My Cyborg Spouse

by Doctor Science

On Wednesday my husband D had both his old knees replaced with new, shiny robot knees. I am now married to a cyborg.

We can rebuild him. We have the technology. We can make him better than he was. Better...stronger...faster.

D and I met in 1974 (as friends, we didn't start dating for 10 years), when The Six Million Dollar Man was starting its first season. I'm pretty sure D owned a jacket very like that one, too. Ah, 70s fashion.

We've had the technology for a while, but because of the frakked-up US health care system, we haven't had the *money* until this year. You don't get to talk about "wait times" in the US unless you factor in the people who have to wait years -- or forever -- because they can't afford care they need.

This is D's first hospital stay since the early 1980s, when his right knee was reconstructed for the first time.[1] There've been a lot of changes in medical care since then. For instance, I don't know when patients scrubbing themselves down before surgery became standard -- it wasn't done in the 80s -- though I helped a friend do it about 5 years ago, so it's not all *that* recent.

I remember when studies proved that keeping patients warm during surgery is a huge plus -- operating rooms are kept so cool (so the surgeons won't sweat) that, before the late 90s, most surgery patients ended up with some hypothermia. So part of prepping D for surgery was to put him in a garment attached to a hose to blow warm air on him as we waited. It looked (and felt) kind of hilarious, but also like what we call the Bed-O-Blaster: the hairdryer we use to warm up the sheets at bedtime on cold winter nights.

I thought it was pretty funny that the OR nurse kept calling him "doll" when she was going over things with him in the pre-op room, but figured that it was just her version of when the waitress at the diner calls you "hon". D thought so too, and reports that when he got to the actual OR both nurses were calling him "doll" or even "buttercup", which would have caused dangerous laughter if *I*'d been there. But then he heard one nurse talk to the other about what they were going to do with "the doll", and he wonders if they were using the word "doll" instead of "patient" as a way to sound friendly to the patient, while giving themselves enough emotional distance to help, y'know, cut a human body apart and put it back together with new bits.

I don't know as much about OR nurses, but it's notoriously the case that surgeons can be a little ... weird. In fact, I have a friend whose father, an ER surgeon, is a, for real, sociopath. He's a really *terrible* father, but he makes a pretty good surgeon, especially in situations (like an emergency room) where he has to make timely life-and-death decisions about people he's never met. Cutting into a living human being takes a *lot* of detachment, objectification, and self-confidence -- a state of mind that comes easily to a sociopath. At least my friend's father was able to use his powers for *some* good, even though he was pretty crappy to his family.

My husband's surgeon seems pretty nice, so presumably he just feigns sociopathy in the operating room. (I'm mostly kidding.) When he actually opened D up, he was appalled by the condition of D's right knee. He told me, "I don't know how he's been doing what he's been doing" -- D is a fencing coach and referee, and still competes as a veteran, though not surprisingly he hasn't been doing all that well lately. I said this was because D has a fairly high pain threshold, and also is actually the stubbornest person in America.

But the fact is, D's right knee has been bone-on-bone for *seven years*, but we couldn't afford the co-pays (and all those little uncovered extras) for the surgery. It's only because things improved financially a lot in the past year that he's able to do this now.

And that's why I hate the US health care system. When people talk about how Americans don't have to wait as long as Canadians for knee replacements, I just want to spit. Americans don't have to wait as long if they can afford it -- but those short average wait times come by not factoring in people, like D, who wait *years* for procedures that people in any other wealthy country can get in months, even if they aren't personally wealthy.

The hospital D went to is brand new, and the joint replacement ward can only be called "swank". Every room is a single, the food is pretty good, and there's a concierge, for cryin' out loud. The atmosphere is more like a nice hotel than a hospital. It reeks of money, and of the fact that the US *already* has a two-tier health care system, just not the kind feared by Obamacare opponents. Or maybe it's a three-tier system, because in the US one large tier has been made up of people who are unable to get needed health care -- because they've had no or inadequate insurance, because they can't afford the co-pays, because they have a realistic fear of medical bankruptcy. *That's* the problem Obamacare was kludged together to address, and that's the problem that no Republican is willing to buckle down and fix.

And in the mean time, D had Seven. Years. Of bone-on-bone pain in his knee, grinding down, damaging his hips and his vertebral disks (at least 2 have collapsed). I would have traded the luxury hospital like a shot for a sane, Canadian-style (or Swiss-style, or French-style) health care system seven years ago. And maybe if we'd had a sane system for all those years, there wouldn't be so much incentive for the hospital to spend so much money on things other than health care. I'm sure the bill is going to be appalling, and it will be completely out of line with what it would cost in another country.

