The flesh of the knee was sliced open about a foot up the mid-thigh to expose the bony femur. Wearing full body covered hazmat space suits to protect them from the splatter and the patient from their breath, the two surgeons and the operating nurse were huddled around the patient as the calf and knee were being flopped around like a limp jelly fish.
This was orthopedic surgery and I was in for a ride.
I had missed the first incision, having taken my lunch break after my morning of observation of an abdominal aortic aneurysm, so when I walked into the operating room, the procedure had already begun. And by the looks of it, it had progressed along nicely.
The patient himself was young, only 24 and a victim of osteosarcoma, or bone cancer. He had a tumor the size of a baseball on his knee. Five to ten years ago his diagnosis would have warranted a total knee amputation, but on this day he was receiving a total knee replacement. The plan was to take a biopsy of the femur high enough and check for cancer cells, if the pathology lab confirmed that the bone was cancer free, then his femur would be chopped and a new titanium knee would be inserted to replace the cancerous bone.
Next to the surgical table was an array of prosthetic knees of varying sizes tools, saws, hammers, and unknown sterile gadgets ready for the surgeon’s disposal. I learned that prior to inserting the patient’s new knee they would insert a tester, to fit for size. After the size was right, then the permanent knee would be inserted. The tester had been in the open leg of hundreds of prior patients; it has since been washed and sterilized of course.
The grinding of the saw on the bone moved surprisingly fast, but it is hardly clean. As the little chips of bone go flying this way and that, the necessity of hazmat suit becomes immediately apparent. Despite the flying bits of blood and flesh, surprisingly bone can be cut quite neatly when the proper tool is used.
The hunk of knee and femur came off like an apple plucked from a tree. A very bloody tree.
It was placed in a tray and inspected by the surgeon. The surgeon didn’t like what he saw. There was a large artery running off of the cancerous tumor. From the words of the surgeon’s mouth “this is bad.” It is an indication that although the cancerous bone was completely removed from the patient’s body and now sitting in a tray on a table three feet from him, outside of his body, there was a very high risk that rouge cancer cells were flowing through his blood and most likely would set up metastatic shop in the lungs. Bone cancers don’t metastisize as often as other cancers; the surgeon said that this was the first case like this he had seen in 12 years.
Poor guy, only 24 and receiving a total knee replacement. Now this.
The surgery progressed despite the finding. The perfectly uncancerous tibia had it’s top chopped off to make way for the implant of the artificial knee. More sawing and grinding. The empty cavity of the lower thigh flopped this way and that. The lower calf and foot were connected by skin, muscle, and hope. The marrow was sucked out to clean the bloody flesh. The surgeons walked back and forth tracking blood throughout the room. In went the tester, more drilling and hammering, and chinking away at bone. Orthopedics has a sculptured art to the skill. Once the size was right the permanent knee was cemented in, all shiny and robotic. A few tests of the hinge and then the muscle and flesh are folded over the knee to let healing run its course.
I follow the patient to the post anesthesia care unit to await his awakening. We monitor his breathing and the beating of his heart as he dazes in and out of awareness. About an hour later he begins to have some lucidity but he doesn’t feel anything in his legs. I don’t want to know what he’ll feel when he finds out about his risk for lung cancer.
