Patient Walks Same Day as Surgery, Expresses Joy and Gratitude
Kathi Ramirez, age 62, was no stranger to physical adversity. Diagnosed
with multiple sclerosis in 1980, she was accustomed to pushing herself
to overcome physical limitations. As a senior account executive for an
international technology firm, she traveled frequently throughout California,
Oregon, Washington and Hawaii. But a knee injury in the summer of 2013
and a subsequent unsuccessful arthroscopic knee surgery in April 2014
threatened her mobility like never before.
“I had been sitting in a very low chair, and I strained my left knee
trying to stand up,” she recalls. “I distinctly heard the
knee ‘pop.’ The knee hurt a lot for several days, and then
the pain went away for a month or two. I thought maybe I had just pulled
a muscle. But then the pain returned – with a vengeance.”
Ms. Ramirez went to see her regular doctor, who referred her to an orthopedic
clinic. She waited a few months to see the surgeon there because of her
demanding work commitments.
“It is really hard for me to take time off work,” she explains.
“Plus, when something like this happens, you just want to ignore
it. When I couldn’t sleep because of the pain, though, I relented
and went to the local orthopedic clinic recommended by my regular doctor.”
After viewing x-rays and an MRI of her knee, the clinic doctor diagnosed
a shredded meniscus – a C-shaped piece of rubbery cartilage that
acts as a “shock absorber” between the thighbone and the shinbone.
He recommended surgery to repair the meniscus, but she again had to wait
because of work commitments, postponing the surgery several months. As
is usual in arthroscopic surgeries to repair meniscus cartilage, Ms. Ramirez
went home the same day, with physical therapy scheduled for the second
week after surgery.
“Things went downhill pretty quickly after the surgery, with bruising
spreading up and down my entire leg,” she says. “When I first
saw the physical therapist, she was shocked at the extent of the bruising.
I went back to the orthopedic clinic, and after feeling the back of my
leg to make sure there were no blood clots, the doctor said the bruising
was normal and prescribed pain medication. I went back to physical therapy,
but it took two more weeks for the bruising to go away. The physical therapy
was painful. The left side of the knee, where the meniscus had been repaired
didn’t hurt, but new pain emerged under the kneecap and on the right
side of the knee. I couldn’t straighten out my leg.”
After four months of painful physical therapy and repeated insistence from
the clinic’s orthopedist that she just needed “more time,”
Ms. Ramirez’s physical therapist noted that the continued pain was
not “normal.” Another patient at the physical therapy clinic
suggested she go see 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.
“At my first appointment with Dr. Sah, I was amazed at the difference
in the way he and his staff treated me,” she notes. “Dr. Sah
reviewed all the x-rays, MRI and surgical photo images that I brought
with me and took additional weight-bearing knee radiographs – the
equipment was right there in his office. He said there was no cartilage
left in my knee and that I needed a total knee replacement. When he showed
me the images, even I could see what he meant. He was so clear in explaining
things and didn’t talk over my head.”
Because Ms. Ramirez had to delay taking time off work until her work schedule
was not as busy, Dr. Sah gave her cortisone injections in both knees to
alleviate the pain in the interim.
“My right knee had been compensating for the left knee,” she
explains. “October and November were pretty painful, but I knew
there was hope. Whenever I called or went into Dr. Sah’s office,
he was so attentive and gentle. He provided me with a binder of pictures
and instructions that explained all the pre-surgery and post-operative
instructions. Then two weeks before the surgery, my husband and I went
to my pre-op appointment, where they did all the necessary lab work, followed
by a pre-operative class taught by a nurse, occupational therapist and
a physical therapist – just a few members of the staff that would
be part of my post-operative care.”
The actual surgery took place on December 16, at 11 a.m., lasting about
an hour. One of the most experienced joint replacement surgeons in the
Bay Area, who recently was named “Best of Fremont” Orthopedic
Surgeon and Best Doctor (by the Fremont Bulletin newspaper), Dr. Sah chose
a newer, “personalized” knee implant for Ms. Ramirez.
“I used an implant that offers more sizing options to better match
the patient’s 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, again to 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
Ms. Ramirez woke up in the recovery room and stayed there for about an
hour before being transferred back to her room in the IJRR.
