Experience Report Total Knee Replacement
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Actually, the implantation of the knee prosthesis went smoothly for Ludwig Franke. However, the 63-year-old lawyer is in pain. That this pain should be linked to his drug addict daughter who lives in Berlin sounded like a bad joke to him at first.

A report by the orthopedist Dr. Philipp Traut, written down by Michael Lohmann

“Is there anything else that keeps you up at night besides your knee problems?”
The lawyer Ludwig Franke (name changed) is in my practice for the first time. At 63 years he still has an athletic appearance, if there wouldn’t be the problems with his right leg. After the implantation of an artificial knee joint, he cannot bend the leg without pain. Riding a bicycle became impossible.

“But the surgeon said: ‘In six weeks, you won’t notice your knee anymore!’ And how! It’s even worse than before.”
During the examination, I realize that it can’t be caused by the joint mechanics which is perfectly fine. Mechanics is the most important part in orthopedics, it has to work. But sometimes, there are problems anyways, and many helpless orthopedists send their patients to me.

“You mean, what I am worrying about?”, he asks me surprised.
I nod encouragingly.
“I am really worried about my daughter. At 22 years old, she is our youngest. Unfortunately, she met the wrong people in Berlin.” Mr. Funke shakes his head and takes a deep breath. “Drugs. She is addicted. It’s a nightmare! But what does that have to do with my knee?”

“Mental stress can absolutely be a reason why your knee doesn’t heal. See, the new knee joint works perfectly. Thus, the surgery was successful. The problem is the lack of healing. Our body controls the healing process through the autonomic nervous system. When we worry about something, our nervous system is unbalanced and healing disorders can occur. This is called arthofibrosis: an excessive scar tissue formation around the joint which leads to painful limited mobility.”

“You mean that because I am worried about my daughter, this tissue formed in my new knee?”
“Of course, it’s not that easy. But it can absolutely be a factor which has to be taken seriously. Today, there is a range of studies proving that mental stress can negatively influence cellular and biochemical processes during the healing process.”

“I actually thought that I am visiting an orthopedist and not a psychotherapist.” Mr. Franke sneers mildly.
“Yes, I know, it is unusual. But during my long career at the rehab clinic here in Bad Oeynhausen, I often experienced that emotional stress can also play a role for orthopedic problems.”

My former job in the clinic led me to study the mental state of my patients intensively. For many patients, I observed again and again that our therapy that was normally successful didn’t work for them. They were patients like a truck driver after a severe rear collision: there was a gas leak, the vehicle caught on fire, the flames reached up and the man was stuck in the driver’s seat like in a cage. He panicked about being burned alive. The fire department could only save him in the last second. Those are pictures you cannot get rid off easily. His broken knee was his smallest problem, far worse were the recurring nightmares, flashbacks and panic attacks.

This is called post-traumatic stress disorder. It was the reason why he couldn’t perform his former job anymore. That’s why he came to us for rehabilitation in neurology, where there is a department specialized in trauma patients.
As he got a new knee due to his accident, he also came to me for consultation. Similar to Mr. Franke, I also diagnosed him with arthofibrosis. He could only move the new joint with great effort. We then tried to mobilize the knee  with the usual physiotherapeutic measures. But although the patient stayed in the clinic for almost three months, we couldn’t improve his mobility to his satisfaction.

We had similar experiences with members of the German armed forces who came to the clinic due to traumatic war experiences in Afghanistan. If they had joint injuries or fractures, there were significantly more healing disorders. Here we also saw that our mobility therapy wasn’t successful.

Thus, the question was: Why does the therapy work for ‘normal patients’ but not for them? For patients without traumatic experiences, only five to ten percent of the cases showed healing disorders after a total knee replacement, this disorder was the rule for trauma patients. It was thus obvious that the mental condition plays an important role, but the particular connections remained unclear.

In order to understand the connections, a coincidence helped me. There is a big Heart Center here in bad Oeynhausen where many heart and lung transplantations are performed. In this institute, there is a fibrosis research center since 1990 because such fibroses occur often during transplantations. Although our clinics are only 500 meters apart, we didn’t know anything about this research. Then, the clinic got a new head physician and we invited him to a speech about fibrosis research in the doctor’s association. Of course, I was immediately curious and contacted the colleague.

That was ten years ago. Soon we were able to conduct our own studies. They showed an important result which had an impact on my whole later job: that fibroblasts which control the healing process are mechanically sensitive. When you irritate them mechanically, they multiply strongly and consequently cannot die as normal within the healing process. This strong increase of connective tissue leads to a painful restriction of mobility, because this tissue is also supplied with pain nerves within a short period of time.

