Expectations of surgery: She's grateful, But

Alina Tugend's story

My father recently had his second knee operation in a year.  The first time, things went poorly.  His rehabilitation was difficult and months later, he still could not walk well or, even more important to him, play tennis.

He had the operation a few weeks ago, and he's already doing much better.  Different doctor, different outcome.  And perhaps, most significantly, different expectations.

"The first surgeon just raised my expectations unrealistically," my father said.  "He told me that in a few weeks I would be out on the tennis court."

I started thinking about how we manage expectations after my father's operation and after a friend, Amy, told me she recently had her cancerous thyroid removed.  The cancer was contained, but one of her vocal cords was paralyzed.  

She wasn't warned about this, but has since learned it is a common side effect of such an operation and can last up to a year.  It makes talking, eating and drinking difficult.

"It's not what I bargained for," Amy said.  "I'm grateful to be alive, but if I had just known, I would have been more prepared before and afterwards."

Advice to people considering surgery:  Consult a professional patient advocate, or read about the experiences of older and wiser patients on the Internet, before consenting to surgery.

Read a story about a man's ill-informed consent for surgery.  Thanks to Alina for her article, "What Did You Expect?  It Makes a Difference," excerpted here from the NY Times of Jan. 14.

Back at the same level: Tom Brady's hospital post-surgical infection

A few minutes before Super Bowl LXIII, and Patriots fans know that in a just world, Tom Brady should be guiding the Patriots to another Super Bowl win.

Tom, of course, suffered a season-ending injury early in the season. He had surgery on October 6 to repair his knee, with a patella tendon graft inserted to replace his torn ACL (anterior [front] cruciate ligament). His torn medial (middle) cruciate ligament (MCL) was also repaired.

Afterward, he suffered a postoperative staph infection – the most common kind of post-op infection. He was put on antibiotics, and remained on antibiotics through at least November 11. The infection was caught early, and was treated aggressively with wash-out procedures and intravenous antibiotics.

The infection has delayed the start of physical therapy to restore his range of motion, prevent the build-up of scar tissue, and protect the cartilage.

But Patriots fans can take consolation in the words of Kevin Wilk, the associate clinical director of Champion Sports Medicine in Birmingham, Alabama, who has helped more than 500 NFL players recover from ACL surgery: "He's going to make it back and play at the same level."

Advice: Bet on Tom Brady.

Read another football knee surgery story.

Thanks to Shira Springer for the source article in the Boston Globe of Nov. 11.

She was visiting: Medical tourism to Israel

Caroline Ardeeser, a 78-year-old retired Florida resident, decided to forgo Medicare and hospitalization in the U.S. and pursued surgery in Israel. She was visiting Israel earlier this year, when her knees "gave out." Rather than return home, where she had stopped paying health insurance premiums, she chose to have the reconstructive surgery performed at the Sheba Hospital in Israel. The 90-minute surgery and a week's stay in the hospital cost her $16,000, which she had in savings.

She says that at her age, she cannot obtain private health insurance in the U.S. And even if she could, she estimates that with the co-pay, the surgery and the rehabilitation at home could have cost three times as much. She plans to have surgery on her other knee soon and is recuperating in a rented house in the West Bank city-settlement of Ariel. "I had a most positive experience here," she says.

Much of the medical tourism industry in Israel depends on brokers like Ira Nissel, who handled Caroline’s case. An immigrant from New York who came to Israel in the late 1970s, he is an entrepreneur who formed IMS Global four years ago to promote medical tourism to Israel.

A survey in 2008 by Deloitte Center for Health Solutions found that in 2007, 750,000 Americans traveled overseas for medical treatment. Spokespersons for the Israeli government said about 20,000 foreign tourists were served in Israel in 2007.

Advice to people lacking insurance: Consider the merits of getting care abroad – or of getting a U.S. president who favors universal health insurance.

Read a story about medical tourism.

Thanks to Netty Gross for the source article in the Oct. 13 issue of the Jerusalem Report.

He doesn't make mistakes: Cadaver grafts for ACL knee surgery

An orthopedic study, released yesterday, found a 24% failure rate in operations on young athletes who get a cadaver graft [from a dead person] in knee surgery to repair an ACL ("anterior cruciate ligament"). Many have discussed whether Tiger Woods should have this surgery. Here's the story of Keith, an avid amateur soccer player in California:

Having played an awesome game of soccer on Saturday the 15th, on Sunday July 16, 2006 I decided to help out a teammate and play for his team since they were short. The league that I play in have artificial turf fields. The league my teammate played in used various grass fields. On this particular day, it was an awful field of a junior high school. I had just recovered from a mild Achilles tendon strain to my right heel, so jokingly I stated "there's a hole out there w/my name on it, watch." 

Unfortunately, I was right, but had no clue what was in store for me. With maybe 10 minutes left in the game, the other guy playing forward w/me was on a breakaway. I was running with him, wide open, so he crossed the ball to me leaving me 1v1 with the keeper (who sucked btw). It was a simple setup that I've played through many times before: a quick cut to the side and pass the ball in. That's all I had to do. So, I did just that. 

