A drama in seven acts.
The surgeon looks you in the eye and warns you, as he must, about everything from infection to inclement weather but the one thing he did not, will not say is –
“This is going to hurt. This hurts more than just about anything. Yes, more than childbirth according to women who’ve tried both. Stabbing yourself deeply in the thigh with a blunt and rusty fork will sting a bit but this is going to HURT. You are about to wake up to two to four weeks of enduring, unrelieved misery.” He won’t tell you this, you see, because he doesn’t really believe it. He thinks it won’t hurt that much. After all, there’s pain relief medication and, like everything else in his universe, it works. But things are never that simple are they.
I’m not trying to put you off. This is a very personal response to my second knee replacement – I knew what I was up for but you may not, so go into it with your eyes open. If your arthritis is as bad as mine was, then a few months after the operation it will all seem worth the trouble and pain. But there is a downside - the process is miserable, you' have numb knees for life and you'll not be able to kneel again without pain (a problem if you're religious I suppose - I'm not, thank god).

Act 1. The Surgeon
Surgeons are odd creatures. Orthopaedic surgeons are odder still. These are people who hack chunks out of your living bones with ‘instruments’ that look more like high class hardware store specials than medical equipment. Imagine a titanium plated cordless drill that can be boiled in a steriliser and you start to get the picture. Orthopaedic surgeons are the ‘blokes’ of the profession.
In order to become the best paid tradesmen on the planet they need one attribute even more than skill – supreme confidence in their own ability. You need them to have it too because with this, they can run their theatre properly and effectively. Whatever they need is provided instantly and to an acceptable standard, or else. This is not really arrogance although it can look like it. And a little arrogance isn’t such a bad thing if it’s earned.
Because of this, your surgeon has a unique view of the world. For them it is a place where things happen as expected, no surprises, no anomalies . Everything can be controlled in any situation, by an exercise of will. Thus the surgeon who gave me a failed arthroscopy on a knee simply denied that the joint was now worse – an outcome like that was not possible in his way of thinking.
Could not happen = Has not happened.
Consequently, expect your surgeon to have the bedside manner of a fascist officer. You are the mere subject on whom he will perform his magic and you may betray him by claiming that the outcome is poor or the pain outrageous. You must be lying of course, or worse – ‘uncooperative’. In worst cases, this person became a surgeon because he prefers dealing with patients when they are unconscious and once the procedure is underway, he gives you no more thought than a painter does his canvas. So what. Get over it. You are looking for a good surgeon, not a friend. I have quite a few friends who treat me with concern and respect but not one of them can perform decent knee surgery.
The problem is not so much with the surgeon but rather with the lesser beings. You’ll hear frequently, “We can’t do that because Mr. Thingo doesn’t like it,” or “Mr Whatsit doesn’t allow that.” Nurses and physiotherapists defer to the list of instructions religiously, regardless of the circumstances. Thus, my knee surgeon required that I wear a thing called a Zimmer splint to stabilise my leg. It wraps around and fastens with Velcro straps. Fine. Except that I was supplied with one that didn’t fit, scratched my leg and would fall down within a few steps and trip me. Irrelevant, I MUST wear it, even though the patient next to me is not hobbled by one because their surgeon does not require it. Not only that, mine had not put an end date on the instruction. Eventually I had a worried nurse who insisted I wear it for the fifteen steps to the lavatory as well – so I had an ‘accident’, managed to pee over the half secured splint, my foot and the wall and handed it to them, wet and smelly, knowing that they didn’t have another. Sometimes it’s easier to let people deal with the consequences of their own inflexibility.
Your surgeon will be paranoid about infection. I understood why after I met another patient whose foot tendon operation got infected – unbelievably nasty. He was waiting for the plastic surgeon to rebuild the damage. Do as you’re told on this one and follow the rules as the consequences can range from the operation having to be repeated through to permanent crippling and disfigurement.

