure. Each dose of this blood thinner comes in its own syringe, and I will need to stick a needle in my stomach twice a day for the next 19 days.
But it’s “graduation day,” so I am not worrying about tomorrow. We have some cake and receive “diplomas.” and T-shirts that proclaim “I Reclaimed My Life.” Yes, it’s marketing and I get it. But still it’s hokey. I don’t expect to wear the T-shirt anytime soon.
Welcome home. Before I “reclaim my life,” I discover there are a few other basics to reclaim:
Sleep: With a right knee swollen to the size of a football (and the staples holding the incision together closely resembling the laces on that football) sleep is a scarce commodity. I am taking the two kinds of prescription painkillers plus some non-aspirin over the counter medicine to combat the pain.
The pain killers are supposed to make you drowsy but the drowsiness doesn’t last for long. I am lucky if I get more than an hour of sleep at any one time. But I lie in bed awake, figuring that I might as well be ready for the next hour of sleep, whenever it comes. One night, fortified by painkillers, I fall asleep at around 10. When I awake I feel as if I finally have had the good night’s sleep that I was craving. I go to the bathroom and look at the clock: it is not yet midnight.
Other bodily functions. It’s impolite to mention, and hardly anyone at the hospital does, but I have heard so many similar reports that a little sharing is warranted. For some of us, apparently, the high powered pain-killer oxycontin and its companion drug oxycodone boast the side effect of causing constipation. I did not expel a single bit of solid waste until five days after the operation. About a week after the operation I started mixing in laxatives to my daily drug ingestion. Relief came only in tortured little increments. On January 25, 11 days after the surgery, I added a stool softener to the mix.
On January 27, when I returned to Gutowski’s office to have the staples removed, he reviewed the status of the knee, took some X-rays, liked what he saw, and then — without prompting — guessed that the rest of me was also not yet back to normal. For most people, he said, “there’s something magical about six weeks. It seems that the body just needs that much time to get back to normal.” And, he adds, again without being asked, “stay on top of that constipation.”
On February 3 my calendar entry marks two pieces of good news: “BM — normal! 4.5 hours of sleep.” I gradually cut back on the pain killers and the laxatives.
Mobility — specifically walking, exercising, and getting back to work.
Since it involves no walking and no exercise, getting back to work seems like it will be the easiest goal to achieve. After having the operation on Tuesday and getting home on Thursday, I feel sharp enough mentally on Saturday to sit down at my home computer and log in remotely to my desktop at work.
The problem is sitting down. After just 20 minutes my knee is in agony. I give up the desk, down a few painkillers, put the knee on ice, and try to create a position on the couch where I can work from a laptop while simultaneously keeping my right leg elevated. It’s not easy. I am able to put in a few hours every day working remotely, but the idea of being “back to work” after two weeks is not realistic for me.
By February 9 I begin driving again — beginning with a trial run in an otherwise vacant parking lot. That would be a terrific moment of liberation, except for the ice and snow that have accumulated during this long, bleak weather. I am worried about falling just on the walk from the house to the car. Once again it pays to have good neighbors.
On more than one occasion I find a path cleared, or the sidewalk shoveled, or trash taken over the icy driveway to the collection spot on the sidewalk. It’s the anesthesiologist’s husband, Benedikt Westrick, who has come to my rescue. In one of our later interviews Anna Westrick observes that modern medicine provides a wealth of treatment options, but it is also “the little things that are important from a patient’s viewpoint.” True in the hospital and in the ‘hood.
On February 18 I finally begin to appear regularly in my office again, arriving with well frozen ice packs in my briefcase. That day the calendar says “2 hours in office — ouch.” I later hear a report on the television news that people who sit all day long have a lower life expectancy than those who stand. I don’t doubt it — I know for sure that it’s about the most painful thing I can do for my knee. I continue to work remotely and I don’t resume full day shifts at the office until almost two months have passed.
Oddly enough, on the tasks that most directly involve the new knee — exercising and walking — I make my quickest progress. I quit using the walker within two or three days of being home. I get around with a cane, and soon leave the cane propped up against a chair while I take a few steps here or there without it. On January 26, 12 days after the operation, I make a calendar note: “Where is the cane?”
Progress is steady, but not fast. On February 10, nearly four weeks after the operation, I am beginning to walk confidently around the house. So confidently that when I suddenly decide to walk upstairs I don’t even think about the cane or the knee. As I take my first step my leg buckles and I catch myself. I still don’t have enough strength in the right leg to support normal step climbing.
But one week later I do.
The Physical Therapy Role. February 4 is my first day at physical therapy, at the new Princeton Fitness & Wellness Center attached to the hospital on Route 1. The therapists (all of whom now have Ph.D.s in their field) ask me to complete a survey assessing my pain levels, knee flexion, and range of mobility. I also get timed on a little obstacle course in which I have to get up out of a chair, hobble with my cane down to a pylon about 20 feet away, and then return and sit in the chair.
