3 Years Later, Knees Made for Dancing

The question most often asked by longtime readers and acquaintances I haven’t seen for a while is, “How are your knees?”

They recall the columns I wrote in February 2005, three months after having both knees replaced, in which I described the unexpected, prolonged and poorly treated postoperative pain and the surprising length of time before I could resume normal activities.

Some readers may also recall the “one-year later” column relating my return to long walks and ice skating, and the ability to stand for hours without pain. I’m happy to report further improvements.

I’m dancing again, and in March 2007, I hiked in Tasmania and walked all over Sydney, up and down hundreds of steps, for many hours each day with no knee or leg pain. This past March, I toured Vietnam by bicycle, riding as much as 35 miles a day over hot, dusty roads without pain.

But the truth is that artificial knees, while certainly an improvement over severely arthritic ones like mine, are not like normal, healthy knees. There are limitations inherent in the devices and surgical techniques that most surgeons use. Although a vast majority of patients ultimately fare really well, in some cases the device fails or there are lasting injuries to internal tissues.

Studies of many hundreds of patients with total knee replacements show potential problems surgeons may fail to mention in advance. “What we as health professionals tell patients preoperatively isn’t always what they need to know,” Ann F. Jacobson of the Kent State University College of Nursing said in an interview.

Managing Expectations

Dr. Jacobson and her colleagues studied the preoperative and short-term postoperative experiences of 27 patients undergoing total knee replacements. Writing in the May issue of The American Journal of Nursing, they concluded, “Patients need to be better educated and supported before and after total knee replacement surgery.”

The researchers found that many people delayed the surgery for months, even years, “despite increasing pain and limitation” and difficulty maintaining their independence. Postoperatively, the main issues for patients were pain, difficulty with the activities of daily living, and the time it took to recover their independence.

“Patients really struggled with having to be a bother to others,” Dr. Jacobson said. “They need help beforehand in learning to let go temporarily of their independence and accept the fact that they’ll need help after the surgery.”

Perhaps the study’s most important finding is that patients are often told that they will be at a certain level of recovery in a certain length of time, which often leads to unrealistic expectations, Dr. Jacobson said, adding, “Everyone heals differently, and there’s no one prediction that can apply to all patients.”

For example, I had been told that I would be driving in four weeks when I still wasn’t ready to drive in eight. And I needed potent pain medication for four months to fulfill the demands of my professional and personal life.

What about the long-term results, years after the surgery? These are some facts that patients might like to know:

¶Kneeling is problematic. It can hurt to put weight on metal knees, even on a cushion, making activities like gardening a challenge.

¶Falling on an artificial knee, even banging it on furniture or a briefcase, can hurt a lot more and longer than you might expect.

¶Going down steep steps can be difficult and may require a sideways, one-foot approach. A normal knee bends at an angle of about 145 degrees, but replaced knees often achieve only 120 degrees, if that. Sitting on the floor cross-legged may be impossible.

¶Despite the passage of time and many months of physical therapy, there can be residual discomfort. I “feel” my knees on every rotation of the bike pedals, though the sensation is not what I would call pain and not enough to stop me from riding.

¶Most artificial knees are metal and set off the security alarm at airports, requiring a personal scan with a wand. This may be moot when new body scanners are in all airports.

¶Some patients require a surgical revision within two years of a replacement because of technical problems like instability or poor alignment of the new joint.

As one surgeon reported in 2005, 52 percent of knee replacement patients experienced functional limits, versus 22 percent among other people their age. Those limits included problems in kneeling, squatting, moving laterally, turning and cutting, carrying loads, stretching, leg strengthening, sex, playing tennis, dancing and gardening.

In a British study of 4,677 total replacements 10 years after surgery, 80 percent of the replacements had met patients’ expectations. Still, 30 percent of patients had a problem, 12 percent needed a revision within the decade, 22 percent had constant or regular pain, and 13 percent had severe pain.

In a study in the United States more than six months after surgery, just 35 percent of patients were able to do all they wanted to and only 13 percent had no restrictions on activities. In another American study, a third of patients were dissatisfied with their operation 6 to 12 months later. As one surgeon, Dr. Pieter H.J. Bullens, put it, “It appears that surgeons are more satisfied than patients after total knee replacement.”

New Designs

Some orthopedic surgeons are using new equipment and techniques that can improve the success of knee replacements and minimize the risk of complications.

One new design, the Triathlon knee, results in quicker recovery and return to function, according to surgeons who have used it.

Other surgeons use computers to help them properly place and align the artificial joint. Still others, like Dr. Peter M. Bonutti, who runs an orthopedic clinic in Effingham, Ill., and is an associate clinical professor at the University of Arkansas, have adopted a less invasive technique. It uses smaller surgical instruments and creates a smaller incision, reduces trauma to soft tissues and avoids moving the patella, or kneecap, during the operation.