Or attempted.

What happened, to my recollection, was that I tried to cut to the left w/the outside of my left foot. Somehow in my footing my left leg got stuck as if I couldn't lift it up quick enough. Maybe I stuttered in my steps while trying to quickly change my direction or something, but my leg was firmly planted as the rest of my body moved over it. Before I knew it, I was on the ground, my knee having bend backward and to the inside a bit and having heard a pop. I was in the most excruciating pain I've ever felt in my life, and as I was literally digging out clods of dirt and grass from the field I could only say two things, "f***" and "oh s***!" I didn't even move for a few minutes (from the ground that is). When a teammate shouted to the sideline "get some water" I blew up. "I DON'T NEED ANY F***ING WATER, WATER ISN'T GONNA HELP ME!" 

And it figures, because with my Achilles tendon strain, I bought and brought a bag of ice from Ralph's every game. The one day I don't do that is the day I tear my ACL, and some ice would have been nice initially. Anyway, when my teammates helped me up, I tried to walk and immediately my knee buckled. It was as if it were jelly, just no stability at all. The fact that somebody else said they heard a pop was a bad sign, but for the time being I had hoped that it was just a severe hyperextension. In high school I hyperextended my knee a few times and may have had Osgood Schlatter's disease (it was a debate, I had a lot of the symptoms but currently show no sign of ever having it).

My 1hr+ drive home was nervewracking because I started analyzing what could be wrong and what it could mean for the rest of MY season (screw my teammate's season!), and where the heck should I drive to. The urgent care I had intended on going to was apparently closed even though they have "24hrs 7 days a week" posted on their window. In tears from the pain, I made it to the hospital (having never been there before) and apparently parked the furthest distance from the urgent center as possible. In time I got a wheelchair and X-rayed, and 4 hours later (it was a long wait) was told to see an orthopedic surgeon. My leg/knee was in an immobilizer brace and a friend picked me up and took me home.




THE SURGEON

The next day, Monday July 17th, 2006, I went to Blue Cross' website and found the closest orthopedic surgeon to me and called. They had an opening if I could get there in 1/2hr, so I lucked out. The surgeon asked me a series of questions and prodded around my knee for a bit, injecting a giant needle into my knee and pushed out a TON of blood. The needle felt like it was going so deep so as to hit the bone, but it wasn't. Definitely painful while it lasted. I wish I could say the amount, because it was a lot even for an ACL tear, but must have been 4-6 CC's worth. He sent me off to get an MRI as it was the only way to tell for sure what was wrong. I had my fingers crossed for a "best of" situation, meaning I didn't want it to be an unhappy triad (torn ACL, MCL, and torn meniscus), but I wasn't gonna be happy with an ACL tear either. During this time, I had not only the immobilizer brace but was on crutches too. Anyway, a few days later I got the MRI results and sure enough...ACL complete tear. Unfortunately, my stupid surgeon was going on vacation to the Caribbean for THREE weeks! I wanted the surgery right away and this wasn't going to help. So, I painfully had to wait nearly a month in order to have it. At some point I got a hinged immobilizer brace which was a lot better than what the hospital gave me. This new brace had hinges which you could lock into various degrees of flexion and would be key mostly for after the surgery. So anyway, let's get to that already shall we?



THE SURGERY

Finally, the big day came: Friday August 25th, 2006. The process I was told would take about 1hr 15 minutes, which I found surprising, but I guess it's not that long for a non life-threatening surgery, heh. The method of surgery was an allograft: a cadaver graft, meaning some dead guy's Achilles tendon was used as opposed to a hamstring (or patellar tendon) autograft. My surgeon explained he preferred this method because it doesn't require cutting into your own body. Why heal from 2 places when you can do it from 1? Fortunately, despite his jackassery of leaving for 3 weeks, he's a very good surgeon in LA. I got extremely lucky by finding him at random!

 The morning of the surgery, I wrote a giant "NO" on my right knee as it is my healthy knee. The docs later laughed at me for doing that, because "he doesn't make mistakes." But hell, why take the chance? Anyway, I was told that after the surgery I would be sent home: an outpatient. I found that cool because who wants to be in a crappy old hospital? BUT, the surgery didn't go quite as planned. Apparently my surgeon's assistant was also assisting another surgery, so rather than 1hr 15 min, it was 4 friggin hours! But, it was a success. I woke up and they wheeled me out of the recovery room and into a room in the hospital...so, rather than being an outpatient, I was an inpatient and had to spend a night in the hospital. 