On February 12, my fourth visit, the therapists believe that my joint is sufficiently flexible to use a sitting elliptical machine.
Two weeks later they tell me the knee is ready for the standing elliptical, a fancy version of what I had been using at home. I’m thrilled to get on it, and charge off at a four-mile-per-hour pace. Within five minutes I am gasping for breath. But by March 11 I have worked up to 30 minutes on the elliptical and — for the first time — I can actually flex my calf muscle.
On February 14, a month past the operation, I manage to walk with the cane from my house to the kiosk on Palmer Square, almost a mile round-trip. Eight days later I walk even further to a college dining hall for a class dinner. I put the cane down and stand around for about 20 minutes talking to classmates. At that point I have to excuse myself and sit down.
March 5. At physical therapy they once again measure the flexing range of my knee. It’s 115 degrees. That’s better than 90 degrees, which is the way your knee is when you are sitting in a chair with your feet flat on the ground. But it’s a lot less than 135 degrees, the range in my all-natural left knee.
I’m a little disappointed. The physical therapist says I shouldn’t worry. The best that most knee replacements achieve is about 120 degrees. I’m surprised — I would have thought it was better than that. But the PT person has a good rejoinder: Unless you are trying to become a major league baseball catcher you are probably never going to need to bend your knee 135 degrees.
March 20. The physical therapists repeat the survey I took the first day and I run the obstacle course again. Comparing my performance now as compared six weeks earlier, they tell me I am ready to be discharged. With my right knee still swollen (though not as much as when I started) and with the knee still causing pain when I try to bend it to its limit, they tell me that more exercise is necessary, but that I can do it on my own at home or at fitness center of my own choosing. (In other words insurance coverage for the fitness center has expired.)
I don’t use the cane much at all after that. By Palm Sunday, April 13, I walk to and from McCaffrey’s in the Princeton Shopping Center — 18 minutes in each direction with a rest in between to do a little shopping.
I augment the exercises at home with 30 minutes on the elliptical in the basement. Gradually I substitute outdoor walks for the time on the elliptical. I add some occasional visits to Princeton Y to do some weight training for my legs.
While progress is slow but sure, even now — more than five months after the surgery — I am still not back to my walking pace prior to my 2008 re-injury of the knee. Then I could sustain a brisk pace for 30 straight minutes, on occasion I would sustain a five-mile-per-hour pace. Now I can do a little over four miles per hour, but I feel the right leg getting a little wobbly toward the end of a half hour.
Is that normal? Is my recovery lagging behind? I am no athlete, as I have known since my senior year adventure on the college basketball court 45 years ago. But what is the experience of other people roughly my age and at the same general fitness level? Gutowski tells me that the joint replacement center is considering designating some “alumni” of the program as “joint replacement ambassadors,” available to offer advice to those following in their footsteps. Not a bad idea.
At one point I imagine an Internet-based information center, where joint replacement recipients could sign in and share information and also avail themselves of professional medical advice if necessary. Like all my great Internet ideas, several others have already acted on it, including one Princeton area start-up that is profiled in this issue (see separate story on VOX Telehealth).
If I had had access to such a system, I would have posted several questions. At one point someone at work asks if I have lost weight. I check at home and discover I have lost 10 pounds. How unusual is that? (I later gain it back.) I get used to my swollen knee, but then I reach around to back of the knee, and discover a lump there the size of an avocado. How crazy is that? (It eventually subsides.)
The “bad knee” is still on my mind. The other day I come home from work and figure I will do a half hour on the elliptical during the Yankee baseball game that will feature the new star pitcher from Japan, Masahiro Tanaka. But a PSE&G transformer on the street blows out, cutting power to the entire neighborhood. I cannot tolerate the elliptical without some sort of electronic distraction. I sit around for a half hour, cursing the electric company’s darkness.
Then suddenly I realize I now have a choice: I can walk a half hour in the great outdoors. Maybe I really have “reclaimed my life.”
On Saturday, September 13, the Jim Craigie Center for Joint Replacement is sponsoring a 5K run and walk (including some walks that might even be appropriate for someone using a walker or a cane) to celebrate the “alumni” of the new program. I’m hoping to be there. Now where is that “I Reclaimed My Life” T-shirt?
Princeton Orthopaedic Associates, 325 Princeton Avenue, Suite 214, Princeton 08540; 609-924-8131; fax, 609-924-8532. Dr. W. Thomas Gutowski, medical director, Jim Craigie Center for Joint Replacement. www.princetonorthopaedic.com.
Princeton Anesthesia Services, Box 3722, Princeton 08543; 609-430-7174. Mary Codd, practice coordinator. Pain management program: 609-497-4371.