Among 24 patients who had both knees replaced using the new technique, Dr. Bonutti reported that there was an early advantage of less pain, much less need for narcotics and quicker return to function, even for patients who were seriously overweight or out of shape. One older man said he went dancing the day he was discharged from the hospital and has been dancing ever since.

In a follow-up study two or more years later of 166 patients ages 41 to 94, including 25 with double knee replacements, 97 percent were functionally excellent, Dr. Bonutti reported in 2005. Six knees needed minor manipulations under anesthesia, and five patients required reoperations, which he said occurred “early in our learning curve.”

My own bottom line? My new knees are a significant improvement over what I had before. I’m not at all sorry I had the surgery, and I’m glad I did not wait until I could not walk unassisted.

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Heavy marijuana use shrinks brain parts: study

By Will Dunham

WASHINGTON (Reuters) - Long-term heavy use of marijuana may cause two important brain structures to shrink, Australian researchers said on Monday.

Brain scans showed the hippocampus and amygdala were smaller in men who were heavy marijuana users compared to nonusers, the researchers said. The men had smoked at least five marijuana cigarettes daily for on average 20 years.

The hippocampus regulates memory and emotion, while the amygdala plays a critical role in fear and aggression.

The study, published in the American Medical Association's journal Archives of General Psychiatry, also found the heavy cannabis users earned lower scores than the nonusers in a verbal learning task -- trying to recall a list of 15 words.

The marijuana users were more likely to exhibit mild signs of psychotic disorders, but not enough to be formally diagnosed with any such disorder, the researchers said.

"These findings challenge the widespread perception of cannabis as having limited or no harmful effects on (the) brain and behavior," said Murat Yucel of ORYGEN Research Centre and the University of Melbourne, who led the study.

"Like with most things, some people will experience greater problems associated with cannabis use than others," Yucel said in an e-mail. "Our findings suggest that everyone is vulnerable to potential changes in the brain, some memory problems and psychiatric symptoms if they use heavily enough and for long enough."

Among the 15 heavy marijuana users in the study, the hippocampus volume was 12 percent less and the amygdala volume was 7 percent less than in 16 men who were not marijuana users, the researchers said.

The researchers acknowledged that the study did not prove it was the marijuana and not some other factor that triggered these brain differences. But Yucel said the findings certainly suggested marijuana was the cause.

"STONED" FOR 20 YEARS

While about half of the marijuana users reported experiencing some form of paranoia and social withdrawal, only one of the nonusers reported such symptoms, Yucel said.

The heavy marijuana users, average age 40, said they had used other illicit drugs less than 10 times, the researchers said.

A U.S. group supporting legal sales and regulation of marijuana took issue with the findings, particularly because they were based on men who were such heavy, long-term users.

"These were people who were essentially stoned all day every day for 20 years," Marijuana Policy Project spokesman Bruce Mirken said by e-mail. "This study says nothing about moderate or occasional users, who are the vast majority -- and the (study) even acknowledges this."

"The documented damage caused by comparably heavy use of alcohol or tobacco is just off-the-charts more serious, and you don't need high-tech scans to find it," Mirken added.

Yucel said the researchers have begun new research on the effects of both short-term and long-term and moderate and heavy use of marijuana.

(Editing by Maggie Fox)

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After livers, cash to UCLA

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Japanese Police

Tadamasa Goto received a life-saving liver transplant at UCLA Medical Center. Goto is one of Japan's most powerful gang bosses, which experts describe as vindictive and at times brutal.

A Japanese mob boss and another man said to have gang ties each donated $100,000 after their transplants. The university said the gifts had absolutely no bearing on the surgeries.

A powerful Japanese gang boss who received a liver transplant at UCLA Medical Center donated $100,000 to the Westwood hospital shortly after the surgery, The Times has learned.

A plaque dated November 2001 at the entryway to a seventh-floor surgery office reads, "In grateful recognition of the Goto Research Fund established through the generosity of Mr. Tadamasa Goto."
UCLA confirmed the amount of the donation Friday. Law enforcement sources say Goto, 65, is the leader of the ruthless Goto-gumi gang. He received a transplant at UCLA in July 2001, The Times reported Thursday. He made his donation less than three months later.

UCLA also acknowledged that it received a separate $100,000 donation from another man who figured in Thursday's story. He donated in 2002, the year of his transplant.

The man was identified by a law enforcement official as one of four Japanese men now barred from entering the United States because of their suspected gang affiliations, criminal records, or both. All four received new livers at UCLA between 2000 and 2004, The Times reported.

The Times is not naming the second donor because it has not been able to reach him or his lawyer about the law enforcement assertion. Japanese police do not generally make public information about gang affiliations.

UCLA spokeswoman Dale Tate said the university had "no reason to question" the source of the money given by Goto or the other donor. Both donations were deposited into the Department of Surgery's Discretionary Fund, she said. When asked if the money had any bearing on the men's transplants, Tate said: "Absolutely not."

In a written statement, Tate said the surgery discretionary fund was used to support research and education for the liver transplant program.

