Knee Surgery Anesthesia
An interview with Dr. John Everett conducted by PJ Ewing
This interview was complete three weeks after Dr. Everett’s knee replacement surgery. In the discussion Dr. Everett covers his two knee replacement surgeries, his work as an anesthesiologist, and various approaches to knee surgery anesthesia. Click on the Play button above to hear the interview.
About Dr. Everett
I’m an anesthesiologist in Lansing, Michigan. I’ve been here for 35 years. My story revolves around the fact that I tore the meniscus in my left knee in 1995. I was told in 10 years I’d need a knee replacement. I put it off. I had what’s called a microfracture in 2010. A repair bought me nine more years. Finally, I decided it needed to be replaced.
I had some experience before my most recent surgery because I had an acute injury on my right knee and had a partial knee replacement in 2017 which went well. Unfortunately, I’m in an old group of people and my business partners needed their hips replaced, so I had to put my left knee off until August 23rd, 2019.
In a nutshell: I’m bow legged runner and I ran and skied too many miles and my knees finally failed.
My Partial Knee Replacement
So it was time to have a partial knee replacement. I had the medial side, the inside of my knee, replaced as an outpatient at a surgery center. I checked in at 12:30 p.m. I was home at 4:30 p.m.. At home I had the X10 Knee Machine, which I nicknamed The Punisher because it hurts (just a little bit).
The big thing in knee replacement is range of motion. So I got my range of motion from 0º to 130º back in about seven days. The biggest thing is not the pain, it’s the swelling. That’s what you have to work on. At three weeks, at the time of this writing, the swelling is gone.
That’s my story. I just push it a bit, not too much, on the X10. Yesterday, which was almost three weeks out, I finally realized I was walking up and down the stairs normally.
I had a double block called a “quad sparing femoral nerve block.” And then a block behind the knee. So when I came home from surgery I had zero pain, which is fake and led me to do too much the next day. I had surgery on a Friday. I was doing yard work on Saturday because I had no pain and the swelling didn’t hit yet. But I’m a bit crazy. The pain regimen we use is a multimodal therapy. We use Celebrex, Neurontin, and Tylenol upfront. I had a Norco and Tramadol, which are both narcotics and had a couple of pills of Dilaudid. It got really bad at night for the first three nights. In the daytime it was easier: you’re distracted by moving a lot more during the day.
They gave me a bunch of pills. I’ve taken about a third of them. I’m down to just the Celebrex in the morning with aspirin to prevent deep vein thrombosis. I had physical therapy come to my home for four visits, but I was already walking, moving, driving and shopping,
I don’t know what the physical therapist is doing for me. Other people might need more. The X10 was three times a day for the first 14 days. And then I cut back to just the morning to get my range of motion fired up. I didn’t need it after that. I kept it for a week more than I should have. Maybe three weeks just because I didn’t know what else to do. At two weeks I didn’t know I’d make three weeks, but today I went bicycling on the spin bike, and went to the Mac (gym facility) and worked out. And that’s that.
All About Knee Surgery Anesthesia
General vs. Regional Anesthesia
I’ve been in practice since 1983. When I left my residency, regional anesthesia was the way to go on total joints. But I went to work at a hospital where the surgeons preferred general anesthesia. Then about eight years ago they decided, well, there’s too much evidence that regional anesthesia, spinal, for example, to numb you from the waist down is better for recovery and decreasing clotting problems like pulmonary embolus and deep vein thrombosis. So we’ve gone back to doing almost all of our total joints with spinal anesthesia. And we’ve gone to a phase of what’s called multimodal anesthesia analgesia, which is using more than narcotics. So all of our total joint patients get Celebrex, which is a nonsteroidal Tylenol.
And then we load patients with Gabapentin, which is a Neurontin type drug that blocks some other stuff. And then, for example, my total knee, I had a double block called a quad sparing femoral nerve block, which blocks the front of the knee. And then I had what’s called an iPACK. It’s really cool. It blocks the pain in the back of the knee. So I had that done on my outpatient surgery and I had 36 hours of no pain, which is good and bad. Like I said before, I maybe did too much because the day after my knee replacement I was doing yard work because my block was still working.
How are these drugs administered?
A spinal anesthetic is inserted in the spine. We turn you on your side, we poke you in the back. We put a little bit of local anesthetic in the cerebral spinal fluid and it will numb you from the waist down for about four hours. Then we do the other blocks at the knee level, so once in the middle of the thigh and the others behind the knee.
The spinal is a standard procedure. We do not use a long-acting local in most blocks except, for example, like me when I had mine as an outpatient. We just use regular local, which gives you about 18 hours of pain, free work. The big thing in total joint rehab is to get up and be mobile. The reason we do this quad sparing femoral block is so you don’t lose the strength of all those quad muscles. You can be up and ambulatory in a hurry. I actually walked out of my surgery, and got in my car. They gave me a walker: I put it in the trunk and that was the last time I used it.
You have to reeducate your muscles with a knee replacement because your muscles do not want to move. I was told by my physical therapist that you can’t flex your knee much cause your quad muscles in the front and go, “no, no, I’ve been injured you, you can’t do that to me.” With the X10 you sit there and relax and it can do what you can’t. My physical therapist said, “I can bend your knee way more, but you can’t do it yourself because the quad muscles on the front won’t let you bend anymore.” After all, the body knows your knee is injured.
“The Anesthesia Cocktail”
How does it differ from hospital to hospital, state to state, region to region?
It should be almost standard across all hospitals. There are some mixes. Some people will not use a long-acting local for the peripheral nerve blocks we do, it’s a drug called XPRL. I use the spinal standard. So the blocks are standard. It just depends on what drug you use.
I guess I just refuse to fail. I had the advantage of having my other knee done already so I knew what to expect. I work for myself, so I do have an enticement to get back to work. And I don’t think in two weeks I lost any strength.
I still want to ski so I didn’t want to give up my whole knee and all those ligaments. I’ll be out biking this weekend. I can hardly wait to start running again. I’ve put off running for eight years. I want to play tennis again. And I’ll be able to do all of that.
The X10 Meta-Blog
We call it a “Meta-Blog” because we step back and give you a broad perspective on all aspects of knee health, surgery and recovery and such subjects as knee surgery anesthesia.
In this one-of-a-kind blog we gather together great thinkers, doers, writers related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. Whether you have a surgery upcoming, in the rear-view mirror, or just want to take care of your knees to avoid surgery, you should find some value here. Executive Editor: PJ Ewing (firstname.lastname@example.org)