Complication

Stubbornness inflicts more pain at my age.

While prepping the Folly for "tenting"--that's how you get rid of termites in Florida--I carried a batch of fairly heavy scalloped concrete edgers from the front yard to the shed in the back wearing flat shoes with no support.  My right heel began to hurt almost immediately but I soldiered on, just as I did several days later when I walked half a mile in flip flops to use a remote shopping mall restroom on our rainy return from Sarasota. Even driving was painful afterward.

A month later I still was limping around, even after substituting more swimming for the five-mile walks I usually took three times a week.  I finally made an appointment to see John Levin, DPM, a podiatrist.  X-rays of my right foot indicated both a bone spur and an inflamed Achilles tendon.  Dr. Levin, not quite a decade younger than me, prescribed a heel lift, stretching exercises and icing three times a day.

"I'm worried how this condition might affect a partial knee replacement if it lingers."

"You should be," he said, before rolling up his khaki pants to reveal what appeared to be several long, stitched incisions on his own right leg.  

"I'm three weeks out from a complete knee replacement," he announced proudly.  Skiing and biking had kept him in good shape.  He was already back at work and his movement wasn't noticeably impaired--at all!

"Wow, that's really encouraging," I said.  "When I mentioned my conditon to the orthopedic surgeon, he referred to it as a soft tissue injury and didn't seem too concerned."

"It's all connected, and if you're not able to walk easily before your surgery, it may interfere with your recovery.  Sometimes doctors are too focused on their own specialties."

I left Dr. Levin's office determined to follow his course of treatment rigorously for the next six weeks.

Primary Care Consultation

After Paul Goldstein, MD, my primary care physician in New York City for nearly 30 years, decided to go the "concierge medicine" route--don't get me started--I found one in Florida, Andrew Berkman, MD.  He had treated the twin sister of a former colleague who lived in Lake Worth and loved him.  More importantly, he met my two criteria in choosing an internal medicine physician:  he was Jewish and he practiced near my home, if only for three months of the year.

During our first consultation in 2021, I leveled with him.  "I'm looking for you to keep me in good health until I'm 75.  I don't plan on living much longer that."  If Dr. Berkman was shocked, he didn't let on but he got the message.  I haven't heard a peep from him about getting another colonoscopy, which I put at the top of my "Never Again" list when I turned 70, just above re-painting 47 Pianos.

I arrived for my annual visit with an agenda:  where should I have my right knee replaced, New York or Florida?  

"Ten years ago I would have told you to have it done in New York, but health care in the West Palm Beach area really has improved.  You probably can find an orthopedic surgeon just as good here," he said while entering some information into his computer. He pulled up the orthopedic surgeon listing for the Hospital for Special Surgery.  Little did he know I had done the same thing prior to my office visit.

After scrolling through the choices and noting the guy with the best local reputation, he zeroed in on John L. Wang.  "This is the guy for you," he recommended.

I'd already chosen him for a second opinion on the basis of his bio and his availability. My New York City dermatologist advised me to look for an affiliation with the University of Miami when seeking local health care.  Dr. Wang, who completed his orthopedic residency there, checked that box too.

I made an appointment as soon as I got home.

Family Consultation

Christmas in North Andover provided an opportunity to discuss a scheduled knee replacement with the people I consider family.

Joe, a pediatrician with a teaching gig at Harvard Medical School, is married to Magda, my goddaughter.  They have three children so we don't usually get a lot of adult time during my visits to their home in South Boston.  But we were tasked to pick up a couple of pies at Whole Foods while Magda drove the D-Kids to Tom's and Audrey's for Christmas in North Andover.

Joe's Graduation from Columbia Medical School

"I'm not an orthopedist but you've got to keep in mind that surgery is their bread and butter," he explained.  "The hospital probably lost money on your consultation.  Of course he's going to want to do the surgery there."

"Yeah, I get that.  But do you think I'm crazy to consider having the operation in New York mostly because I trust this guy after he replaced my hip?  His refusal to replace my knee eight years ago convinced me he's motivated less by money than by doing what's best for the patient."

"No, trusting your physician is only natural," Joe replied.

I also confessed that I had been feeling less knee pain since scheduling the surgery.  "Isn't that crazy?  Nothing has changed."

Joe smiled.  "Medicine still doesn't entirely understand the impact our minds have on our bodies.  You probably reduced a lot of stress just by making a plan to move forward."