Act 2. The Pain
The surgeon is off cutting another knee so you are now managed post-operatively by a physician. At least they are usually reasonable human beings. They say things like, “There’s no need to put up with pain.” Very reassuring but sadly unrealistic for all sorts of reasons. It isn’t going to happen because several people will want to restrict your medications, all for the very best of reasons of course. At times, you will honestly and sincerely feel the need to kill them.
I have experienced worse pain – a serious toothache for instance when I was sitting in the dentist’s waiting room moaning, rocking and bashing my head backwards against the wall to try and distract myself. That was a ‘10’ but only lasted a couple of hours, not a couple of weeks. And yes, they do keep asking you to grade your pain on a scale from one to ten. Annoying because that ache in your knee is only a six, to be honest but it just goes on and on – that makes it feel much worse. Give in, call it an eight – they’ll discount your description a bit, assuming that you’re exaggerating to get more pain killer out of them. It’s really only for a basis of monitoring your own pain anyway, not for comparing with others.
Do not be a stoic – people admire ‘brave little soldiers’ but I’d rather be happy than admired. I do not deal well with pain and I have a low threshold. If it hurts, say so. If nothing is done, complain politely. If still nothing is done, staff will respond well to a patient who moan, gasps occasionally and rocks around in bed. Act out – it hurts so all you have to do is convince others that it really does hurt a lot.
There will be two kinds of pain. The first I call bone ache although it’s probably coming from sore muscles too. Bone is sensitive and it’s been cut, shaped and drilled. That deep ache that you feel in your fingers when they get really cold is bone ache and it is persistent – you need to soak your hands in warm water to stop it. This is a grinding, steady , unrelenting pain that makes you feel queasy and you constantly stretch, turn and reposition your leg or whole body in an attempt to reduce it. Nothing works. It doesn’t seem that bad, until you realise that you are moaning and thrashing in the night. The worst of it is that it just doesn’t stop.
The other I call nerve pain. The nerves in your leg have been cut, bruised disturbed and now have bruising and swelling pressing on them. The result is flashes and stabbing twinges of pain, like electric shocks, in the shin, kneecap and thigh. These really do make you wince and moan.

Act 3. The Drugs
You start flat on your back after the operation and you aren’t going to move for some time. Not to worry, you’re taking morphine and you don’t care about anything much, except perhaps for the weird dreams and hallucinations. When that stops you have to work out a combination of drugs that will mask the different types of pain. I heard of one person who managed with nothing but a bit of Panadol – insensitive clod!
Some people feel queasy or nauseous when taking opiates like morphine. That’s unfortunate because that’s the best there is. Accept the nausea and go on a diet dammit – you’re probably overweight anyway, right? That’s why your knees surrendered in the first place?
At first you’ll be on morphine and they may give it to you by ‘patient demand’. You press a button and it delivers a hit of a tenth of milligram into your saline drip. There’s no point pressing the button rapidly several times as it won’t give you a dose unless the previous one has gone through – wait about 3-4 minutes between presses. It’ll also lockout after a preset limit is reached so take it easy or you run out.
Funny stuff morphine – you’ll feel weird, giddy and may even have hallucinations and nightmares. But time goes quickly and after about two days they’ll take you off it and replace it with a whole bunch of stuff that doesn’t quite work. You can now at least focus well enough to read and remember what you read but you don’t bother because it hurts.
There’ll be something like slow release Oxycodone (Oxycontin) for a base level of pain relief, with Endone and Panadeine Forte used to treat the pain when it breaks through. Never, ever refuse painkillers on the grounds that you don’t quite need them yet because you will and once an episode of pain starts, it’s hard to get rid of it. Best advice I received was to ‘let the pain chase the pills, not the other way around.’ You’ll need descending doses for at least a month after the operation and probably longer. Get off the Oxy first as it is addictive and you will have some withdrawal symptoms.

Act 4. The Nurses
These come in two basic varieties. There are those who think that ‘patient care’ is the title of a chapter in one of their nursing textbooks. And then there are those who actually practice caring for their patients in their many, varied and often delightful ways. There’s nothing quite like an experienced nurse with a dry sense of humour – wonderful people.
This is a common divide in most jobs. There are those who like doing the job itself and then there are those who see it as merely a set of processes. The first group are the ‘doers’, the second are the ‘managers’.
You see the difference quickly. You ask for pain medication and the carer will express sympathy, check your chart to see what they can give you now and then they go get it. The manager type will inform you that there is a drug ‘round’ in half-an-hour and they’ll bring you something then. Incidentally, that means one and a half hours before you get relief as the trolley may take half an hour to reach you after the ‘round’ starts and the meds will kick in some time after that.
My worst experience of this was to do with an air mattress. Because I was immobile after the operation I had an air mattress to prevent pressure sores. On the third day I was helped to stand and to get to the toilet and shower. The mattress was removed immediately as I was now classified as ‘mobile’ – actually I was anything but. The idea was that I would now ‘sit out’ on a chair during the day. Unfortunately I had bad bruising under the thigh and some sciatica and found sitting in a chair for longer than ten minutes impossible. This is not allowed for in the processes that they follow there – the book says that ‘sitting out’ is the thing to do, regardless. At one point they confiscated my urine bottle to force me to get (painfully) out of bed.
As soon as the air mattress was removed I discovered that the regular mattress was horribly inadequate. Three inches of foam over a steel plate. They have to be firm in case CPR is necessary but this was positively painful. I have back problems and within a couple of hours I had back pain, getting worse. This was causing severe sciatica. I explained this and asked for the air mattress to be returned. This was impossible apparently because they are reserved for the immobile patients. After a couple of days of (very polite) requests and complaints about back pain he nurses shut me down by putting me on rotation – every time I pressed the call button, I got a different nurse who claimed to know nothing about anything. It was pretty obvious that they’d marked me down as being ‘difficult’ on their notes. I had to make do with lying on a set of pillows. This was a place where the processes were inflexible and ‘patient care’ was governed by a set of procedures and policies, rather than examining the patient’s individual needs.
My final answer was to get out of the hospital and into the rehabilitation unit as soon as I could. The beds were far more comfortable but the gift of back pain and sciatica stayed with me for some time.