This clearly revealed why our usual movement therapy didn’t work for these patients: We tried to mobilize the joints with stretching exercises and that was exactly what led to the strong increase of cell tissue and connective tissue what made the movement more and more painful. It was a vicious circle.

It still remains unclear which role emotional stress plays in this pathological increase in connective tissue. However, in 2015, studies showed that stress hormones make the fibroblasts more sensitive to mechanical stress. Subsequently, we were also able to prove in the cell culture that stress hormones lead to a strong multiplication of fibroblasts. These results coincide with an American-Hungarian study with depression patients. This study proved that emotional stress is noticeable even in the cellular area: The metabolism of the fibroblasts, which are responsible for the healing process, is altered.

Thus, the mind can alter things even at the cellular level. Even though I already knew due to my experience with traumatized patients that emotional factors had to play a role, I was still surprised that these alterations can even be proven in cellular metabolism. On this basis, we developed a new treatment model which also implies expert psychological help. Concerning the orthopedic part, we don’t try to mobilize the stiffened joint anymore. We forego the mechanical stress completely and move away from the idea that the problem has to be solved mechanically. The aim is to help the body to remove the excess tissue, that way the knee joint becomes flexible on its own.

“And I thought that I didn’t train enough although I did my exercises everyday – despite the pain. This worked for my neighbor. He is ten years older than me and had the same surgery last year. He was able to ride his bicycle again after only six weeks. He didn’t have any problems at all”, says Mr. Franke.

“That is usually the normal course. But when there is a healing disorder, the usual training is like poison for your body. It is then important to calm down the body and to reduce emotional stress.”
“But what does that mean for me now? Will I only recover when my daughter stops taking drugs?”
“No, but it means that we have to consider these emotional factors. Like I said, our aim is now to calm down the body. We need the right physiotherapy with comfortable body experiences. I recommend lymphatic drainage, massage and osteopathic treatment. Treat yourself to something good! Like you caress a child when it got injured, you are in need of a stroke now!”

“That sounds good!” He smiles. “I didn’t want to go to physiotherapy anymore because it hurts so much.”
“Very important: Your physiotherapist mustn’t treat your knee anymore! You are the only one who is allowed to move it, because only you notice the pain. Rather do nothing than do a lot wrong! Instead, he should treat you with body therapy: foot reflexology, back or connective tissue massage. All that will calm down the body.”

“How long will this take? I need sports to compensate for my job – will I ever be able to ride my bicycle again?”
“I can really understand your concerns, I also need sports. We can be optimistic: Fortunately, your surgery didn’t take place very long ago. If we change the therapy now, you will feel significantly better in six to eight weeks.”
“I was already afraid that it would stay like this.” Mr. Franke was obviously relieved.
“No, you don’t have to worry about that. When these disorders are treated at an early stage, they will disappear quickly. You still need some patience, though. It is very important to learn to listen to your body!”
“How can I learn that?”
“The body sends us signals which we should perceive. Pain is a strong signal: If a treatment is painful, it isn’t the right one at the moment. Very simple. Conversely, our body gives us signals when something feels good. Now you should give your body a wellness program.”
“But when I have to worry about my daughter again, it will be hard to feel calm”, Mr. Franke says.
“Yes, that’s right. That is why you should maybe think about getting psychological support. There are very good relaxation techniques that help body and mind.”
“Yes, I have already thought about that as well.”
Finally, I hand Mr. Franke a doctor’s letter with the therapy suggestions.

When I meet Mr. Franke half a year after our talk, he looks completely different. Fresh, filled with verve and he is able to bend his knee again.
“Have you heard of MBSR, this American method to reduce stress?”, he asks me.
“Yes, of course. That’s a wonderful method to calm down your body as well as your mind.”
“And it helps against stress. I always take some time in the evening now for my exercises.”
“Very good!”, I compliment him. “And how is your daughter?”
“Things are getting better. She moved away from Berlin and started an apprenticeship as a goldsmith. There is a reason for cautious hope.”

This text is an excerpt from the book: Wenn eine Begegnung alles verändert – Ärztinnen und Ärzte erzählen. (When an encounter changes everything – doctors talk about their experiences.) Doctors talk about encounters with patients that left their marks and discuss new treatment methods. ©atp Verlag, Cologne 2021.