I wrote this piece some years back intending it to be a “Personal View” for the British Medical Journal. It was rejected quite rightly as it was “about 200% too long, introspective and had no real point of relevance for the Medical Community”
Indeed it maybe! However I enjoyed writing it and thought it might warrant an airing somewhere to be read or ignored at will.
So here it is for those who can be bothered
Personal View:
I am a 52 year old Consultant and three years post total knee replacement. I am not an orthopod. The TKR came as a result of a variety of enthusiastic insults to my right knee over a number of years, beginning with a misguided attempt at a black run in a blizzard about 27 years ago. I was a novice, and skiing with a boyfriend who was an expert. Predictably, I didn’t get very far down the mountain and ended up in a heap only a couple of hundred yards from the top. My boyfriend, completely oblivious, skied on down and went to the bar. The weather was too bad for a helicopter extraction so my removal from the mountain was effected by a combination of the blood wagon, towing my stretcher behind a snow plough, and a descent in the cable car. At the clinic, the resident medic looked at my X ray and my rapidly expanding knee, sucked in a breath, like a (Gallic) garage mechanic, shrugged (Gallicly) and then slapped on a full length POP and sent me away to fly home for treatment.
I have to admit, the journey home was rather fun – I was rebooked on a different flight to my holiday companions, needing 2 seats to accommodate my non flexible appendage and I got back in record time, whisked through passport control and baggage reclaim on one of those beeping buggies that I have wanted to travel on since I was a small child. The only minor hiccups were the airline booking my two seats across an aisle so I had to usurp a very grumpy German woman from her window seat, and the discovery that I couldn’t sit down on the loo with the door shut so I had to go about my business with my leg sticking out of the open door and two air stewards holding towels up to hide my modesty.
The resulting arthrotomy to retrieve the bits that had come off my tibial plateau necessitated 6 months off work from the A&E job which I had started the week before I went skiing. This went down like the proverbial balloon. I had spent three months prior to starting, negotiating (pleading) for the leave, however I was able to provide a ready prepared locum in the guise of my boyfriend who was between jobs on a self made GP training scheme, which did help somewhat.
My first experience of orthopaedic surgery was challenging to say the least. I went to outpatients clutching my “foreign films” and the Consultant instantly ushered me into a bed on the orthopaedic ward with instructions not to leave it lest it be taken by someone else less needy. I apparently needed surgery immediately. My boyfriend had to do a mercy dash to my hospital accommodation for an overnight bag.
On waking in the recovery room the following afternoon I was asked by the recovery nurse – “do you need any pain relief?” Being drowsy from the anaesthetic I said “No” and went back to sleep. I had a brief 2 hours of happy ignorance before I experienced 48 hours of the worst, most relentless, deep and nauseating pain I had ever encountered. The nursing staff on the ward were wonderful but completely unable to get on top of the pain with Pethidine, which made me throw up endlessly. I asked for diamorphine but they looked at me very strangeley and backed away muttering.
The orthopaedic Senior Registrar thought I was being a wuss and made no bones (sorry) about letting me know. As, a week previously, I had been terrified of his bullying tactics towards A&E juniors and avoided referring him anything if I could, I felt quite unable to argue with him. I did, however, tell him on the third morning after another sleepless night that it still ”jolly well” hurt (I paraphrase). He laughed.
I was astounded that I could not use my quadriceps muscle at all and had to relearn how to straight leg raise – a completely unexpected result for which I felt I ought to have been prepared. I couldn’t recall being taught this during any orthopaedic attachment as a medical student.
I was 25 and postoperatively had a knee with minimal flexion and no quadriceps power so was started immediately on physiotherapy.
As a student and as a junior doctor, I had never fully appreciated the wonders of physio. On day four, a tiny slip of a woman appeared at the end of my bed and completely changed my life. It sounds rather dramatic, but her daily ministrations as an inpatient and an outpatient got me back to full mobility, through a mixture of gentle encouragement, surprising brute force, strength, bossiness and great skill. I still think of her with a combination of admiration, fear, fondness and wincing. I was back at work before my sick pay ran out and got back to full function playing squash, badminton and hill walking by the end of the year.
Roll forward twenty odd years. I am on the wrong side of 45, the wrong side of 11 stone and pondering middle aged spread. The children are at school and the dogs need daily walking. I take up running. I start with the 5k Race for Life and work my way up to a 10K easily. I run 5 miles twice a week on my days off work, through the forest or on the beach. I love it. “Me” time and dog walking plus I get fit, see wildlife and get thinner. What could possibly go wrong?
At 47 I enter myself for a half marathon. The training goes swimmingly up to 10 miles. Beyond this I can feel my ageing body physically disintegrating. I ignore the nagging twinges from my right knee and press on with training. I complete the half marathon on a freezing day in February. It is not an enjoyable experience. On balance it is up (down?) there with childbirth but slightly worse, as at least then I had no possible opt out. The mental urge to veer off into the nearest ditch and have a rest is almost irresistible. The only thing driving me forward is the desire not to be overtaken by four men running behind me carrying a fully inflated lifeboat. I manage to cross the line in front of them, but everyone at the finish has gone home, apart from a bored man handing out the medals and my friend who came along to “run with me” and has finished, had a shower and a meal and re-run the last mile to accompany me – jogging backwards and shouting encouraging things like “I’ll buy you a bag of chips.”
My knee seems to be OK after this and I go back to my regular 5 miles until one day about 3 weeks later. I get a severe, acute pain rendering me almost unable to walk and I spend an hour hobbling back home with a pair of confused and concerned hounds trotting beside me.