Act 5. Rehabilitation
After your week in hospital you can go home – if you are a complete lunatic. A far better option is to go to a specialist rehabilitation hospital for a couple of weeks. If you live in a nice, single storey suburban home with a bedroom which you can set up properly, family members to care for you and a family doctor who will visit regularly, fine. I live on the side of a mountain and my wife works for a living. This is where you need to have good insurance cover. Forget the extras cover that pays for naturopathy, acupuncture, aromatherapy and whatever – when you’re getting on a bit, just get the high level hospital cover instead that guarantees you a single room at no cost. If you are underinsured, you get a shared room and the toilet/shower is a way off down the corridor. You may be able to walk that far, but not necessarily get there in time. I once wet myself in the attempt and had to walk back to my room with soaked pants, through throngs of other patient’s visitors. Not a happy experience. Fortunately I was able to upgrade to a good room within 24 hours.
A rehab unit is unlike a regular hospital in many ways. The purpose of your stay there is to get your pain under control, your wound monitored, the staples removed and to persuade your new knee to bend to around ninety degrees (eventually you’ll expect 120). It is dominated by the Physiotherapists and has things like gymnasiums and hydrotherapy.
And it’s fun. The staff are used to patients who hang around a bit longer and so are friendlier and more relaxed. When you’re asked what you’ve been up to lately it’s nice to reply, “Oh I had to spend a couple of weeks in rehab.” Quite a fashionable claim these days. My favorite experience was to be stretched out in my undies late one night when a rather attractive twentysomething nurse burst in waving small packages and with a laugh asked me if 'I needed any drugs'. I resisted the fifty or so rather obvious responses but I spent part of the night giggling.

Act 6. The Physiotherapist
You thought dentists were bad? They inflict pain but a Physio insists that you cause yourself pain. “Bend it as far as you can…a bit more…now hold it while I measure the angle.” You really do want to hurt them but they are usually such nice girls with charming smiles and a determination to get you moving. Ramp up your painkillers before each session. They want to get your knee bent to about ninety degrees before you go home and they have all sorts of weird exercises and instruments of torture to help achieve this. Try not to scream too loudly, or too often – it frightens the older victims.
For about a week after the operation you will be quite unable to lift your leg. This is a weird effect – the quadriceps muscles are paralysed and simply don’t hear the command. Just when you are beginning to worry about it, you wake up one morning and they are back, just like that.

Act 7. The Occupational Therapist
Not the basket weavers of old. They want to make sure that you can survive outside the hospital environment so they’ll organise activities like cooking meals in their kitchen and show you how to manage. They can suggest a range of aids to help you like trolley for the kitchen, a frame to go around the toilet, a grabber hand for things on high shelves and even a device for drying between your toes (a flat stick with a little sock).
They are also mostly nice young girls and not vicious like the Physios. They also have very little idea about people who live in anything except a nice, suburban home. People who live halfway up mountains in forests are a bit of a mystery to them. They are very useful for geriatrics and the permanently maimed but you won’t get much use out of them. I organised a remote grabber hand because it was fun, rather than useful. (God, I was bored).

Finally –
You get to go home about 2-3 weeks after the op. Your leg still looks like a swollen pudding with a livid scar. They’ll have pulled the 30-40 staples out of it at about the two week mark and that swelling will subside after about six weeks, once all the bruising has broken down, everything is healed and it’s all back to normal. Only then can you resume your career as a tango dancer. Visit your general practitioner as quickly as possible to get enough painkillers to see you through – you’ll have been discharged with only enough for a week. Get some additional physiotherapy as well, about twice a week, as when the swelling finally subsides, you’ll really start to get some movement.
Oh, and just reflect on how bloody amazing it is that you just got a replacement for your knee instead of spending the rest of your life crippled with pain every time you tried to walk. Wonderful.