When the weather warms this spring, Mary Saunders of Hackettstown hopes to go bike riding with her grandchildren—something she’s been unable to do for a long time. Last fall, the 64-year-old office manager underwent a knee replacement operation—a procedure common in her age group—and she credits her new mobility and freedom from pain partly to an innovative medication method that makes life easier for people getting new joints.
Saunders’ journey has been a difficult one. Over the years she developed arthritis in her right knee, and two years ago she took a fall. “That’s when everything started to go downhill,” says the mother of five and grandmother of four. “The pain became worse and worse.” Arthroscopic surgery didn’t help, and when she asked one doctor why it hurt so much she was sent to see a rheumatologist— who then contended that her problem was more orthopedic than rheumatologic, because it had to do with damaged bone and tissue. The confusion ended when she received a recommendation from her brother, who’d had reconstructive ligament surgery performed by Michael Rieber, M.D., an orthopedic surgeon at Saint Barnabas Medical Center.
“That’s when I decided to see Dr. Rieber,” she says. And Dr. Rieber told her it was time for a knee replacement.
“She really had the typical arthritic knee story,” the doctor recalls. “Pain in her joint, difficulty walking, pain going up and down stairs, even trouble just getting comfortable at times. She was losing range of motion, her knee was showing signs of deformity, and it made the typical arthritic crunching noise. And she’d already tried conservative management therapies such as medications and physical therapy.”
However, joint replacement is a complex operation, and it can involve a lot of pain. “These surgeries hurt,” Dr. Rieber says matter of fact. “We are always looking for better ways to control pain and improve function.” And he thinks he has found a better way: injecting a pain-killing medication right into the open knee cavity just before and after the new knee is implanted.
The usual pain control protocol in joint replacement is a femoral nerve block, which stops the main nerve in the leg from transmitting pain signals to the brain during the operation. That takes care of pain, Dr. Rieber says, but it also impairs motor function after the surgery. “Patients may fall, break their legs or tear open their wounds.” The nerve block is also combined with narcotics. “Those can make you nauseous, constipated, dizzy and so loopy that they also prevent functioning and slow the rehabilitation process.”
The better way, he says, is with a painkiller called bupivacaine (trade name Exparel). “It is basically a long-acting Novocain,” he says, referring to the numbing agent dentists’ use. But this medication lasts up to three days, typically the entire length of the hospital stay after replacement surgery. “The first few days are the worst for any surgery,” Dr. Rieber says. “Every day afterward brings improvement, and once the first few days have passed, there may be some pain, but many patients have very little. “Here’s how it works: The patient is given a spinal epidural to numb the entire lower body. A light anesthetic is also administered to help him or her sleep through the procedure—but not a general anesthetic. Dr. Rieber opens the knee and removes the diseased joint. He then makes one injection of the Exparel into the tissue at the back of the knee. Once the new knee is implanted, he makes several more injections all around the knee, and then closes the wound. Saunders, who had her knee replacement in October, says that her recovery this time was far easier than it was following the general anesthesia she’d had in her earlier knee arthroscopy procedure. “There was no comparison,” she says. “This time I just needed a little Advil for a while.”
That evening she was sitting on the side of her bed, and the next day she was walking and starting orthopedic rehabilitation therapy. And that is a critical component of successful joint replacement. “We need to control pain or patients won’t rehab,” says Dr. Rieber. “That’s why pain management is paramount; it’s the whole procedure right there.” The rehab program of various exercises is “awesome,” Saunders says. “I was amazed at how well I was able to do.”
She continued physical therapy at home, but just a week after the surgery was able to fly to Florida for a funeral. In January she reported that she was “far better than I used to be. There is still some stiffness, but my range of motion is better and I’m walking better than I could before.”
Besides her bike-riding plans, Saunders is looking forward once again to going bowling with friends for the first time in years.
“I went around for too long with chronic pain, and I’ve learned it’s important to find out what the problem is and attack it,” says Saunders. “Dr. Rieber explained everything in detail—he doesn’t pull any punches. Before the surgery he told me he would get me to 100 percent, but I said, ‘We’ll see what happens.’ Already I can do many things I couldn’t do for a long time.”
“Not everyone is as fortunate in avoiding pain as Mary has been,” Dr. Rieber carefully explains. He sends his patients home with a narcotic painkiller prescription just in case, and some of them do need to fill it. “But she’s a champ, and this procedure has changed her life. This is why we go into this business—to help people improve the quality of their lives.”