After a number of Xrays, two arthroscopies, an MRI and three orthopaedic opinions it transpires I have an unstable knee with tricompartmental OA and a large osteochondral defect on my medial femoral condyle. I am informed it may never heal and any attempt to graft or repair it would just be tinkering. I need a TKR. “When?” I ask. “Whenever you want” he says. I am 48 and find it all a bit much to take in.
My mobility is affected, I am in constant pain, I think twice about taking stairs, I park as near as I can to my destination to avoid walking, It doesn’t, however, wake me at night. I tick a significant number of the boxes recommended before considering a TKR. My knee is progressively and noticeably deteriorating. I ask what I feel are the relevant questions and after a couple more years of vacillation, internet research and advice from an orthopaedic colleague I decide to award myself a Du Puy prosthesis for my 50th birthday.
I think I know what to expect. I am confident that postoperative pain management will have moved on in the 25 years since my last orthopaedic intervention and am pretty keen to get it done and get back to doing all the things I have not been able to do.
I’d like to say I was right.
The surgery was a piece of cake. Done under spinal with a large slug of Midazolam to keep me happy, I have pleasant memories of snoozing, being woken by various carpentry happenings somewhere south, and “helpfully” craning round to check my own obs from to time. For the first three hours post op I slept with no pain whatsoever. Then the spinal wore off. I was horrified to find that post operative pain management had not moved on at all. The pain was dreadful and completely unremitting. Again the nurses were incredibly sympathetic and caring as they dosed me up on Oromorph, made me tea and toast in the wee small hours and attempted to get a handle on it, but it took 3 days before I was remotely comfortable. I was sleepless, woozy, vomiting and totally constipated. I asked why I couldn’t have had some kind of self administrated pain pump postoperatively and I was told that this was not offered as “post TKR, people are in such pain that they would probably overdo it.” Another passing comment was “We don’t tell people how much a TKR will hurt because it would put them off the operation”. An anaesthetist friend was puzzled why I had not had some kind of nerve block as well as the spinal. The physio got me out of bed on day 2 and I immediately threw up over her. I felt terrible about complaining constantly but I really wasn’t coping. Was I being a wuss again? Once the pain was eventually controlled, however, I was getting up and moving and doing my physio enthusiastically, with rewarding results.
Then the pain team came to see me on day 4. They noted I was being let home at the end of the week and to my dismay they rapidly wound down the analgesia in preparation for my discharge. By the time I went home I was in constant pain, only marginally improved by the Paracetamol, Naproxen and Tramadol TTOs.
I didn’t sleep a full night for 8 weeks. The pain slightly receded to a permanent heavy ache, exacerbated severely by any forced flexion of the knee which would render me speechless, nauseated and pale. I progressed well to a stick by 3 weeks and was driving by 6 weeks. Outpatient physio involved visits to the department where about 10 people did their exercises supervised by a single physio and a weekly “hip and knee” class with a wonderful collection of frisky, crude and hilarious Octagenarians (definitely the highlight of my week). I doggedly did my daily exercises, but was hugely disappointed to find that I couldn’t turn the pedals on the exercise bike due to my lack of knee flexion. With much pain and perseverance I managed eventually to obtain 108 deg of flexion and made a wobbly circuit of the garden on my bike looking like “a hunchback duck in labour” according to my ever sympathetic husband.
So here I am 3 years down the line. My knee is stable and has stopped falling apart. I am more confident and do more walking. My husband says he definitely sees an improvement. However, I am never pain free. I stopped cycling as it was extremely uncomfortable, I didn’t feel safe and I couldn’t enjoy it. I can no longer cycle as my knee flexion has fallen back to 90deg. I stopped going to physio as I could not get the required hour off at lunchtime and be back in time to do clinic/MDT/lists. I got busy at work and at home. And it hurt like hell. And I got stuck at a plateau with no appreciable improvement for the pain I experienced. I definitely lost out without a personal bully (Physio) to manhandle me against my will and better judgement. I cannot walk downhill or over uneven ground without looking at my feet due to lack of proprioception and limited flexion – catching my toe on something and forcibly flexing my knee makes me fall over inelegantly, swear loudly and feel sick and temporarily homicidal. I wake at night with pain. I can walk up any hill but it takes me twice as long to get back down and the picnic has usually been consumed by the rest of the family by the time I get to the car so I have taken to carrying my own provisions. I don’t take regular painkillers as the dose and variety I would need to render me pain free is not allowed according to the back of the packet. I feel old and creaky – but perhaps that was inevitable and is just me getting on a bit.
It has been quite cathartic writing about my experience, but there is a point to all of this navel gazing. It makes me realise I am lucky to have had the option to arrest the disintegration of my knee via our beloved but ailing NHS. It also raises the question of how to be a good patient when one is a medic, and how to be a good doctor to a fellow medic who is a patient. More questions abound. Should I have known about all the things which I didn’t expect? I wonder if it was assumed I would know because I was a medic. Was this level of information usual for all patients? Why had I not appreciated that a knee flexion of 90 degrees was the acceptable post op result? Why had I not been fully briefed on the expected level of pain post op? Why was my post op pain so badly managed? Surely there must be some kind of evidence based best practice for anaesthetists? I read myself about the unfortunate percentage of patients with permanent anterior knee pain but was never informed about it pre op or ever expected to be one of them. Was it my age, budget considerations or a change in NHS practice that prevented me getting the fabulous and I would say essential one on one physio like I did at 25? Am I just whingeing and should I pull myself together?
Answers on a postcard please.
Comfortably Mum 