Happiness, a Fred Astaire/Ginger Rogers fanvid by Ice Pixie. The editing in her vid No Cheap Thrill may be even better, but this one is just so consistently *happy*.

On Tuesday I happened to walk by a Fred Astaire Dance Studio, and I stopped and wondered, maybe we can do that again. In college our gang went dancing a lot, but D and I weren't each other's favorite partners. After we got married, we had a kind of fight when we realized we didn't dance together all that well. Rather than give up dancing, we decided to take ballroom lessons. This turned out to be a lot like marriage counseling (the teacher told us we were both wrong; we learned to pay closer attention to each other), only *much* more fun. And you get to dance!

---

1. IMHO the factory warranty on the human knee only covers 35 years of normal use -- after than you're on your own. Note: normal use. I'm pretty sure taekwondo voided the warranty on his right knee -- like many modern sports (including dance), it doesn't count as "normal use" as far as the evolutionary factory is concerned.

Comments

[Countme-In]

"I just want to spit"

In America, that alone will set you back $200 in co-pays and a warning from a judge.

Then, there is the waiting list to spit, which shouldn't be confused with the waiting list for internal bleeding.

Spitting in a hospital zone is extra.

You could spit in Mitch McConnell's face, but you'll have to pony up a million or so to his campaign coffers so that he can make your medical care even more inaccessible.

[Hartmut]

Ironically, if my memory serves me right, I have seen Astair and Rogers each in a single film only and not together ('On the Beach' for him and 'Golddiggers of 1933' for her).

[Nombrilisme Vide]

We've had the technology for a while, but because of the frakked-up US health care system, we haven't had the *money* until this year. You don't get to talk about "wait times" in the US unless you factor in the people who have to wait years -- or forever -- because they can't afford care they need.

Invalid. I'm not sure where it says it in the Code, but I'm pretty sure you're legally required to assume an average American is independently wealthy, has a premium healthcare plan, and is probably also the CEO of their HMO before you're allowed to make apples-to-apples comparisons between things like wait times in US helthcare and the Communist systems in Europe. Or maybe that's just in the Congressional rules and procedures.

[chris y]

and there's a concierge, for cryin' out loud.

WTF for? This is really spitting in the eye of people who need hospital treatment.

[Tinky]

While I share your concerns about the health care system, I'm afraid that you also show signs of having been mesmerized by decades of propaganda as it relates to healthy knees.

There are countless men, the vast majority of whom played sports, who never suffer any serious knee issues through ripe, old age. I am 57, played basketball regularly into my mid-40s, do serious vertical hiking to this day, etc. My knees are completely pain-free and there is no reason that they cannot remain that way.

Why is that? Because I am not overweight, and learned very early on the importance of stretching and serious massage therapy. Knee issues are rarely primary. In most cases they are related to muscular tightness in hips, hamstrings, calves, or feet. I learned these valuable lessons when I did suffer minor knee pain as a younger man, and figured out, with the help of "alternative" therapists (e.g. Rolfers, etc.) where the sources of pain were.

The vast majority of those who end up with serious knee issues have either ignored symptoms for years, and allowed degradation to occur, or have gone to orthodox MDs who mostly treat symptoms with pain relief, rather than (much less expensively, by the way), identifying the core problems and treating them sympathetically.

Sure, some people injure knees (including, perhaps, your husband), but those are a small minority. Most of those who end up with real problems could have avoided them with more enlightened maintenance.

[John M. Burt]

My wife has had two cyborg hips for several years and can't say enough good about them. Even before that, though, the kids admired her "robot teeth" (gold crowns).

[dr ngo]

Ah, enlightenment! How readily and easily you solve all our problems!

[Tinky]

My comment was quite clearly directed at this part of your post:

"IMHO the factory warranty on the human knee only covers 35 years of normal use…"

I might have thought that you could have mustered more than a straw man response. Oh well.

[dr ngo]

Wasn't my post, just my reaction to your dismissal of "orthodox MDs."

Oh well.

[Tinky]

My mistake about the authorship, but a straw man is still a straw man.

Apparently you don't believe that mainstream MDs are, as a group, at least partly responsible for the incredibly poor general state of health in the U.S.

We see things very differently.

Also, for future reference, learning about one's body and maintaining its health in an enlightened manner is not the same as "enlightenment".

[Julian]

"There are countless men, the vast majority of whom played sports, who never suffer any serious knee issues through ripe, old age. I am 57, played basketball regularly into my mid-40s, do serious vertical hiking to this day, etc. My knees are completely pain-free and there is no reason that they cannot remain that way."

