Anyone here have a TKR?

[djg21]

I'm 49 and finally have succumbed to scheduling a TKR on Feb. 26. I've had a number of ACL reconstructions/revisions over the years, and now have no meniscus and significant OA in one knee. I've tried synvisc, and cortisone, and all sorts of anti-inflammatories. These put off the inevitable for a bunch of years, but no longer help much.

The final straw was being unable to ski despite wearing a new CTI2 unloading brace a few weeks ago. I use only freeheel gear, and would get stabbing pains in my knee whenever I put my ski on edge. Interestingly, my knee hurt more when carving an upright parallel turn than it did when my knee was flexed during a relatively deep telemark turn. I was able to last for only a few runs.

Cycling has not been too much of an issue. I did have to place some valgus wedges under my speedplay cleats to unload my knee a little, and i do get shooting pains in my knee if I twist it the wrong way while pedaling, but I am still able to ride relatively hard.

I'm getting a Depuy rotating platform knee, which supposedly will allow me a greater range of motion than other alternatives.

Has anyone here been through this? Am I unrealistic in hoping to be back on my bike putting in hard miles by the summer? About being back on my tele skis next November? I'm starting to have some second thoughts: the devil you know . . . .

Any guidance would be appreciated!

[Louis]

I'm not sure I would trust J&J (happily for you, this is about hips, not knees, still, it's pretty scary)

NYT story on DePuy hip joints (http://www.nytimes.com/2013/01/26/business/johnson-johnson-hid-flaw-in-artificial-hip-documents-show.html?smid=pl-share)

Part of NYT story:

Maker Hid Data About Design Flaw in Hip Implant, Records Show
By BARRY MEIER

Johnson & Johnson executives knew years before they recalled a troubled artificial hip in 2010 that it had a critical design flaw, but the company concealed that information from physicians and patients, according to internal documents disclosed on Friday during a trial related to the device’s failure.

The company had received complaints from doctors about the device, the Articular Surface Replacement, or A.S.R., even as it started marketing a version of it in the United States in 2005. The A.S.R.’s flaw caused it to shed large quantities of metallic debris after implantation, and the model failed an internal test in 2007 in which engineers compared its performance to that of another of the company’s hip implants, the documents show.

Still, executives in Johnson & Johnson’s DePuy Orthopaedics unit kept selling the A.S.R. even as it was being abandoned by surgeons who worked as consultants to the company. DePuy executives discussed ways of fixing the defect, the records suggest, but they apparently never did so.

Plaintiffs’ lawyers introduced the documents on Friday in Los Angeles Superior Court during opening arguments in the first A.S.R.-related lawsuit to go to trial. The company faces more than 10,000 lawsuits in the United States in connection with the device. An estimated 93,000 patients worldwide received an A.S.R., about one-third of them in the United States.

DePuy executives insisted before the A.S.R.’s recall in mid-2010 that the implant was working well, despite years of complaints from doctors that it was failing early. In late 2009, the company announced plans to phase out the model but said it was doing so because of slowing sales, not safety concerns.

In opening arguments — followed remotely over the Courtroom View Network — a lawyer for DePuy, Alexander G. Calfo, reiterated those positions, telling jurors that DePuy had behaved ethically throughout the A.S.R. episode.

“The evidence will show that DePuy acted as an extremely responsible manufacturer,” Mr. Calfo said.

But a lawyer for Loren Kransky, the plaintiff in the case, painted a far different picture of DePuy’s behavior for jurors in his opening arguments.

The lawyer, Michael A. Kelly, also introduced a number of internal records that suggested that company executives’ concern for profits might have exceeded their worries about patients. For example, Mr. Kelly said, DePuy officials never told doctors that the A.S.R. had failed an internal performance test against another company hip.

“They did not report the data to American doctors,” Mr. Kelly said. “They changed the test and tested it against other things until they found one it could beat.”

The A.S.R. represents one of the biggest medical device failures in recent decades. According to DePuy’s internal estimates, it is projected to fail within five years in about 40 percent of patients who received one. That is eight times the failure rate of most orthopedic implants.

The A.S.R. belonged to a once-popular class of hip implants introduced about a decade ago in an attempt to address problems associated with hips made from traditional materials like metal and plastic. But surgeons have largely abandoned devices in that class because their components can grind together, releasing metallic debris that damages a patient’s tissue and bone.

[djg21]

I've been following. I haven't heard bad stuff about the knee. The doctor is comfortable with it.

[bargainguy]

First of all, sorry to hear about this. My best wishes for your healthy return to the slopes and the saddle.

Not a doctor, but sounds like you have two primary knee issues: ligament damage and osteoarthritis. Of the two, TKR is typically done more for OA than ligament issues, as there are various reconstruction techniques to try and hold the joint together without resorting to total replacement.

