Everyone that talks to me about knee problems and my need for a knee replacement has a suggestion of "this doctor" or "that doctor" that I need to see, that would be my miracle doctor. So when a family friend suggested I see Dr. M, I wasn't expecting much. The friend did say Dr. M was known to help when no one else could. So I made an appointment...
The visit started off with the usual set of X-rays (standing, bent knee, and seated on the table with the knee bent about 90 degrees). I filled out all the usual paperwork - most of which had little to no application to me (When did you injure yourself?) or was just impossible to answer (What makes the pain worse? A: Everything; What makes the pain better? A: Nothing). And of course, the tiny box into which I am supposed to squeeze all my prior surgeries (I went for the "See Attached" approach).
Finally, the moment I was waiting for - Dr. M came into the exam room. I braced myself for the "Sorry but I can't do anything for you" and "Sorry but you're too young for a knee replacement" lines. They never came... Dr. M didn't treat me like a child, he didn't think I was there to get my hands on some narcotics, and he didn't think I just wanted someone to slice me open. He took me seriously. He saw how bad my knee was from the X-rays and he asked how my pain and problems interferred with my daily life. I'm not sure what came over me, but as I tried to tell him how I come down the stairs in my townhouse in the morning with everything I could possible need so that I don't have to climb the stairs until bed, the tears just started rolling down my face. I told him how the pain keeps me up at night or wakes me up in the middle of the night. I told him how the pain keeps me from concentrating at school or work. I told him how little I am able to exercise. And the tears kept coming... I'm not sure if the tears were because I needed to unload how much pain I was in or if it just was that tough to admit out loud what I kept bottled up. Either way, the tears didn't stop until I stopped talking about how terrible my life has become and how limited I am and how I just want to get around like a normal person again.
And then came the magic words - he is willing to do a total knee replacement on me as soon as I am ready. He told me what alternatives are available and he told me all the risks - but he also told me that he is confident that he can do this.
He told me the two alternative surgeries are an HTO (high tibial osteotomy) and a partial knee replacement. The HTO essentially means they cut the tibia bone and either take out a wedge of bone or insert a wedge of bone graft to change the angle of the tibia plateau; the purpose is to shift more of the weight bearing to the "good" side of the knee. In my case, my medial side (inner) is in worse shape than my lateral side (outer), so the bone would be cut and repositioned to shift the weight towards the lateral part of my knee. Most people are somewhat familiar with partial knee replacements (also called a unicompartmental knee replacement); in this surgery, only the medial or the lateral side of the joint is fitted with the metal and plastic parts. Again, since my medial side is worse, the lateral side would be left alone and the medial side would be replaced. However, Dr. M told me that neither is a good option for me because, while the lateral side is in better shape than the medial side, the lateral side is still significantly damaged. In addition, I had already tried a deloading brace which does approximately what the HTO procedure does and Dr. M said the HTO surgery makes a later knee replacement much more difficult.
Now, on to the risks... Of course, there are the general risks anyone undergoing surgery faces such as blood clots, heart attacks, strokes, etc. Specific to the knee replacement (and similiar to risks of other joint replacement), there is concern the implanted joint becomes dislodged or loose over time or that the implanted joint wears out. Of course, these risks are greater for younger patients - we are more activity and will be expected a longer life out of the joint. In my case, being only 26, it is pretty much assured that the joint will need to be replaced again in my lifetime. Another risk is infection; unlike regular surgeries where infection is a concern immediately but only until the surgical site is healed, with joint replacements, the concern can be lifelong. Any time bacteria gets into the bloodstream, there is the chance that it can make its way to the joint and it will colonize and grow on the metal and plastic. For this reason, patients need to take antibiotics before any dental procedures or similiar procedures where bacteria could be introduced into the bloodstream. At this point, I'm not sure whether I would have to do that forever, as some sources say, or whether it would be for a shorter term such as five years, as others sources state. In either regard, this is a serious risk. If the infection of the joint occurs, the doctor may be able to clean out the joint or they may have to take out the implanted joint. If the latter occurs, the doctor may be able to do a revision (essentially do a new replacement) or may have to go to the "optionss of last resort" (which I will explain in a moment).
The scariest risk is that, in the future, the replacement will fail and a revision will be impossible. Revisions are more difficult than the original replacement and are not always possible. In that case (as well as in the case of an infection which cannot be treated), there are only two options - what I have termed the "options of last resort": knee fusion or amputation above the knee. The knee fusion will result in the inability to bend the knee which will make walking awkward but will still enable the patient to lift leavy objects and be mobile. The amputation may be better for someone behind a desk, where a permanently stick-straight leg may be problematic). Dr. M told me that if I'm not ready to face the options of last resort, I am not ready for the replacement. However, for me, this is not a large concern. While the thought of only having half of a left leg is odd and not particularly pleasant, I asked Dr. H years ago whether he would simply amputate above the knee joint and let me live a mostly-normal life with a prosthetic. (I simply feel that many amputees have a better quality of life than I do.) And, being a law student, I intend to spend most of my life behind a desk, so a knee fusion, while it would allow me to look more like an average person (until I start walking), it would make office life difficult.
Dr. M was willing to schedule the surgery right away, but he also encouraged me to seek any second opinions I needed, to take the time to talk it over with anyone, and to ask him any questions I might have. He gave me his email address so that I can communicate with him whenever is best for me - he said he would answer any of my questions and could even schedule my surgery through email. And, before I left, he gave me a cortisone shot, though he doubted it would do much, just so I wouldn't question whether such shots could buy me some time and so I didn't feel as though I got nothing out of my visit. (FYI: It's two days later - the numbing medicine in the shot felt great for an hour, then I spend the next 12 hours with a super-stiff, painful knee, and then was back to my normal pain level. Conclusion: cortisone shots are worthless to me at this point.)
Dr. M has given me plenty to think about and discuss, but most importantly, he has given me some hope. My family and I are so grateful that he is willing to do what no one else is and that he comes so highly recommended.
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