Debora Waxer’s history of knee injury and pain dates back to her
college days when she played on the varsity basketball team at Massachusetts
Institute of Technology (MIT).
“In one final game, a girl on the opposing team ran into me on the
court, causing me to fall and damage the cartilage in my right knee as
well as the anterior cruciate ligament (ACL),” she recalls. “I
had to have surgery, and back in those days, they simply took out the
Now in her mid-50s, Ms. Waxer coped with pain in her knee over the years,
trying everything she could to forestall additional surgery. In the past
10 years, however, the pain got progressively worse.
“I tried exercises and a couple of steroid injections,” she
says. “I saw several doctors, who said I would probably need to
have the knee replaced at some point. Then in January 2012, I fell again.
I wasn’t even doing anything fun – I was just carrying something
out to the car at night, and I missed the curb. This time I completely
severed the ACL that had been damaged in my previous fall.”
At the time of her second knee injury, Ms. Waxer was living near Reno,
Nevada. A doctor there recommended total knee replacement.
“I opted to try a knee brace, extending from my thigh to the calf,
to see if I could do without knee replacement surgery for a while longer,”
she explains. “Without the ACL, I had no stability in the knee,
and it still hurt so much, but the brace did help line up the knee better.”
Ms. Waxer continued to postpone getting her knee replaced because of her
demanding job commitments as an environmental and safety engineer for
the U.S. Navy, working as a civilian. In November 2013, she returned to
working in the Monterey, California area full-time. (She also works on
a referral basis as a real estate broker.) Finally, in the spring of 2014,
she decided to meet with orthopedic surgeon Alexander Sah, MD at the Washington
Hospital Institute for Joint Restoration and Research (IJRR), where he
and John Dearborn, MD serve as co-medical directors.
“I had heard many times over the years about Dr. Sah and Dr. Dearborn,
and they came highly recommended by other doctors and a physical therapist,”
she notes. “Dr. Sah agreed that the knee replacement needed to be
done. Partial knee replacement or just surgery to repair the ACL weren’t
considered viable options. I still had to wait for the surgery, though.
I knew that I would need to take a fair amount of time off work to recover
from total knee replacement. We were very short-staffed at work, and no
one could fill in for me. We scheduled the surgery for December 2, 2014,
so that I would be able to take time off around the holidays.”
One of the most experienced joint replacement surgeons in the Bay Area,
Dr. Sah chose a newer, “personalized” knee implant for Ms. Waxer.
“Because she is a younger patient, I used an implant that offers
more sizing options to better match individual patient anatomy,”
he says. “It is also partly fixed by bone ingrowth, which can possibly
increase the longevity of the knee replacement. I also used newer plastic
liners that contain vitamin E as an antioxidant, to again possibly improve
durability. In addition, I used aspirin instead of stronger blood thinners
to prevent blood clots, while reducing the risk of postoperative bleeding
and swelling in the knee.”
Dr. Sah had another innovative idea for improving Ms. Waxer’s surgery
recovery and getting her back to work sooner – getting her to walk
on the new knee within hours after surgery and possibly allowing her to
go home the day after surgery. Prior to December 2014, knee replacement
patients at the IJRR had not walked until the day after surgery, and most
required a two- to three-day hospital stay.
“I’ve worked with many colleagues who are among the leaders
in joint replacement surgery, going to meetings and conferences where
we share our experiences and ideas, and I assimilate their best ideas
into caring for my patients,” he explains. “Getting certain
patients to walk the same day as surgery helps speed their recovery and
provides equal – if not better – knee range of motion.”
Prior to starting the new protocol for having select knee replacement patients
walk the same day as surgery, members of the IJRR physical therapy (PT)
team had some concerns.
“We had always gotten knee replacement patients up the next day,”
says PT Clinical Coordinator Alisa Curry, PT, DPT, GTC (physical therapist,
doctorate of physical therapy, geriatric training certified). “Our
standard practice was to ‘wean’ patients off their epidural
anesthesia gradually. Dr. Sah’s new protocol called for taking patients
off the epidural right after surgery and using an injectable, long-lasting
local pain medication instead. So one concern was whether pain management
would be as good with the new protocol. Another concern was whether post-operative
swelling would be worse because of the increased early physical activity.
The keys to great results after total knee replacement are pain management
and control of swelling, and I didn’t want to sacrifice either of
After the first three patients she had walking the same day as their knee
replacement surgery, Curry’s concerns were put to rest.
