Ken Monaco tore the meniscus in his left knee playing basketball a decade ago. It never healed quite right, so the retired U.S. Department of Labor criminal investigator decided a few months ago it was time for a total knee replacement.
Dr. Cindy Romanowski, a rehabilitation physician, prepared Monaco for the surgery and recovery. Her husband, Dr. Marcus Romanowski, an orthopedic surgeon, handled the replacement in late August at the 24-bed Kenmore Mercy Hospital Knee and Hip Center.
“I followed what they told me to the letter,” said Monaco, 60, of the Town of Tonawanda.
He and his wife, Karen, attended a class Cindy Romanowski has led for nearly two decades that lays out exercises to strengthen the muscles around the knee joint before surgery and provides detailed information about what to expect during the procedure and recovery. He left the hospital three days after surgery, did his physical therapy at home – with help from a hand-picked therapist Cindy Romanowski requested – and was cooking pizza for his family during a Bills game three weeks later.
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Cindy Romanowski estimated she’s replicated about the prep and recovery process about 10,000 times over nearly 20 years. She has written a new book so patients in other parts of the country can get a better handle on their surgeries, too. “A Patient’s Guide to Total Knee Replacement: How to Achieve Your Best Possible Outcome Through Preoperative Education and Planning,” is available in the hospital gift shop and online for $19.99 at amazon.com.
“When you know what to expect, the anxiety is lower. Care is getting more expensive and the only way to do it better is to take more of the care into your own hands. The guide can help you do that,” said Romanowski, who met her husband in medical school at the University at Buffalo in the mid-1990s. They live in Williamsville with their five children, ages 18, 15, 13, 11 and 7.
Q. Why is preparation and understanding the surgery so important?
Marcus: When you hit the ground running and come into the procedure knowing what you’re going to be doing each day you’re here in the hospital, then you make the most of every minute. You can get better faster.
Cindy: You want to recover as quickly as you can, not only because it’s better for your outcome but it’s also more cost-effective. By following the format, you can spend more preparation time on your own and you need less recovery time afterward.
Q. Who do you recommend read a book like this?
Cindy: Those who are going through surgery, and the caregivers, too.
Marcus: It’s a huge resource for whatever loved one is accompanying the patient because if you know the game plan then it’s easier to coach your spouse or your parent or your sibling through the procedure. This isn’t the only path to success with joint replacement but 85 percent of what’s in that book is the core makeup of all successful paths. ... Any good care plan will have these elements and it’s good if you know them ahead of time. Whether you’re in Seattle, Washington or had your surgery in Louisiana or Texas or Arkansas, the same principles apply. It’s all about the knowledge you’re going to need about the medications you’re going to need to take, the exercises you’re going to do, how you can protect yourself from complications, what you can do to prevent from becoming constipated. Making sure you’re not getting too much medication. No matter where you get your joints done, this helps.
Cindy: The surgeon is the technician who does the surgery. They don’t get into bowel movements...
Marcus: Is your daughter in town? Who’s going to be here with you after the surgery? There’s so many different facets. That’s another reason why the book is helpful. If the patients know the things in the periphery that help make their experience better and more comfortable and easier, then they can get themselves lined up ahead of time. There’s so many little things that there’s no no way your doctor in a 15- to 20-minute visit can give you everything ahead of time. They can’t. If they have a class, it helps. But if you have a resource ahead of time that says, “99 percent of happy patients have these 20 things lined up,” that’s it. You have the game plan, a formula for doing well.
Cindy: And you have a resource to flip back to. … I’m used to speaking the language of a non-medical person. My class is geared toward a level anyone can understand. It’s not like when I go to the garage for an oil change and they start talking about ball bearings and all this work that needs to be done. People are worried about narcotics these days and I have graphics about that.
Q. Does it answer the question, where do I go for a knee replacement?
Marcus: Pro Publica took all the Medicare data and sifted through it, so you can put in a hospital name and find the complication rate and the case volume for knee replacement surgery wherever you live. You can put in your doctor’s name for a knee replacement and it’ll tell you the volume of procedures that person did for Medicare and the complication rate. (Visit projects.propublica.org/surgeons.)
Cindy: You really want to go to a surgeon who does at least 50 joints a year and a hospital that does at least 200 joints. The hospitals that do less than that have a complication rate about four-fold higher.
Marcus: Medicare is trying to make sure that patients who have the ability to go home instead of to a rehab facility after surgery choose that path. Ultimately, that is the best path for most people. If you’re in your own environment, you’re going to get better faster. But some people can’t go home and you have to have sub-acute care. We’ve probably been sending a few too many people to rehab over the last few decades because of joint replacement because it’s more convenient, it’s easier, but it’s not cost-effective and it doesn’t necessarily give you a better outcome. Your functional ability is the number one goal but you want to make sure you get there in an efficient manner.
