Most people don’t have knee surgery until they reach middle age or beyond, but tennis great Billie Jean King is not most people. Slicing across world-class tennis courts year after year inflicted undue wear and tear on her joints, causing her to undergo the first of many knee surgeries in her early 20s when she was the reigning queen of women’s tennis.
“In those days,” said King, now 68, “they used to put you in a cast or a half-cast that was totally straight with no bend in it.” Doctors offered her little advice on how to rehabilitate her knees, so she desperately set about paving her own path to recovery, uncertain whether to use ice or heat, and improvising leg exercises. As a professional athlete, she needed to get back on the court as soon as possible, playing through the pain.
Over the years, King tried to make do with less invasive knee surgeries, but two years ago she was so hobbled by arthritis that she had to hail a taxi just to go two blocks to the gym near her New York City home. That is how she arrived at Lenox Hill Hospital on Manhattan’s Upper East Side, where she sought the advice of Jose Rodriguez, MD. “He’s the top guy there for knee replacement,” said King.
“Wow, her knees are really messed up!” Rodriguez recalls thinking as he examined her and reviewed her xrays. He noted extensive damage to her cartilage, which is supposed to serve the knee as a shock absorber. Without cartilage, however, joints lose elasticity and wear away, while tendons and ligaments get over-stretched and cause pain. As bones begin to rub against each other, patients experience excruciating pain.
From what Rodriguez could tell, King’s problems were mainly in her kneecaps, resulting in a number of operations to clear away torn cartilage to make her knees function better.
“There’s not just one reason people have surgery,” according to Rodriguez. “You might have somebody who twisted their leg when they were young, and that created a situation of gradual deterioration. You may have an alignment issue with your knees that can predispose you to having trouble. More often than not there’s not just one problem, but multiple problems.”
While doctors generally recommend that joints be replaced one at a time, King decided to have both knees done at once. Rodriguez only allows this if a patient is “youngish, healthyish and motivated to do the physical therapy,” which he said King was. She spent eight months rehabilitating her knees, often booking physical therapy sessions in cities where she intended to travel. Today, the champ who couldn’t walk two blocks to the gym, is back on the court, enjoying the sport she’s always loved.
“She could beat the pants off me, I’ll tell you that much!” Rodriguez said with a laugh.
While hips and knees are the joints most often substituted with prosthetic ones, “we can now replace almost every joint in the body,” said Douglas Garland, MD, medical director of the MemorialCare Joint Replacement Center in Long Beach, CA. Everything from shoulders, elbows, fingers and thumb joints to hips, knees, ankles and toes may be repaired. Like Rodriguez, Garland most often operates on knees and hips.
At the root of any joint-replacement surgery is pain and loss of function. Obesity, trauma and genetics are common culprits in the downfall of knees, while hips are vulnerable to dysplasia, a condition in which components of the hip joints aren’t in sync with each other, ultimately leading to friction and arthritis. While our parents and grandparents dealt with the problem by using a cane or a wheelchair to help them get around, baby boomers and later generations are less likely to put up with the ravages of age when medical science can be tapped to help them maintain more active lifestyles.
From a young age, Erica Lansdown, who is now 56, remembers being athletic. As a child, she turned cartwheels in the house and taped posters of ballerinas to her walls, begging her parents for lessons. At age 12 she got her wish.
“I was an obsessive-compulsive exerciser from 11 years old to my mid-20s,” said the Southern California librarian, who started out as a ballerina, then became a teacher of language arts and dance. She also used to run 4-7 miles a day and later, at 38, added surfing to her athletic resume.
She started running in college to manage her weight and because she enjoyed the “runner’s high.” But one of her legs was slightly shorter than the other, and the ball of her hip was small for the size of the socket, so over time the cartilage began to wear down and cause a dull ache in her hips. When she couldn’t run as much, she swam and then biked.
Over the years, she found it increasingly difficult to sleep because of the pain, and then she could only stand up straight for minutes at a time. When she reached her limit, she would bend over and rest her hands on her knees. She initially consulted “running” doctor Eric Feldman, MD, while using crutches to get around. Feldman recommended she summon one of the big guns: Dr. Garland.
