“Total knee replacements are one of the most successful procedures in all of medicine.” Over 6,000 websites contain this exact sentence. Nationwide the annual number of knee replacements is twice the population of New Orleans. Aging baby boomers with debilitating knee arthritis and Medicare dollars are the fuel feeding this multibillion dollar operation.

Knees, like children, begin life pristine and unbattered by life’s various forces. Aging knees are another matter. Joints have memory. Just as a commuter chip stores bits of data, the knee joint keeps a permanent record of hits. Microscopic changes to the sensitive cartilage that covers the end of the bones making up the knee cause problems down the line.

“As for size, the knee is the largest joint in surface area,” says Dr. Julius Levy who teaches gross anatomy to medical students at Tulane. Since anatomy Ph.D. educators are dying out and new ones are not being hatched, medical schools have turned to retired surgeons like Levy to teach anatomy. “The knee was never made to play football. It is a flexion/extension joint meant to move back and forth in two directions. A hit from the side is the easiest way to damage the knee joint.”

An unhappy knee is slow and creaky. Knee crunches or crepitations are easier felt than heard. As a physical finding, crepitations are neither sensitive nor specific. That means some folks have severe knee problems with no crunches. Others have loud crunches and no problems.

Thinking about a knee replacement? What is the best way to find a surgeon and a hospital? The Internet teems with posts by orthopedic surgeons, hospitals and companies hawking the value of their brand of replacement knee parts. A Google search linking knee replacement and New Orleans returned 244,000 hits one day and 246,000 the next.

The first site to pop up, fueled no doubt by some payment to Google, promises an “advanced technology and technique” yielding better clinical outcomes, quicker recovery time, reduced pain, highly accurate placement of knee implants and shorter hospital stays.

Checking a Medicare website, I was unable to verify the claim of shorter hospital stays, but this hospital’s complication rate after knee replacements was “no different than the national rate.” Looking at other measures this hospital reported fewer intravenous line infections but more surgical site infections after colon surgery. And the amount of time patients were kept in their emergency room before admission was almost twice the Louisiana average.

The second hit took me to a company website promoting a replacement joint “lab-tested to simulate the number of steps the average person takes in 30 years.” Insert your location in their Find a Physician box ,and up pop names of select orthopedic surgeons who use their “exclusive technology.” There were eight surgeons certified to use their specific device on the Northshore but only four in Jefferson and Orleans parishes. Scrolling down to technical notes, I read, “The results of laboratory wear simulation testing have not been proven to predict actual joint durability and performance in people.”

The third hit was a Northshore orthopedic surgeon who believes in “the body’s natural ability to heal itself.” Another local practice site describes in laymen language what knee replacement involves both during and after surgery. I searched some text from this local website online and found huge hunks of identical wordage online from Mayo Clinic.

Angie’s List popped up part way down the first page of hits. It promised to name 12 knee replacement surgeons to avoid and 35 top-rated ones. When they asked for my credit card number to collect a monthly fee, I moved on, knowing that office staff and PR firms can outdo even former Assistant Federal Attorneys in their posting abilities.

Another link was to an archived local television news segment reporting how “a local surgeon has created a way for knee replacement patients to go home the same day and heal faster.” Turns out the Rapid Recovery Knee Replacement this team “created” is a an off-the-shelf program sold to hospitals and physicians to market and streamline joint replacement surgeries with an eye for higher revenue returns.

Does anybody really pick a surgeon on the Internet? The answer, believe it or not, is yes. A respected gynecology colleague whom I consider top-notch told me that a woman cancelled a scheduled surgery and later rescheduled with one of her partners after reading a single negative comment apparently posted by a former patient.

Younger persons needing surgery may be more seduced by Internet postings than the older folks generally lining up for knee replacements. In past years, a person needing surgery mostly followed the lead of their internist, but an amazing number of people who decide they need a knee replacement don’t have established relationships with primary care physicians. Also, referral patterns these days might be weighted toward criteria other than successful outcomes, especially when physicians are employed by hospitals and informed patients know this.

“Nurses know which doctors get the best results. They know whose patients do well and whose end up with complications,” says Dell Jordan, a nurse who was once the manager of an in-patient unit dedicated to joint replacements. Jordan says infections and ending up with one leg shorter were two complications she occasionally saw as a nurse until she retired just before Hurricane Katrina. A limp caused by a leg length disparity evolves into secondary back and hip problems over time.

I agree with Jordan. Nurses and physical therapists working in hospitals with active joint replacement programs know the good surgeons, the mediocre and the ones to avoid. Some infections are unavoidable; others are not.  Nurses know the surgeons most skilled in using postoperative anticoagulation to prevent formation of dangerous blood clots in the leg after surgery while not causing excessive surgical site bleeding, fertile ground for an infection.

Surgical site infections after knee replacements can be catastrophic. Replacement of a failed hip prosthesis is a big deal. Occasionally an infected prosthesis can be saved by multiple returns to the operating room for what surgeons call washouts. But the pain and discomfort from returns to the operating room cause additional complications. An increased need for strong pain medication and mental cloudiness go hand-in-hand to fuel a second layer of medical and social problems that can threaten a person’s independence.


Double or nothing

“Both my knees were shot so I decided to get both fixed at the same time,” says David Wessel, speaking several weeks after his double knee replacements. “My brother also had a knee replacement, but he only had one bad one. He is back playing tennis.”

“I just didn’t want to go through it all twice, and my surgeon said OK. The surgery took  hours. I was in the hospital about 3 days and then moved to the rehab center on Clearview for just over a week.”

“The nurses and the rehab therapy were excellent. There was one other person also rehabbing from double knee surgery. The nurse said they don’t take patients who only have surgery on one knee. I was impressed by all the attention I got, but it wasn’t easy. The food was awful. They kept me for just over a week dismissing me with instructions to walk on my own.”

“That was easy as I live next to Audubon Park. This is my 5th week after surgery. I am walking slowly around the entire park, two miles, with a few rest stops. I’m also doing aqua therapy at the Loyola pool. My recovery has been slow but persistent. It is worse than they tell you.

“You walk and move your legs a lot. It seems to be working. For me it was worth doing both at the same time. It is tough, but I don’t have to do it again. And yes, you can give my age. Call it ancient at 76 years, but still walking.”