He was right, of course.  Instead of imagining the worst case scenario--having to leave New York City--on a daily basis, I started to think more positively about the future.

Tom, Joe's father-in-law, and I go all the way back to Columbia.  We also share another, more relevant bond:  the same orthopedic surgeon at the Hospital for Special Surgery. Dr. Ranawat replaced both of Tom's hips; prior to the surgeries, he barely could walk. But both Tom and Audrey thought I was nuts to have my knee replaced in New York when I could just as easily do it in Florida through the same hospital.

"Does he know that you have to climb two flights of stairs?  That you grocery shop 20 blocks away from where you live?  That you ride your bike to do your laundry?  That you live with two other people in Florida who can help you recover?"

They wore me down.  I agreed to explore other options upon arrival at the Folly. 

Grin and Bear It

It's amazing what you can get used to.  I lived with occasional knee pain (~ level 5 on a scale of 10), mostly going up and down the stairs of my rent-stabilized apartment in Manhattan, for eight years.  Relocation to a ground-floor unit or a building with an elevator was never an option because a significant increase in rent would have had a negative impact on my already modest lifestyle.

But I'd also followed my orthopedist's advice, up to a point.  Not long after he suggested I move instead of replacing my knee in 2016, I bought a house in Florida with two friends. And he was absolutely right:  not much knee pain at all during my three snowbird months every year although the pandemic proved that if I resided at the Folly any longer than that I would go crazy.  Sunshine, ocean swims and flat surfaces do not feed the heart and mind, although the social benefits (and frustrations) of house-sharing cannot be denied.

Still, time catches up.  After returning to 47 Pianos last spring, the knee pain became more constant and debilitating enough to change my routine: instead of carrying my bike and up and down the stairs nearly every day, I left it locked downstairs, outdoors.  And once my knees occasionally started to buckle, I began to fear a fall bad enough that would leave me no choice but to give up the space where I had lived since 1978.

I scheduled another appointment with Dr. Ranawat at the Hospital for Special Surgery whose office seemed somewhat diminished, if not his brusque intensity.  He ordered X-rays for both knees and hips.  My hip had been replaced at the relatively youthful age of 57, at which time he told me that the ceramic prosthesis he had implanted generally lasted 10-15 years.  I was at the outer limit but he said everything looked OK, and I realized the estimated lifespan probably had more to do with the mortality of elderly patients than the durability of the hardware.

But the X-rays also indicated that the arthritis in both my knees had worsened.  Given my reluctance to move, he recommended a knee replacement.  "Some people with arthritis like yours that affects mostly the knee cap area opt for a partial knee replacement, but they're not always satisfied with the outcome," he said.  Without thinking too much about it, I shook my head no and insisted I would want a complete replacement and began peppering him with questions.

Question:  Will I be able to get up and down the stairs after surgery?

Answer:  Yes, we don't release you until you can walk up stairs.

Q:  How long will it take to recover?  Staying physically fit by swimming, biking and walking definitely contributes to my mental health. 

A:  Around three months before you'll be able to resume your regular activities.

Q:  Can I get both knees done at the same time?

A:  No, I don't recommend that.  Your recovery will be more difficult and a blood transfusion may be required.

Q:  How soon can I get the other knee done?

A:  Three months later.

Q:  Would it be better to do have the surgery in Florida where I don't have any stairs and there are people around who can help me?

A:  Not necessarily.  But if you want to go to Florida after the surgery, you can fly in three weeks.

Q:  I'm a single man without family who doesn't plan on being around much longer than five more years. Living in New York means almost everything to me. Will successful knee replacement surgery reduce the pain enough to avoid moving to Florida full-time?  

A:  It should.

Q.  Will my knees get worse without surgery?

A.  Probably.

Embarrassingly, tears welled up in my eyes during the final part of this exchange. Whether or not Dr. Ranawat and his fellow realized it, they were witnessing a depressed man making a very emotional, life-altering decision.  To their credit, neither reacted with discomfort although I easily could imagine a de-brief where each expressed his desire to get out of that consulting room before the unstable patient broke down completely.

I scheduled an appointment for April 30, two weeks after my planned return from Florida.

Here's the peculiar thing:  my knees didn't bother me at all while walking the two miles back home.  Just making the decision, I felt better than I had in weeks.

Early Knee Consultation

Almost exactly five years after he replaced one of my hips--so successfully I couldn't even remember that it had been on the right side--I returned to Amar S. Ranawat, MD, at the Hospital for Special Surgery in Manhattan complaining of knee pain.  "You have moderate-to-severe osteoarthritis in both knees," he diagnosed, after reviewing my X-rays.