UCLA's actions drew attention Friday from a leading U.S. senator and mixed reaction from doctors and transplant professionals.

The surgeries took place at a time of persistent shortages of donor livers. In the year of Goto's transplant, 186 patients on the list for livers died while waiting for the operation in the greater Los Angeles region.

U.S. transplant rules allow hospitals to provide organs to patients with criminal histories and to a limited number of foreign patients, but both topics have been controversial. News that UCLA had provided livers to foreigners barred from the country generated considerable comment Friday.

Sen. Charles Grassley (R-Iowa), who has considerable influence on federal health policy and an interest in transplant oversight going back several years, said he was "worried about the credibility of the transplant system" and would demand additional information from the university.

If the transplant system "doesn't have credibility, we're not going to have people donate organs," said Grassley, the senior Republican on the Senate Finance Committee, which oversees federal hospital funds. "I think I have to get to the bottom of things."

Some said they worried the surgeries would discourage people from donating organs; others said that there are so few transplants going to either foreigners or criminals that it should have no effect.

All four of the transplants were performed by Dr. Ronald W. Busuttil, executive chairman of UCLA's surgery department, according to a person familiar with the cases. Goto's lawyer, Yoshiyuki Maki, previously confirmed that his client received a transplant at UCLA and that Busuttil subsequently examined Goto in Japan. Neither Maki nor Goto could be reached for further comment Friday.

Goto had been prohibited from entering this country before his transplant, but the FBI agreed to help him get a visa in exchange for information on potentially illegal activities in the United States by Japanese gangs, commonly known as yakuza, a former FBI official said. Goto provided little information of use, he said.

There is no evidence that UCLA or Busuttil knew at the time of the surgeries that any of the patients had a criminal record or ties to the yakuza. Both said in statements earlier this week that they do not make moral judgments about patients and treat them based on their medical need.

Busuttil, a world-renowned surgeon and co-editor of a leading text on liver transplantation, said in his statement that he considers it "part of my responsibility and obligation as a physician" to ensure that his patients receive proper care whether in the U.S. or abroad.

Busuttil declined to comment Friday through his attorney, citing federal patient-privacy laws.

It is not uncommon for transplant recipients or other grateful patients to donate money to hospitals after receiving life-saving medical care. Businessman Robert A. Day and his wife Kelly, for instance, donated $30 million last year to the UCLA Department of Surgery to express their gratitude for his liver transplant two years earlier.
Even so, Arthur Caplan, a bioethicist at the University of Pennsylvania, said hospitals have a responsibility to inquire about the source of their gifts.

"It starts to defy credulity that you're not going to be curious about who these people are, if only to ask them for more money down the road," he said. "Any development officer who didn't follow up a $100,000 gift with a check of who this guy is and who his friends are would be an ex-development officer."
Wealthy foreigners, he added, are attractive to transplant programs because not only do they pay the full cost for their procedures, but they often make gifts of gratitude later.

Dr. Joseph Tector, chief of transplant at the Clarian Transplant Institute at Indiana University, defended UCLA's actions. The occupations of his patients are not relevant, he said.

"As doctors, you are not a member of the clergy to ascertain someone's worthiness," he said. "You don't want to discriminate. These calls don't come so much into questions with other procedures. But with livers, the water is muddied because not everyone can get transplants. There aren't enough livers. "

But Dr. David Mulligan, a liver transplant surgeon at the Mayo Clinic in Phoenix, took issue with UCLA's statement that it does not make moral decisions when it adds patients to its transplant waiting list. He said transplant professionals make such decisions every day.

"By saying that we don't impose any kind of a moral judgment on people is not entirely complete," he said, "because I think that every transplant center has members of the [selection] committee who are social workers and financial aid advisors and psychiatrists who are intensely involved in the estimation of every potential recipient and their ability to progress with a full and long-standing recovery."

"I don't think that transplant centers can turn a blind eye to patients' social histories and their backgrounds," he said, adding that his center has run criminal background checks on some American patients about whom it has questions.

Transplant rules give hospitals and doctors the final say on which patients get added to their waiting lists, and they have the discretion to refuse patients with unhealthy lifestyles that could compromise the transplant's success. Patients may be refused on other grounds as well, including an inability to pay.

One L.A. doctor said he believes that UCLA's reputation as a first-class transplant center will suffer from the news of the four transplants.

"It's going to have a real negative effect," said Dr. David Boska, an internist in Brentwood who says he has referred 10 patients to UCLA over the last decade. "Their interest is to make sure people know they have a first-rate program. This isn't going to help."

Boska, who said he is a friend of Busuttil, added: "I have lost faith in the system, not the program," he said.

"You have a brother who dies because he doesn't have $500,000 to spend on a liver. That's a terrible thing to think about. Then you learn that we have foreign criminals who come in and get livers. That's not good.

"But it's terrible thing that we don't have any guidelines. We should have them. We have all these people dying in Los Angeles."

charles.ornstein@latimes.com

john.glionna@latimes.com

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