That night was the longest friggin' night of my life. I knew that surgery would be painful, but I figured that knee surgery was small in comparison to hip replacement, shoulder surgery, etc...WRONG! Sorry to say but you're gonna have pain and it's gonna be extreme. I was asking for morphine every 4 hours on the hour and didn't sleep for s***...kinda sucked. I didn't eat nor drink much while there either. The next morning was quite a task as it was time to go home. Time to go home after going through traumatic surgery and having no food in my stomach. It also meant moving with a recently-operated knee. A therapist-type guy came in and helped me out of bed (painful) and showed me how to go up and down stairs w/crutches. After a long process of getting me into a wheelchair, into and out of my mom's car, and into my bed...I was home. Aside from moving, there really wasn't much pain...from surgery and on I only took 3 Vicodin pills and honestly didn't really need them. This is to say that while laying on my back all day I wasn't experiencing pain. Getting in and out of bed (basically, when my leg wasn't laying in bed) hurt, but that's to be expected. Maybe 3 inches below my knee was, and still is to this day, numb because apparently they have to cut through a nerve, but the area is only 4x3 inches? Its not bad, but it's one of those things that I'd like to have back just because I'm supposed to. 

There are some other side effects of the surgery such as lightheadedness. Considering you're stuck on your back for such a period of time AND a loss of blood/traumatic surgery AND your usual eating habits have been changed temporarily, it's entirely natural, but I tried to sit up when possible to read, etc. 

So, my surgery was Friday Aug 25th, right? Well, Wednesday August 30th I was back at my surgeon's office for a followup, and my first day of physical therapy. I guess this leads us to our the next point...



THE RECOVERY

The goal of therapy is to achieve full flexion (bending) and extension. When I saw the therapist the first time, he just did some electro-pulse type stuff on my knee. I've done it before back in high school so it was nothing new. Because a little more than a month passed between injury and surgery, my leg muscles atrophied pretty bad. If there's one thing I've always had pride over, it was my muscular soccer legs, heh. My right leg hadn't changed, but my left was kinda chicken-legged. Most notably, my quads. 8 months later, my quads are still diminished...better than post-op, but still not to where they need to be. I'd like to say that my therapist didn't have me work on them in the early stages of therapy. He stressed that the hamstrings are really important because they're the muscles that aid flexion. But, I still feel like he neglected them when it was key because I'm only doing 15 lbs on my left leg...it's not that my muscles can't handle the weight, it's that the ACL is still weak at this point. Which is normal.

Advice: Look into other patients' stories thoroughly before choosing elective surgery.

Read a more grim story of a young athlete's knee surgery.

Thanks to Keith, and to Drs. Kurre Luber and Gene Barrett for their presentation at the 2008 American Orthopaedic Society for Sports Medicine's Annual Meeting.

Put it in writing: Wrong site knee surgery

A surgical team at a southern California hospital made repeated errors that led to a patient operation on the wrong knee, according to a state investigation that was just made public. Even after the patient noted what knee needed surgery, the surgical team still performed the operation on the wrong side, the report says.

The surgery schedule incorrectly indicated that the patient was to have surgery on the right knee. During a preoperative interview, the patient told a nurse the surgery was for the left knee. That nurse then notified the anesthesiologist and the surgeon about the correction.

Hospital records show the word "right" was crossed out and the word "left" was written in by hand, according to the state report.

Another nurse told state investigators that the left knee was marked for surgery but she incorrectly prepared the right knee for surgery. The patient was not asked to verify the correct knee, nor was the patient's history reviewed before the surgery, as called for in the hospital's protocol, the report says.

Before the surgery, the surgeon read out loud that the surgery was for the right knee.

The error was discovered when the patient woke up in the recovery room and pointed out the mistake, the report says.

Advice: Put it in writing. On your own skin, write "the right place to operate" and "do not operate here" on the wrong place, before surgery.

Read another wrong site surgery story.

Thanks to Courtney Perkes for the source story in the May 7 issue of the Orange County Register.

He'll Be Back Playing Football in the Fall: Surgical error

His mother says about her son Jimmy, "His whole life was in a team uniform," first baseball at age 4 and then football at age 7. And he was good--he'd won his local Punt, Pass and Kick competition as a child. Then at age 15 he had a bicycle accident that required outpatient knee surgery. He was told he'd be back on the football field in the fall. But he developed a staph infection, probably from a dirty surgical instrument or doctor or nurse who didn't wash their hands thoroughly enough.

MRSA (Methicillin Resistant Staphylococcus Aureus) and other bacteria had invaded his blood, bones and joints. His treatment has involved massive amounts of Vancomycin and other antibiotics, physical therapy and multiple operations. He requires bone grafts from his hip and heel to replace the lost bone damaged by infection. Now Jimmy Toolen can't go to school, and needs a cane, walker or wheelchair to get around. The hospital infection has also damaged his mother and father's health, and has wrecked them financially.

His mother Lisa Toolen has worked hard to support a state law requiring the disclosure of hospital infection rates in South Carolina. Efforts like hers have persuaded 16 states to pass some form of public reporting law. She has told her story to the Consumer Reports organization, which is collecting these stories.

Advice for parents: Tell your story loud and long, here and elsewhere. Join with other victims' families to get laws passed to reduce hospital infection rates.

Read more in articles by Robert Kittle and David Hutchins.