“There was no pain,” she remarks. “On a pain scale of
zero to 10, the pain was zero! The staff was very attentive, listening
to me and making sure I was as comfortable as possible. All of the people
there are so patient-focused.”
Dr. Sah had another innovative idea for improving her 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 three-day
hospital stay. The standard practice had been 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
a new injectable, long-lasting local pain medication instead. With the
injectable pain medication patients can feel their legs, so they have
better motor control and can safely be mobilized faster.
“I’ve worked with many colleagues who are among the leaders
in joint replacement surgery, going to 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.”
Vicky Feng, PT, was the physical therapist who got Ms. Ramirez up to walk
for the first time.
“I walked with Kathi just before 8 p.m. the evening of her surgery,
and she did really well,” Ms. Feng says. “When Dr. Sah requested
the change in protocol, we started doing it the first week of December,
with some skepticism. But we quickly appreciated how well patients do
with it, and it is now our preferred method. He is very progressive and
is always looking for ways to improve our patients’ experiences.”
On the first night after the change in protocol, Dr. Sah jumped in and
helped the physical therapists, walking patients that night.
“I was taken aback by his willingness to stay late and help get the
patients up, even after a full surgery day,” Ms. Feng admits. “It
just illustrates how committed he is to his patients and his new protocol.
Dr. Sah is exceptional in the care of his patients. He’s obviously
Ms. Ramirez was delighted to be able to walk the same day as her surgery.
“When the physical therapist came in and asked if I wanted to try
to stand, I was surprised,” she says. “She helped me up, with
no problem at all, and had me take a few steps to the left and the right.
Then, later that night, the staff helped me walk to the bathroom. I couldn’t
believe what I was experiencing. Whenever I woke up, I was expecting pain
– it wasn’t there. The injection of long-lasting pain medication
worked unbelievably well.
“The next morning, another physical therapist came in to escort me
to physical therapy class,” she adds. “I used a walker to
go down the hall to physical therapy and then back to my room afterward.
Then a nurse came in and said they were preparing my discharge papers.
Dr. Sah told me, ‘You’re doing so well that there’s
nothing we can do here that you can’t do at home with the help of
your husband and visits from the home physical therapists.’ I absolutely
preferred the idea of going home the next morning after surgery, rather
than staying in the hospital for three days – I would get to sleep
in my own bed!"
Since the change in protocol, roughly 70% of Dr. Sah’s total knee
replacement patients have been able to go home the day after surgery,
ranging from 48-84 years of age. However, not every patient is a candidate
for next-day discharge. The patients’ medical condition, motivation,
and support at home are important factors. Thus far, Dr. Sah’s patients
have preferred his rapid recovery program citing a faster overall recovery.
“My range of motion was great, and so was the pain management,”
says Ms. Ramirez. “I’ve told my story to other people, and
they can’t believe I went home 25 hours after surgery – they
think I must have slept through a couple of days. When I went back to
the same physical therapy clinic where I had gone after my previous surgery,
they were amazed at the difference. Within two weeks, the wound was healing,
and I had full range of motion. I was at the same stage where many other
patients are at six to eight weeks.”
When asked about her overall impression of her knee replacement surgery
and Dr. Sah’s new protocol for walking patients the same day as
surgery, Ms. Ramirez responds, “I’m sure there’s an
adjective to describe it – empowering, effective, respectful, extraordinary?
I probably should pull out a thesaurus to find the right terms, but I
guess I would start with joy and gratitude.”
To help people in the community learn more about treatments for knee pain,
including partial and total knee replacement surgery, Washington Hospital
is sponsoring a free seminar on Friday, May 1, from 3 to 5 p.m. The seminar
will feature a presentation by Dr. Sah, followed by a question-and-answer
period. To register for the seminar, which will be held in the Conrad
E. Anderson, MD Auditorium at 2500 Mowry Avenue in Fremont, visit whhs.com/seminars
or call (800) 963-7070.
For more information about Washington Hospital's Institute for Joint
Restoration and Research, visit www.whhs.com/joint-restoration/.