From "countless" to "I" in the blink of an eye. I guess we can safely assume your anecdotal experience is representative of millions, right?

[JakeB]

He is Legion.

[Tinky]

Please do present a shred of evidence to support the assertion that the human knee breaks down after 35 years in a meaningfully high percentage of people who are not significantly overweight.

i won't be holding my breath.

Even arthritis – not a serious issue leading to the need for replacement in most cases – tends to begin after 50.

[dr ngo]

Dear Mr. Tinky:

Allow me to enlighten you.

You have not been subjected to a "straw man" response, one which attempts to refute an argument that has not been made. Repeating this assertion does not make it so.

You have been mocked. There's a difference.

You swan into this group and announce to all of us (most who do not know you from Adam) that we are dupes of the medical system, and imply (moreover) that we are fools for not taking care of ourselves in the "enlightened" way that you do, so it's our own bloody fault if we suffer the pangs of aging.

And - "for future reference," as you so quaintly express it - when you talk about the "enlightened manner" of your personal health regime, the noun form of the adjective you thus brandish is "enlightenment." Denial of this elementary linguistic fact is not refutation.

The reasonable response to such gratuitous fatuousness is mockery. I'm sorry that you didn't recognize it as such. Next time perhaps I will decorate it with "smileys," so you know that humor is intended.

The alternative, to which I may yet resort, is simply to ignore you.

No way can I - nor will I - take you seriously.

Yours, etc.

dr ngo

[Julian]

"Please do present a shred of evidence to support the assertion that the human knee breaks down after 35 years in a meaningfully high percentage of people who are not significantly overweight.

i won't be holding my breath."

Funny, I was specifically mocking your unsupported generalization about countless men--well, not totally unsupported, since you do cite yourself (always a great source!) as an example of undimmed vigor.

So why don't you scurry off and collect the evidence yourself, chief?

[liberal japonicus]

Mr. Tinky

Even if the textual evidence didn't point to it, the overwhelming essence de testosterone would have been a dead giveaway

Please do present a shred of evidence to support the assertion that the human knee breaks down after 35 years in a meaningfully high percentage of people who are not significantly overweight.

Here ya go!
In this study of 504 Chuncheon city residents aged 50 yr and older, the prevalences of radiographic knee OA and symptomatic knee OA were 37.3% and 24.2%, respectively. Furthermore, the presence of hypertension and a manual occupation were found to be significantly associated with radiographic and symptomatic knee OA, whereas a lower level of education and a female sex were found to be significantly associated with the presence of radiographic and symptomatic knee OA, respectively. A small number of studies have attempted to assess the prevalence of knee OA in Korea, but reported prevalences vary considerably. Furthermore, these studies were limited by the use of self-reports, the inclusion of only symptomatic subjects for radiographic investigations, or the lack of standardized knee radiograph and a grading system (3-6, 14). Cho et al. reported prevalences of hand and knee OA in the largest community cohort reported in Korea. In this previous study, which involved subjects over 40 yr of age, the prevalences of radiographic and symptomatic knee OA were found to be 14.9% and 5.4%, respectively.

and

It is known that the prevalence of knee OA in East Asia among men is similar to that reported for Caucasian Americans, but that it is higher among Asian women (15, 16). For example, in a study conducted in Beijing among individuals aged ≥60 yr, prevalences of symptomatic knee OA were 15% in women and 5.6% in men (3), and in a community study of Japanese women aged 63 yr or older, the age adjusted prevalence of knee OA was found to be higher than in Caucasians (OR 1.96)
link

Say what you will about Asians, significantly overweight ain't one of them.

[cleek]

Even arthritis – not a serious issue leading to the need for replacement in most cases – tends to begin after 50.

or, early 40s, in my case.

[russell]

I learned these valuable lessons when I did suffer minor knee pain as a younger man, and figured out, with the help of "alternative" therapists (e.g. Rolfers, etc.) where the sources of pain were.

Who paid for your Rolfing sessions?

Can we all get some?

[Julian]

hell, I'll rofl you for free:

http://boingboing.net/2014/06/26/gimpsuited-greenscreen-fluffer.html

[russell]

not to put too fine a point on it, but if you avoided middle-age (or later) knee damage via a regime of rolfing, massage, and other forms of physical therapy earlier in life, you are more or less *making the point* that, absent all of that stuff, some amount of damage by mid-life is nothing unusual.

so, it's lovely for you, and well done, that you jumped through all the right physical therapy and training hoops early enough in life to help you avoid knee damage later on.

not everyone has those options.