TKR is more typically done when you have constant or near constant pain from bone-on-bone damage from OA. A lot of folks in your situation would just gork up on antiinflammatories and call it a day. But you want to remain active. That's a good indication for replacement as you want to return to activity soon and enjoy your previous lifestyle. It certainly keeps the orthopods and hospital chains happy.

There are caveats. Getting the soft tissue all stitched up and healed takes a good surgeon as well as good PT and rehab. You cannot rush the postop recovery phase without risking stuff happening like adhesions, where you have nowhere near your previous range of motion because of soft tissue scarring and not healing properly.

You may find your riding style changing to accommodate your new knee. Same with the slopes. Of course, much of your knee pain will be gone, but not necessarily soft tissue pain as everything heals up.

As long as you don't rush the postop phase, try to do more than you should, and keep a positive outlook, you should be fine. Maybe not 100% as before but a good 80 or 90%. Then the question is keeping your other knee happy as your body dynamics change and you don't start loading that knee unnecessarily, which could lead to the same situation as the one you're having replaced.

Good luck. Let us know how it all works out.

[schneiderrd]

I had a TKR on my right knee last June and on my left knee two weeks ago. I can give you some general comments and would be glad to follow up with any specifics you might have.

As best I can tell from my own research, it's the quality of your surgeon that is more important than the manufacturer of the hardware. Each surgeon usually has a preferred manufacturer and is trained in that particular manufacturer's equipment. Among the people who will be in the operating room during your operation is a representative from the company, in your case DePuy, in mine Zimmer. The representative brings an assortment of sizes with the decision as to what size you get being made after they have zipped you open. What you need to know about your surgeon is what is his rate of infections for TKR patients after surgery and what is his rate of revisions after two years. Obviously you want both of those numbers to be low.

With respect to how fast you recover, that is always an individual experience. Since you are active in general and a cyclist specifically, you should be going into the surgery in good shape. The stronger you are going in, the stronger you are coming out. I stayed off the road for three months (I did use stationary almost everyday) just to make sure that there would not be any problems caused by the twisting motion of clipping out. If you do not mind toe clips for while then maybe you can get back sooner. Check with your doctor. Essentially you are still recovering for one year after the surgery. At the one-year mark what ever you have is probably as good as it will be.

I don't have any experience in skiing with a TKR, but I am told the more you work it, the sooner it will wear out.

I hope this helps you out. Good luck and let me know if you have any more questions.

Sorry if the typing is less than perfect as I am still on pain meds.

[2LeftCleats]

If you are asking should you have this done, sounds like you have little choice. Most surgeons advise against replacements until you've tried everything else--which you have-- and until the pain is bad enough that it limits normal activities. What are normal activities for one are not for someone else. While it would be preferable to wait until older due to the lifespan limitations of artificial materials, it's better to do it now, IMO. You'll be going into the surgery fitter and likely will make a quicker recovery. Active people tend to be much more willing to do the hard and sometimes painful work of rehab. The longer you wait and are sedentary, the weaker the leg muscles, the fatter you get, etc.

The procedure can create a leg-length inequality, so you may need to be refitted on the bike. I assume your surgeon knows of your athletic inclinations.

Nothing's foolproof of course, and there are always chances of infection, malfunction of the joint, blood clots, etc. but there are many competent surgeons these days and much standardization of peri-operative care to prevent them.

Good luck and let us know.

[djg21]

Thanks all.

Bargain guy got it right. My knee has not been stable for a while, the instability has caused the meniscus to wear, and I now am bone on bone. At this point, it's a constant annoyance. The only time it feels decent is when I'm on my bike, but even then, I get stabbing pains in the lateral compartment at times.

One concern I have is stability. Maybe Schneider rd can help. Can I expect my new knee to be stable? Did your doc retain your PCL?

What happens if you take a fall on your knee? Do you need to be concerned about damaging the prothesis?

I know running distance can cause premature wear, but what do you think about cross? My left leg has been a problem over the past couple of years, as the twisting and torque during dismounts has been a problem. Is this possible with the prothesis, or a non-starter.

Thanks for the input,

[schneiderrd]

With respect to stability since both knees are with in the one year window I won't know until June of this year for my right knee and January of next year for my left what the final out come will be. I do not do any high impact exercises and, with the exception of clicking out of my pedals, avoid twisting motions. The doctor was adamant about the twisting motion during early recovery and I haven't asked him about this recently. At least one of the ligaments is removed (not sure which one(s). My doctor said that with the Zimmer replacement I did not need it any more.