Lansdown remembers the moment when the surgeon put her x-rays up on the light box. “Yeah, these are ugly,” he told her. “He looked at the x-ray, and then he looked at me,” she said. He looked at the x-ray again, and then said, ‘We’ll do them both at the same time. You’ve got good upper body strength from surfing; you’re lightweight, and you can have one surgery and one recovery.’”
Although their doctors allowed both King and Lansdown to have one surgery on their knees and hips respectively, it’s often recommended that such operations be performed first on the joint that’s most problematic, with the second surgery following within a few months, so the patient has “one good leg to stand on,” as they say.
The “one at a time” approach is often advisable not only because it decreases the health risk to the patient, but also “because usually people have one joint that’s a little bit worse than the other, and by correcting the bad one, a lot of times the other one is no longer taking all the weight and doesn’t hurt as much,” says Constance Chu, MD, orthopedic surgeon and director of the Cartilage Restoration Program at the University of Pennsylvania Medical Center in Pittsburgh.
To replace a joint in the thigh, doctors make a five-inch or so incision down the front or between the front and the side (anterior or posterior), while on the knee, they make the cut down the front.
“With the knee laid bare, for instance, there are two people on each side who are moving the kneecap to the side to remove the parts that aren’t working well. They then replace that part with plastic directly under the knee surface that rides over a metal joint socket, thus allowing the knee to bend again,” explained Chu.
Although many patients are on their feet, getting acclimated to their new joint the day of or day after surgery, recovery takes several months, sometimes longer for older patients.
“I had a home health therapist come two times a week for three weeks to a month, and that’s when they turned me over to a rehab center called Movement Works where they re-taught me to walk,” the librarian recalls. “After surgery, they told me that there is a seven-week optimum window to regain mobility and flexibility. Rehab was intense, painful and nauseating.”
It was also like being a child again. For example, Lansdown had to figure out how to get her shoes on, and she had to have someone drive her around. But a few months down the road, she was enjoying her new hips and all the activities she could do with them. These days, she swims, pedals an elliptical machine and takes long walks or bike rides to her local farmers’ market. The surgery cost about $100,000, of which roughly $75,000 was covered by insurance.
Garland says recovery times at his facility have diminshed over the 30 years since he’s been performing jointreplacement surgery. Fewer patients need physical therapy and the duration of that therapy is shrinking. One of Garland’s patients, Jeff Davis, for instance, who had his right knee replaced a year ago at age 63, could hardly bike, ski or walk. But after the operation he wrote a thank you letter to the doctor: “I never used a walking device. You threw me out a day early. I was driving within 2-3 days (a six-speed stick shift), began therapy one week after surgery, only one day a week.” Within two weeks, Davis reported that he was riding his bicycle 15-20 miles at a clip.
While Chu, at the University of Pennsylvania, heralds joint-replacement surgery as “one of the most successful operations of the 20th century,” she cautions that even now, 50 years after it was first pioneered, it’s still in an experimental phase. For instance, doctors are not yet clear on how early is too early to have one’s joints replaced.
“In my own practice, I see young people who have suffered some type of knee injury, such as having torn their anterior cruciate ligament (ACL) when they were a teenager, and today they have pretty severe osteoarthritis in their 30s, 40s and 50s,” said Chu. In her opinion, thi is rather young to undergo joint replacement surgery if a person intends to remain highly active.
“We have this burgeoning group of active baby boomers and also younger people who want their joints to function so they can ski, run, play sports, and enjoy activities with their children, and in many instances with their grandchildren, and those joint replacements were not designed for that,” Chu cautions. “They’re designed for people who maybe have severe disease in their joints, but who aren’t planning to put quite as much mileage on them as the younger more active crowd,” she added. “If you drive a car hard, it’s not going to last as long.”
For those in their 60s and 70s, dealing with decreased mobility, joint replacement is absolutely the best option, she asserted. “Patients in those categories love their new knees, and it’s a very satisfying procedure for the surgeon.” But that is because they tend to have modest expectations, while younger recipients think of new joints the way they think of a new car, as in the next car is going to be better. “The difference with a joint replacement is that your next car is not a better car; it’s more metal and plastic, and less like a normal knee (or hip or shoulder, etc.) than the first one.”