Rolfing, in my area, runs about $125-$150 a session. and, it's typically not a one-or-two session deal, more like months of sessions are normally recommended to really address and rectify postural issues.

That's great if you have thousands of $$$ to drop on perfecting your posture and bodily alignment. And, since we're talking about therapies that are not often covered by insurance, it's thousands of $$$$ out of pocket.

Lucky you, Tinky!!

[wj]

Say what you will about Asians, significantly overweight ain't one of them.

LJ, doesn't that depend on whether you include (as often happens in the US) Pacific Islanders, specifically Tongans? ;-)

I would not that, for most of Asia, non-manual labor combined with sufficient wealth to over-eat is a very new phenomena. After all, it didn't really become significant in the US and Western Eurpoe until the middle of the last century at the earliest. There may be reasons, genetic or cultural or dietary or otherwise, why widespread overweight won't happen to Asians. But it is rather too early to be certain yet.

[Hartmut]

Not to forget arthrosis. My mother is happy to 'only' have that since her own mother suffered from osteoporosis so severe that by the laws of physics she should have been a foot shorter. Those bones should not have been able to withstand even her low weight. I wonder if granny ended up in medical textbooks for real after her doctors commented that they had never seen so extreme a case before. Mum is on her own way to cyborgization with one knee already replaced, one forthcoming, and a few screws in a femur. Can't remeber at the moment, whether one hip was also included in one of the previous sessions. Her hearing aids are still detachable though and not implanted.

[liberal japonicus]

I didn't mean to imply that Asians have some magic genes to prevent them from putting on the pounds, just that currently, the population is not 'significantly overweight', yet they still are having trouble with those gosh darn knees.

[wj]

I seem to recall reading, a couple of decades ago or more, that someone did a mechanical engineering study of the human knee. (Not having any luck finding the original source on Google, however.)

His conclusion: the human knee is designed for someone weighing under 180 pounds. Significantly under. And as any engineer will tell you, when you exceed the design parameters for something, you are asking for trouble.

It isn't just that we've gotten heavier (fatter) recently. We've also, even if we aren't overweight, gotten bigger -- taller as well as heavier.

[Slartibartfast]

My knees have been ok since I gave up sprint breaststroke. Therefore, I recommend that for everyone who has knee problems.

True story!

[dr ngo]

Slarti: I half-believe you. I've had a somewhat unreliable left knee (chronic recurring synovitis) since a sports-related (if touch football counts) injury when I was 23, and not overweight. Can't complain - it kept me out of the infantry, and thus Vietnam.

But my right knee remains as solid/stolid as ever, after 70 years so far. And I've never attempted a "sprint breaststroke" in my life! So your cure works - but only on one side, apparently.

[thompson]

mechanical engineering study of the human knee.

wj, I'd be interested to see it if you can dig it up. I did some minor knee biomechanics during my phd (class work, not my dissertation work, focused on load transfer and lubrication, maintained a passing interest and am not an expert), and I'm having trouble seeing what assumptions you would have to make in order to get a 'designed body weight'.

The knee is incredibly complex, with both biological and mechanical aspects to it. The cartilage and subchondral bone remodel and adapt to usage, as do the supporting ligaments. It's not something I see being readily reducible to body weight.

There are, of course, frequently very clever engineering assumptions that can be made to simplify seemingly complex systems to a few important and easy to model parameters.

I'd be curious which ones this study used. I sadly couldn't find it going through my references and some googling. If you remember anything else about the study, I might be able to make use of of university library access to track it down.

[wj]

thompson,
my recollection is that they were looking at the size of the joint, and especially at the compression strength of the meniscuses (meniscusi?) that keep the bones from rubbing together. I'll see if I can find the actual reference. But it was sufficiently long ago that I am not terrible optimistic.

This, for example, talks about the strength in tension, rather than compression. Sigh.

[bobbyp]

Knees, hell. What gripes me is despite all the tender loving enlightenment I give my automobiles, I can't get much more than 150,000 miles out of them before they turn into a useless piece of junk.

All those who brag about their machines getting 300k and still running "like a clock" can kiss my ass.

Maybe I should try "alternative maintenance".

PS: I am 65, and the knees are starting to hurt, but I got through my 40's and 50's with nary a problem. I attribute that to my experience as a smoker and drinker.

[liberal japonicus]

more shreds

To hear Scott Dye [an orthopedic surgeon at California Pacific Medical Center] speak of it, the knee joint is among the greatest of nature's inventions, "a 360-million-year-old structure beautifully designed to do its job of transferring load between limbs." But it is also among the most easily injured joints in the human body; medical procedures involving knees total a million a year in the United States.

