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     Tuesday, Mar. 1, 2005

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            New knees come with new problems

           JANE E. BRODY

           Total knee replacement is now one of the nation's leading
orthopedic
           operations, and it promises to become even more popular as the
           population ages (and grows heavier) and the body's most
vulnerable
           joints fail to withstand the punishment of decades of use and
abuse.

           Debilitating wear-and-tear arthritis is the major reason that
knee
           bones are being replaced by two-pound pieces of metal in people
who
           wish to remain mobile, pain-free and active in their later
years.

           And so, at age 63, I decided to have both knees replaced. I had
been
           nursing my increasingly arthritic knees and bowed legs for two
           decades.

           With the aid of physical therapy, the orthopedic surgeon said, I
           could expect to be driving again in four weeks and well on the
way
           to full recovery in six. Even the reputedly horrific
postoperative
           pain associated with this surgery, he added, is now fully
controlled
           with morphine.

           I was not prepared for the swelling. When I arrived at the rehab
           center on the fourth postoperative day, I weighed in at 120, 15
           pounds more than I weighed at surgery.

           My legs were filled with fluid, hard as rocks, with no visible
           bones, veins or tendons. In four days I was down to 103, but my
legs
           continued to swell and stiffen for more than two months.

           As for pain, the surgeon was right on one count: The morphine
was
           bliss ? not a bit of pain the first two days after the
operation.
           Then it was withdrawn and replaced by two narcotic oral pain
           medications, which worked pretty well for about five days.

           But as the various tissues in my knees began to heal and
physical
           therapy got more demanding, the pain grew worse and worse, until
at
           three weeks I found myself moaning, then crying for much of the
day
           despite the narcotics and repeated icing of my swollen knees.
Sleep
           was my only relief.

           Thinking something must be radically wrong, I returned to the
           surgeon 26 days after the operation, only to be told my knees
looked
           perfect on X-rays and that my mobility placed me in the top 2
           percent on the recovery scale.

           As reassuring as this assessment was, it did nothing to control
my
           pain. So he changed my medication to a potent anti-inflammatory
           drug and suggested that I gradually cut back on the narcotics.
That
           proved to be something of a pipe dream, at least for the next
           several weeks. And there was no sleeping without a nightly dose
of
           Ambien.

           My biggest complaint was not that I was suffering. (The pain at
five
           weeks after the operation had definitely eased on most days.) My
           biggest complaint was that I hadn't been warned. I was presented
           only with the best-case result, not the worst.

           I complained to my internist that in the first three
postoperative
           weeks all I had been able to do was read three simple novels.
Even
           knitting and crocheting seemed too much for me, let alone the
many
           projects I'd hoped to tackle.

           My doctor explained why: "Intense pain is all-consuming. It
takes
           over your life, and it's impossible to focus on much else." In
fact,
           it changes your personality, and now I understand far better why
           patients with chronic pain can be so difficult to live with.

           Compounding my physical discomfort was the emotional turmoil
caused
           by insane insurance policies. My plan was to go from the
hospital to
           an inpatient rehabilitation facility, which my policy covers for
           patients with double-knee replacements.

           The insurer, however, wanted me to leave the hospital on the
third
           day after surgery, when I was still restricted to using a
bedpan. My
           hospital-provided case manager argued for an extra day, but that
was
           covered only because I experienced severe chest pains on the
fourth
           day, not because my walking was limited to a few steps.

           Then the insurer limited me to four days of inpatient
           rehabilitation, not nearly enough, especially since I was going
home
           to a four-story house. After six weeks of post-op, I still could
           descend stairs by bending only one knee.

           But the most irritating insanity was the limit placed on my
sleep
           medication: 14 tablets every 23 days. Was I supposed to sleep
only
           every other night? The pharmacy failed to tell my husband that I
           could pay for the drug myself, about $4 a pill.

           People ask, "Are you sorry you did two knees at once?" Not at
all.
           In fact, I can't imagine going through this twice. I've met
people
           in rehab who had one knee done and need to replace the other.
But
           having endured the first replacement, they say they are now very
           hesitant to do it again.