New York Times
February 8, 2005

A New Set of Knees Comes at a Price: A Whole Lot of Pain
By 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 physically active in their later
years.

Dozens of people I know who've endured the surgery say it has changed
their lives very much for the better. They can walk again with comfort,
even play tennis and ski, after years of sitting on the sidelines.

The Time Was Right

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
- at first with ice packs and ibuprofen whenever I did strenuous
activity, graduating to daily Vioxx and Tylenol with growing limits on
what I could do without life-limiting discomfort.

The last straw (after giving up tennis, ice skating and cross-country
skiing) was my inability to hike or even join my friends on our morning
fitness walk around the park. Even Vioxx (before it was withdrawn from
the market) was not keeping me comfortably on my feet.

I consulted one of the world's leading orthopedic surgeons, a man who
had done thousands of knee and hip replacements, including 500 double
knees. He was very reassuring.

With the aid of physical therapy, he 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 through epidural
anesthesia supplemented by extra doses that the patients can
administer.

A neighbor who had one knee replaced last summer had warned me, "The
first four weeks are hell," but I discounted her prediction, given that
I was in good health, top physical condition and slender going into the
surgery.

A preoperative education session at the hospital emphasized the
importance of good pain control because without it patients cannot do
the physical therapy essential to a good recovery.

I gave two preoperative blood donations (one for each knee), arranged
for inpatient rehabilitation after leaving the hospital and thought I
was fully prepared for what lay ahead.

Facing Reality

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, but one can't do that 24/7.

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: I could walk and go up and down stairs, albeit slowly,
and I could fully extend my knees and bend them 90 degrees.

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.

I learned much later that I could have been prescribed a much higher
dose of narcotics with no ill effect and much better pain control. No
doctor I reported to, however, including the surgeon, even considered
that.

The fact is, This operation, which involved cutting my leg bones to
straighten my bowed legs, hurts like hell. To the few patients I spoke
with who had relatively little postoperative pain, I say, "Count your
blessings."

My biggest complaint was not that I was suffering. (The pain at five
weeks after the operation had definitely eased on most days, although
my right knee hurt much more than the left. So much for driving!) My
biggest complaint was that I hadn't been warned. I was presented only
with the best-case result, not the worst.

Too Sore to Knit

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 during my self-assigned six-week recovery
period.

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. It's hard to be
pleasant when all you want to do is chop off the part of your body that
hurts so much.

Continuing physical therapy is critical to a full recovery, but at
first I overdid it by going three times a week. I have since cut back
to twice a week to give my body more time to recover between sessions.
It seems to be helping.

Insurance Madness

Compounding my physical discomfort was the emotional turmoil caused by
insane insurance policies. My plan from the outset 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 (every hospital must have them these
days to negotiate with insurance companies) argued for an extra day,
but that was covered only because I experienced severe chest pains (due
to indigestion, it turned out) 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 in my view, 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? Who came up with such a formula? Certainly not
anyone who has ever had major surgery. Although my husband asked, the
pharmacy failed to tell him that I could pay for the drug myself, about
$4 a pill, far preferable to lying awake in pain all night.

I'm still waiting for that blissful day when I can walk better than I
did before the surgery, get through the day without multiple pain pills
and sleep without medication. I'm reasonably sure that day will come in
the next few months, but I must admit I'm fast losing patience.

People ask, "Are you sorry you did two knees at once?" Not at all. In
fact, I can't imagine going through this twice, and both knees were in
horrible shape and needed to be replaced.

I've met several 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.

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February 8, 2005
Knees of Titanium and Bills of Gold
By JANE E. BRODY

Few are unaware of the shocking costs of medical care these days. The
bill for my grandson's 10 days in the neonatal intensive care unit in a
suburban Los Angeles hospital last November was $110,000. Still, the
costs of my surgery surprised me.

Hospital: $45,732, all but $211 for unspecified "miscellaneous" covered
by my insurance. Among the charges were $14,000 for four days in a
semiprivate room, $17,668 for my titanium knees, $600 for giving me
back my own blood, and $1,136 for unspecified "supplies."

Surgeon: $25,000. How much of that will be covered by my major medical
insurance remains to be seen. The surgeon accepts only Medicare.

Anesthesiologist: $5,200. Again, we'll have to see what my policy will
pay, since the doctor accepts no insurance.

Pathologist: A mere $640 to confirm what we already knew: advanced
arthritis in both knees.

Rehabilitation center: $6,634 for five days as an inpatient, including
four days of therapy, with $5,430 expected to be covered by insurance.
After some mysterious "adjustments," I was charged only $12.

Outpatient physical therapy: Thirty visits a year supposedly covered by
my insurance. I haven't had to pay a cent so far, but I received a bill
for $193 for a first visit and $44 for each subsequent one. No telling
how long this will go on, but I will do whatever is needed to return to
full physical activity.

Drugs: Insurance pays most of the cost. But the emotional cost of phone
battles with the insurer almost makes you wonder if it's worth it.

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