Q. How do folks get into the position to think about needing a knee replacement?
Marcus: They’ve had pain at least six or eight weeks and they’ve noticed it at least three days a week. It’s starting to impede their ability to do what they want to do, whether it’s go get your groceries or run the Turkey Trot.
Cindy: There’s an inability to straighten, difficulty driving – getting in and out of the car. Or previous knee surgeries. When I do my class, I start out with X-rays. I say, “This is a good knee X-ray and this is what you people look like. You’re having pain when standing, weight bearing, and the biggest thing is getting up from a seated position. The get up and go got up and went.” Some might have had a football injury 25 years ago. You had a cortisone shot and you did well for 10 years. Then you had an arthroscopy. The course can sometimes be like this. Hips generally are a downhill things. With knees, you have good days and bad days. When you start having more bad than good, though, you’re getting there.
Q. How important is it for someone to prepare for a knee replacement?
Cindy: When you’re having a hard time getting from a seat into a standing position, it’s not just because you’re having a knee problem. It’s also because your quadriceps muscles are weak. The most important thing you can do is strengthen that quadriceps muscle before surgery.
Marcus: You’re also preparing yourself mentally to take this on and you have a much greater likelihood of doing phenomenally well.
Cindy: Any patient who’s educated is going to do better. I have a lot of people who’ve got to worry about their pets, too. You have to be a forward thinker in terms of “Where am I going to be in one week?” “Where am I going to be in two weeks?” You have to do the exercises. Even doing 3 to 5 minutes a day will make you better off than doing nothing. People also want to be familiar with what their insurance covers. They might want to go to a rehab center. I hate this time of year because the new benefits are coming. Your plan might have paid for rehab this year but, whoops, it could cost $1,000 when the new benefits come out Jan. 1.
Q. Would the same principles hold true for a hip replacement?
Cindy: To a certain degree. A lot of the exercises are very similar. The bowel program, preventing infection are the same. But hip replacements are easier to recover from than knee replacements.
Q. What percentage of patients in your unit end up going home instead of into a rehab facility?
Cindy: Probably over half are going home. It has to do more with attitude than age or anything else. I have 85-year-olds, World War II generation people who don’t want to go into a nursing home. They’re afraid they’re not coming out. They have a cute spouse, or a daughter who comes in for a couple of days. Because they want to do it, they find a way. Then I have some people in their 40s or 50s who say, “My husband doesn’t want to take a week off, so I want to go to rehab.” You need to educate yourself and understand you’re going to be OK. You should be able to do this at home. We send support into the home – and it’s safe. As long as you know the signs and symptoms to look for, you take your care back into your own hands.
Q. How long does recovery generally take and what signs of improvement should be noted along the way?
Cindy: We usually have our patients in a formal therapy program two or three weeks after surgery. A lot of the recovery takes place in the first couple of months but I’ve had a lot of patients tell me it can take up to a year before they’re feeling 100 percent.
Q. How long can someone reasonably expect a joint replacement to last?
Cindy: Twenty years. That’s why you don’t want to do it under 50.
Marcus: Average age for joint replacement in the U.S. is about 64. When I was a resident, it was very rare for anyone under 60 to get a joint replacement but the thinking on that has changed somewhat because that resulted in a lot of people losing a lot of productive years. You do see people in their late 40s, early 50s with terrible arthritis. They will benefit from a joint replacement. And I’ve had patients in that age group who have had surgery that has allowed them to continue working. Genetics can be cruel but it’s like a bell curve. At the extremes of the spectrum, you see people in their late 30s or early 40s and you see people, rarely, who will benefit from joint replacement surgery in their early 90s, but the vast majority are in their 60s.
Q. What percentage of surgeries do you do that are a second joint replacement?
Marcus: Only about 15 percent of the joint replacement that get done get redone. The vast majority of patients take that joint with them when they go.
Cindy: A technique that my dad (orthopedic surgeon Dr. John Repicci) perfected, a partial knee replacement, is for people with limited arthritis. We can try to do that in a younger person because it’s easier to revise that (into a full knee replacement).
Q. How can a friend or loved one best help someone who is planning or recovering from a knee replacement?
Cindy: Stop over. Give them a call. Go for groceries once a week. That’s the level of care that most patients require.
Marcus: One of the reasons the book is so important is that you have to set your expectations for the procedure and the recovery ahead of time. Physicians have to do a good job helping patients set what those expectations should be. On the internet, everything happens instantaneously but recovering from joint replacement surgery is a process. There are certain things you can’t rush and certain things you have to do along the way. If your family is aware of the process and the key steps, they can remind the patient, “This isn’t a 6-day horizon line. This is a 6-week horizon line, so don’t get discouraged."
Twitter: @BNrefresh, @ScottBScanlon