“I realized this new protocol would be a game-changer,” she
says. “I’m a member of the American Physical Therapy Association
working on guidelines for total knee practice, and I knew that other facilities
were getting patients up the same day. But those patients’ legs
were still numb from femoral nerve blocks. I think Dr. Sah’s protocol
for using the injectable pain medication after surgery is better because
the patients can feel their legs. So they have better motor control, and
we can safely mobilize them faster.”
The pre-operative education for all knee replacement patients at the IJRR
was modified prior to Ms. Waxer’s surgery to let people know that
they might be candidates for getting up to walk the same day as surgery.
“Now, with the patient education that we wrap around this change
in protocol, I am definitely an advocate,” Curry admits. “Approximately
70 percent of Dr. Sah’s knee replacement patients are able to get
up and walk the same day as surgery, and they can go home the next day.
The patients are pleased to know they have the chance to continue their
recovery at home – in their own bed, with their own food, and with
no restrictions on people visiting – as opposed to staying in a
facility. The patient education is an important component, letting them
know what will take place and making them part of the recovery team with
an important role to play in their own recovery process. They understand
that while their knee is not healed, they are more functional and can
participate better in their rehabilitation. They are managed very well
from a pain standpoint to make this procedure very tolerable.”
Curry emphasizes that while every patient is not a candidate for next-day
discharge, the patients’ ages don’t really matter as much
as their condition and mobility prior to surgery. Other medical conditions
might affect their recovery time, too. Range of motion at hospital discharge
is a very important factor. Patients need to have at least between 90
and 110 degrees range of motion to be considered for going home the next day.
“Each patient is different, and we need to do a thorough evaluation
of what is best for them,” she says. “Our team doesn’t
just get people up walking and send them out the door. We have a long
record of having patients leave with great range of motion – our
average is 96 degrees at discharge, which is high compared to other facilities.
We are creating a ‘better patient’ by having them be more
functional and mobile at discharge, which helps in their recovery over
the long run.”
In Ms. Waxer’s case, she was stable and steady on her feet, walking
a short distance the evening of her surgery, according to Curry, who walked
the patient the evening after her surgery.
“Ms. Waxer had 118-degree range of motion the day after surgery –
well above where she needed to be in order to be safe and heal well at
home,” says Curry. “She had climbed 10 stairs and walked 200
feet in the hallway easily with a walker. She walked out of the hospital
that day with just a cane.”
From Ms. Waxer’s point of view, the experience was nothing short
“I had my surgery around 9 a.m., and was back in my room by early
afternoon,” she relates. “The pain control was really phenomenal.
The physician’s assistant involved in my surgery and recovery, Abigail
Goetz, and the nurses were all excellent. My husband Michael actually
said, ‘Wow! Hospitals can be a positive experience, not torture!’"
“I was happy, but not too surprised, to be able to walk the same
day,” she adds. “Dr. Sah and the staff had let me know ahead
of time that walking the same day was a possibility. By the next day,
my range of motion was equal to what is usually achieved after six to
eight weeks. I also knew that the typical hospital stay for knee replacement
was two days or longer, but I was really happy to go home after just one
day. I felt ready to go.”
The IJRR arranged for Ms. Waxer to have a home health care nurse visit
a couple of times a week for three weeks. She also received physical therapy
at home, two to three times a week, through December.
“The transition of care from hospital to home was very well-coordinated,”
she says. “Dr. Sah even called me at home once a day for several
days to check on me. I never had a doctor do that before. I was really
impressed. My husband and I are both MIT graduates, and we asked a lot
of questions. Dr. Sah was very patient and thorough in answering.”
Ms. Waxer started outpatient physical therapy at a clinic and returned
to work at her office in January. Three months later, she reports that
her recovery is going well, with additional physical therapy to continue
gaining more strength in her right leg and improving her posture.
“I was really limping before the surgery – my body had been
out of alignment for more than 20 years – and I am so much better
than I was,” she says. “Sometimes I think I shouldn’t
have waited so long, because the outcome is so great! It was definitely
a better option to wait and to travel from the coast to Fremont so I could
have Dr. Sah for my surgeon. I was very impressed with the educational
efforts and the amazing care from all members of the team. I also thought
Dr. Sah’s protocol for walking the day of surgery was excellent
– it worked really well for me. I am absolutely thrilled with the
results, and I highly recommend Dr. Sah and the whole team at Washington
For more information about Washington Hospital's Institute for Joint
Restoration and Research, visit www.whhs.com/joint-restoration/.