They may also run the risk of needing the surgery a second time. Joints are predicted to last 10 or 15 years, but anything beyond that is not promised. So if you’re in your 60s or 70s, chances are a prosthetic joint could last you the rest of your life. But if you’re a decade or two younger and put the joint under highly demanding conditions, it could give out, and result in additional surgery.
At MemorialCare in California, Garland requires that every patient who has a knee or hip replaced attend a two-hour class, which covers every aspect of the operation. “They actually go to the recovery unit and see what the floor looks like. They have the opportunity to talk to the nurse who runs the unit, and after that they go to the lab and do their pre-op,” said Garland.
For the class, each patient is required to bring a spouse, friend or family member to serve as a coach, “…because the patient listens more to surgical aspects of the discussion, whereas the coach listens to the potential complications, or how to use the crutches or walker.”
Nile Jordan (due to a lawsuit against his former employer, this person chose to remain anonymous and has been given a ficticious name) brought along his wife to help him. He’s had both hip- and knee-replacement surgery, having injured both knees in the late 70s as a truck driver.
“I must’ve driven three million miles, and I wore both knees out,” Jordan said. Before the company he worked for downsized, he would drive with ice bags on his knees, trying to deal with the pain and swelling. He wanted to take narcotics to manage it, but couldn’t be under the influence on the road.
As his condition worsened, he couldn’t fly on a plane or garden, and could sit through only half of a movie before he had to get up and move around. A fall on his knees complicated matters. Meanwhile his hip deteriorated as well. With work drying up, he decided to sit it out and get some of the surgery that had the potential to help him while he still had insurance to cover it, including his right hip in 2010 and his left knee in 2011. Initially, he didn’t report it to his job because he worried that he would be penalized, but when he did he was put on workman’s compensation, which brought in only a fraction of his usual income.
“Disability only lasts 52 weeks,” he said. “Without my wife I’d be on skid row.” And now that his knees and hips are in good shape, problems with his back have surfaced. But overall, he said he’s pleased with his joint replacement surgeries. “I can ride a bike now, kneel in the garden and take a plane ride.” Today, his biggest challenge is finding work at 55.
Claire Beekman recently retired from her career as a physical therapist. She too liked gardening and riding her bike, and it was while pedaling that she discovered her bad right knee had reached the point of no return.
For nearly a decade before her surgery at age 69, she nursed her knee with injections to dull the pain and improve function. But it was a temporary solution that ultimately did not resolve the pain and stiffness from arthritis and a fractured patella. Then, roughly a year ago, “I was out riding my bike and I got a catch in my knee. I couldn’t bend it or straighten it. The same thing happened a couple of days later,” she said.
For Beekman, this was a clear sign she had to shift from taking injections and living with a bum knee to having it replaced. Last September, she had the surgery. She remembers that everyone who had the surgery at Long Beach MemorialCare got up the same day and walked the length of the unit with the aid of a walker.
Back home she’d organized everything so she didn’t have to exert herself. She set out her clothes and mostused items, installed a toilet with arms, and moved her bed so there was room for her walker to clear it. Three months later, Beekman’s new knee worked great.
Beekman said, “I hiked in India right at the three month mark after the surgery, just before Christmas. We walked around temples, a mile and half here and there, up and down big sets of stairs, and I couldn’t have done it without the surgery.”
by Pamela K. Johnson
Articles in the Push Girls Issue; Senator Harkin — Working for Jobs; Ashley Fiolek — Switched at Conan; Paralympics — Better Than the Olympics?; ABILITY Award — Accenture and Prudential; DRLC — Affordable Health Care Act Benefits; Billie Jean King — Bouncing Back; Joint Replacement — Hard as a Bone; Tourette’s — A Friendly Fil; Geri Jewell — Paper or Plastic; China — Exposing the World; Push Girls — Living Large; Marathon — Horses Help Vets to Heal; John Williams — He’s the Man; ABILITY’s Crossword Puzzle; Events and Conferences…