Much to my surprise, however, Dr. Ranawat didn't recommend surgery.  "Knee replacement is a lot trickier than hip replacement," he advised, before asking me why I was in such a hurry to schedule it.  "Mostly because getting up and down the stairs of my apartment is a lot harder than it used to be," I replied, but also because I'm a sooner-rather-than-later kind of guy.

His follow-up surprised me:  "Why don't you move to another apartment without stairs?"

"I'm not going to give up my rent-stabilized apartment until I have to," I answered.

He gave me a corticosteroid shot before I left his office but it didn't do much to relieve the discomfort.

First Follow-Up Visit

January 27 had assumed the significance that last day of school had when I was a kid: restored to freedom.  So I wasn't happy when I awakened to 18" of snow and no bus service.

Still, I prepared for work as usual, even leaving at the same time to make my early appointment on East 77th Street.  Fortunately, the 86th Street transverse road under Central Park had been plowed and traffic was light at 7:30 a.m.  I trekked crosstown, snapping photos along the way.  The snow already had been cleared from the sidewalks in front of the apartment buildings on Fifth Avenue and the snow blown entrance to the Metropolitan Museum of Art was bathed in early morning light.

A lone technician manned the phones at the radiology clinic.  He couldn't believe that I had walked to my appointment just six weeks after hip surgery.  We chatted easily until enough staff had arrived to begin the day.  Another technician x-rayed my hip and I arrived at my 9 a.m. appointment with plenty of time to spare.

The resident who had enlisted me for an orthopedic study picked up several forms from me.  He answered a couple of questions that I couldn't wait to ask ("Can I go swimming now? Can I ride my bike?  Can I get rid of the elevated commode?") but assured me Dr. Ranawat would be in soon.

At 9:45 a.m. the receptionist finally heard from Dr. Ranawat, who was stuck somewhere on Long Island.  All appointments were cancelled for the day.  Tough luck GHI patients! He abandoned 3 of us.

I hadn't realized how much getting the all clear from my physician meant to me.  I really wanted an interaction with the guy that fixed me.   Speaking to the resident, or hearing from a woman who left a message on my answering machine this afternoon just doesn't do it.  "Your x-rays looked great.  You can abandon all your hip precautions and go back to work," announced Julie in a chirpy voice, not realizing that I had passed that threshold of recovery 3 weeks earlier.  More than anything, I wanted to walk pain-free without a limp in front of my physician and hear him tell me that my recovery has been as remarkable as I think it has.  That's something they should teach in medical school if they don't.

But as my first after-work swim at the Columbia pool in nearly 2 months proved, my recovery is just beginning in some respects.  My kick seemed a little . . . mechanical, and it felt like I was doing the breaststroke in concrete.  I swam just 30 laps instead of my usual 70.  On the plus side, my Speedo nearly covers the scar and being able to sleep on both sides of my body without a pillow between my legs was pure heaven!

Maybe my stamina and exercise routine will have returned to normal at my 3 month follow-up visit.  Let's hope Dr. Ranawat shows up this time.

Back To Work

This is what I tell people when they ask:  "The surgery was a success, I'm recovering very well, but only time will tell if replacing my hip solved the problem."  I still walk with a slight limp and some discomfort but Anna, my physical therapist, assures me this will go away.  I'm not convinced--knee pain suggests to me that I will need to have that replaced, too, before I'm completely back to normal.

An overweight, much younger colleague at the Health Department, who has had both her hips replaced, observed "the surgery must be less invasive than when I had it."  She couldn't believe that I was able to get around without any assistance at all.  I held my tongue.

The only bad thing about returning to work today was carrying my hip cushion on the subway.  I had planned to stand during the subway ride from 86th Street to Chambers Street because of self consciousness, but as soon as an end seat became available, I put the cushion down and sat on it.  I even got a seat going home.  Too bad if people thought I had a delicate ass!

Anna told me I should massage the scar on my hip as soon as the bandages fall off so that the tissue doesn't stick to the prosthesis.  That sounds a little strange, but the exercises she has been recommending are helping me build strength.  Over the weekend I tentatively began climbing stairs normally.  Today, I completely abandoned the method I have been using since leaving the hospital.

Anna also eliminated the tingle machine after tonight's therapy visit.  "We use it mostly for people who are in pain," she explained.  I didn't miss it at all.