"In standing upright, we have imposed unprecedented forces on the knee, ankle, and foot," Bruce Latimer says. When we walk quickly or run, the forces absorbed by our lower limbs may approach several multiples of our own body weight. Moreover, our pelvic anatomy exerts so-called lateral pressure on our lower joints. Because of the breadth of our pelvis, our thighbone is angled inward toward the knee, rather than straight up and down, as it is in the chimp and other apes. This carrying angle ensures that the knee is brought well under the body to make us more stable.

"But nothing is free in evolution," Latimer says. "This peculiar angle means that there are forces on the knee threatening to destabilize it. In women, the angle is greater because of their wider pelvis, which explains why they are slower runners—the increased angle means that they're wasting maybe ten percent of their energy—and also why they tend to suffer more knee injuries."

link

[thompson]

wj:

Found a bunch of papers (mostly paywalled, sadly). Spent way too much time on it, really. Couldn't find the one you were referring to, but could potentially hack together an argument from a few disparate pieces if I have time. The hoop stress on the meniscus (the major stress involved in tears) is roughly understood. There is also a really poor understanding of at what stress damage is induced.

In my searching, I did come across a comparison between mammal and dinosaur joints (http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0075216#ack ), though. So to those of you who think government grant money is frittered away on irrelevant research, I respond:

Dinosaurs are cool.

The study is fun if you have the time to plow through the math. They are basically arguing that the thin layers of cartilage that mammals have hinders their ability to become giants...while dinosaurs had thick articular cartilage, allowing for better cushioning (but worse stabilization) of the joints. Everything is a tradeoff. But the meniscus seems to be a halfway point:

In contrast, in archosaurs, the close association of the joint surfaces in combination with thick, deformable cartilage would perhaps aid in diminishing joint stress over a much larger range of body sizes (Figure 7). Are there examples of thick deforming cartilaginous tissues enhancing joint function under load? Within the knee of all amniotes are fibrocartilaginous discs known as menisci [61]. In fact, the deformation of menisci plays a critical role in dissipating loads imposed upon the knee joint. For example, when human cadaveric knee joints are loaded after the removal of their menisci, the articular cartilage and subchondral bone experience nearly 120% of the force typically distributed through the joint [62]. Moreover, in kangaroo knees, their relatively supple and broad menisci deform greatly under load, enhancing both joint congruence and safety factors [58]. Although articular cartilage is not fibrocartilage, the menisci demonstrate that, in principle, thick cartilage deformation can effectively reduce stress.

[Barry]

About waiting times - I had a hip replacement several years ago. I have gold-plated coverage. My co-pays for *everything* over months, were several hundred dollars.

I waited seven months for surgery. Major elective surgery has very long waiting lists.

When my mother fell and broke her hip, that was replaced immediately. Major emergency surgery.

When somebody says something like 'Canadians wait an average of nine months for a hip replacement' as a criticism, my only uncertainty is if the speaker is ignorant or dishonest.

[wj]

Barry, as with any statistical study, the results can be heavily dependent on just how the question is framed. For example, do you count the wait from the first time you see a doctor about the pain in your hip, or from the time the doctor says "It probably needs to be replaced," or from the time you actually start trying to get the surgery scheduled?

And then there's the fact that a lot of people will, in all good faith, read the result and assume that the question was framed in a way that they think reasonable (and that the author didn't just make stuff up). I suppose that might count as ignorance, but it may not be something that they are aware of.

[Tinky]

liberal japonicus –

I find it remarkable that you quoted me, and then failed to produce any evidence whatsoever that knee joints break down after 35 years.

Even had the author of the post and I used the number 50 rather than 35, the studies that you reference don't provide any context.

My point all along was that knees (and other joints) have tremendous potential when the body is treated well. When it's mistreated, not so much.

[liberal japonicus]

What people find remarkable differs from person to person. For me, it is remarkable that you choose to respond to what I said, yet ignore what everyone else points out. Do you take issues with the study that indicates that knee problems not simply a problem of the "significantly overweight"?

I also find it remarkable that you don't seem to realize that the majority of the human race might not have the same ability to lavish the same amount and level of care on their bodies as you have been able to.

Additionally, I find it remarkable that you don't seem to understand that the line was simply a set up for the punchline, which was 'I'm pretty sure taekwondo voided the warranty on his right knee -- like many modern sports (including dance), it doesn't count as "normal use" as far as the evolutionary factory is concerned.'

You may also want to read Stephen Gould's piece entitled 'The Median is not the message' and think how that might impact on your interpretation of these 13 words in a footnote of a blogpost.

Remarkable things abound, eh?