A Perfect Fit: Surgical Team’s Intricate Dance Results in New Life for An Old Knee

IMG 8168currentphotoLast spring, I entered a local hospital operating room for the very first time (as an observer), that is. Four times previous, I was wheeled in (as a patient) for successive shoulder operations. It was a remarkable and personally meaningful experience getting to actually watch the intricacies of this surgical procedure that repaired both of my shoulders and helped me regain muscle strength and optimal mobility. The truth is, I was hooked. Having had the rare opportunity to actually see how a surgical operation plays out (especially after having undergone it myself) piqued my interest in a big way.

Since then, I started looking ahead and wondering what it would mean if I ever needed a hip or knee (or God forbid…shoulder replacement surgery). How similar would the recovery process be to my other surgical experiences? Would it take a longer or a shorter amount of time in terms of function and mobility? Are there special considerations I’d need to take into account that are unique to “replacement” surgeries versus the type of shoulder repair I’d already had? And finally, I just plain wondered, “How do they do it exactly?”

So on a recent cold winter morning, I was treated to a repeat performance of sorts. Re-entering the outpatient surgical entrance, I checked in at the surgery desk where I was given a temporary visitor tag for retrieving my scrubs for the day. And to my delight, I discovered upon swiping the identification card into the Scrubex Machine that I was already entered into this hospital’s system. Donning a pair of scrubs, shoe covers, hair net, and facemask, I was ready to learn a thing or two (and more, much more).

One of the nurses escorted me into the OR directly behind the elderly female patient whose knee was being replaced via a procedure termed, Total Knee Arthroplasty. I stood to the side and once again watched in awe as a process of step-by-step precision unfolded before my eyes over the next two plus hours. All around me, the orthopedic surgeon, an anesthesiologist, a nurse anesthetist, two certified surgical technicians, a circulating nurse, a physician’s assistant, and even the replacement knee product sales representative, moved in and around the room expertly performing their specific tasks in turn.

Once the patient is anesthetized and prepped, and the surgical team is properly attired in hoods (helmet-like coverings with full face shields) and tents (gowns completely covering each individual from neck to feet so as to protect them and the patient) a tourniquet is positioned onto the patient’s thigh area to minimize bleeding during the operation.

Next, the knee is pulled up into a ninety-degree angle and held there by a retractable foot brace on the operating table. The surgeon marks the knee and cuts through the skin while his assistants use metal retractors to keep the area fully open as he works to inspect and evaluate the damaged area and then determine the bone resection from the femur. Once decided, the surgeon makes four angled cuts producing a box shaped femur that must be exact or the replacement knee will not fit correctly (possibly developing problems down the road).

Then he makes the tibia cut and repeats the previous process. Again, the emphasis is on producing a flush, tight fit. A temporary implant (called a femoral and tibial trial) is positioned in the patient’s knee to make certain there is 100% accuracy before placing her new permanent Cobalt Chrome replacement knee in the joint. Once the implant process is underway, the surgeon checks for symmetry and stability by releasing the foot from its brace so as to freely move the knee around. Both extension and flexion movements must be equally balanced, otherwise, more cuts are required to achieve that perfect fit.

Finally, the undersurface of the patella (knee cap) is removed and replaced with a trial patellar button completing the bone cuts. When the surgeon is satisfied with the movement, he immobilizes the leg once more and using rods, pins, and the like will remove the trial components and place the permanent (three part implant-consisting of femoral, tibial and patellar components) replacement into the patient’s leg. (For accuracy’s sake, the cement is mixed prior to placing the final implants.)

As the surgical tech mixes the cement that will bond the knee to the patient’s bones, others alternately irrigate and then dry out the surrounding bony area. The surgeon deftly applies the cement in place as he positions all three parts of the replacement knee with careful precision into the patient’s leg. The entire area is then irrigated thoroughly before the surgeon and his assistant begin closing up the eight or so inch incision. The tourniquet is then deflated, removed, and the whole leg is again sanitized before special bandages are applied and the patient is readied for the Phase 1 Recovery room.

Sounds seamless and straightforward, yet it’s anything but that. Throughout this decisively complicated procedure, the surgeon is continually measuring, re-measuring, and expertly manipulating the bones, ligaments, and tissues surrounding the knee in between checking and rechecking every step and calculating how to make his patient’s replacement knee a “perfect fit” for the rest of her life. Amazing to me as an observer and essential to this patient’s future health.

Immediately following the surgery, I felt a physical letdown that left me exhausted. After all, I’d just been standing at alert for over two hours straight. I was more than ready to sit down, rest, and take a break. Then I realized this is only one case for these OR medical professionals. They frequently work from early morning into the evening hours, case after case, with little pause in between. This realization made me stop and consider how grueling their jobs are from both a mental and physical standpoint. I left the OR on this particular day feeling exactly the same way I did last spring, completely humbled and grateful for those individuals who make their career that of mending the broken and injured among us.

With pen and paper in hand, I exited the OR, changed into my street clothes and made my way back to where it all began, the Scrubex machine. I swiped my ID visitor’s card and replaced my scrubs into the Scrubex depository and suddenly doubled my “credits.” Last spring, I had seven. Total accumulated to date: 14!

But, once again, I knew I was leaving the hospital with much more than mere Scrubex credits to my account. Far more.

Dr. Christopher A. Foetisch, orthopedic surgeon, Toledo Clinic, Toledo, Ohio Offers the Following Insights:

A Physician May Recommend a Total Knee Replacement Depending Upon These Factors:
· Your age
· Your activity level
· Degree of pain you are experiencing
· Level of disability caused by your knee’s condition
· Your other medical problems

Treatments Physicians Routinely Try First:
· Exercise
· Medication
· Physical therapy
· Daily lifestyle adjustments
· Weight loss
· Injection

What to Expect Following Surgery:
· Significant pain during the first couple of weeks.
· Most patients will be up and walking the next day with help of a walker/crutches.
· Physical therapy begins immediately and is intense for several weeks.
· Routine movements such as walking, standing, sitting, usually resume within a few days.
· Full recovery can take up to one year.

Life With a Knee Replacement:
· Maintaining an active lifestyle is important
· Controlling your weight will lengthen the life of your new knee
· You can resume most activities. Running and impact activities are discouraged.

Michele Howe is author of the Burdens Do a Body Good.

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