Total Knee Replacement Restores Woman's Mobility

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 knee.”

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 very dedicated.”

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.”

Learn More

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/.