I have not experienced any instability doing routine daily activities. The one thing I do have is "clicking or clunking" in the new knee. It doesn't hurt and comes and goes but so far does not seem to be a functional issue. My doctor says that this is normal. You may want to do some more research on the DePuy knee to see if is tolerates twisting better than other designs. I would go directly to DePuy to see at they have to say. Maybe they can put you into contact with patients who have their knee and a similar life style to yours.

The one thing that the PT (Pain and Torture) therapist had me do six weeks after surgery, is go to the gym and work the muscles that support the knee. My routine included leg presses, leg curls, partial leg extensions (not full range only last 10 to 15 degrees, calf raises, hip flexors both interior and anterior and partial squats. Initially you will have a leg strength discrepancy in your legs. I would do the above exercises (except for the hip flexors) as single leg to force the weaker leg to work harder. Once I got parity I went back to doing both legs simultaneously to save time. Once you get to a reasonable mount of resistance, increase the reps while keeping the weight constant as going over board on the weights will only wear the knee out faster.

With respect to falling, I try not to do that. I am not an aggressive rider and don't go ape on the bike. My main goal when I begin a ride is to come back in one piece; everything else is secondary to that. Bottom line is I haven't fallen on the knee and do not have any input on how resilient they are.

[Louis]

go to the gym and work the muscles that support the knee. My routine included leg presses, leg curls, partial leg extensions (not full range only last 10 to 15 degrees, calf raises, hip flexors both interior and anterior and partial squats

I don't want to derail DJG21's thread too much, but if you had to design a 15 minute "use a few times a week to improve your knee support muscles" routine for a cyclist with pretty good knees who wants to try to keep them that way, what would you recommend?

TIA
Louis

[schneiderrd]

Louis:

Since you are already cycling a fair amount and probably have well developed leg muscles, with only 15 minutes to work out, the one exercise that you might want to consider is the Partial Leg Extension. You can do these at home by sitting on the floor and putting a couple of rolled up towels under your knee. Then just extend you leg straight,hold for a second a let your leg relax. You don't need to pile on a lot of weight just go for a lot of reps.

The muscle that this exercises focuses on is the inner muscle that runs along the inside of the knee. While cycling builds up your leg muscles, it does not work this one as much as the others. Strengthening this muscle will help stabilize the patella which some cyclists have problems with. For a cyclist that does not have a lot of time for leg exercises, this is the one that was recommended to me a while back.

[skijoring]

I second this - coming back from a broken femur, this is one exercise that I still do almost daily. Lots of reps, no need for additional weight.

Louis:

Since you are already cycling a fair amount and probably have well developed leg muscles, with only 15 minutes to work out, the one exercise that you might want to consider is the Partial Leg Extension. You can do these at home by sitting on the floor and putting a couple of rolled up towels under your knee. Then just extend you leg straight,hold for a second a let your leg relax. You don't need to pile on a lot of weight just go for a lot of reps.

The muscle that this exercises focuses on is the inner muscle that runs along the inside of the knee. While cycling builds up your leg muscles, it does not work this one as much as the others. Strengthening this muscle will help stabilize the patella which some cyclists have problems with. For a cyclist that does not have a lot of time for leg exercises, this is the one that was recommended to me a while back.

[bargainguy]

Knee joint prostheses are pretty durable. I don't think I ever saw a case where one was fractured by sports-related injuries. Now if you suffered major trauma as the result of an auto accident or industrial injury, different story.

CX riding raises a bunch of different issues. Although there have been tremendous advances in joint replacement design, most of them function best in one plane only. So the caveats about twisting / turning are true. It is possible to wear one side of the prosthesis more than the other.

As much as there is the desire to return to a really active lifestyle, I think it best to approach the situation cautiously for a few reasons.

1. You'll probably have the TKR for the rest of your life without wanting to go through replacement surgery, which is about as much fun as the first.

2. Lotsa folks with one TKR will eventually have the other done, because arthritis rarely affects one knee only unless it's traumatic arthritis (i.e., major injury when young and gets to be an issue decades later).

3. Your new knee will probably not have the flexibility of your original one but will be close. That margin might be enough that you can enjoy cycling, but cross will load that knee a lot. A heckuva lot. Sports orthopod can comment here better than I can.

4. Body dynamics. How are the hips doing? Any OA? They'd better be good, because as you get a TKR, you're changing the dynamics of how the hips handle the stress of walking, cycling, whatever. A new knee is great but since it doesn't pivot as well, may load that hip a lot more. That might start wearing down the hip prematurely. I think you see where I'm going with this.

[Louis]

S & S - Thanks guys - that's good to know.

[djg21]

At the hospital at 5:30am, into surgery at 7:00. I'm getting a Depuy rotating platform knee. The plan is o e on my bike outside by May, and back on my tele skis by next winter.

[schneiderrd]

Good luck on you TKR. My first three weeks was all about regaining range of motion. I m now in the rebuild leg strength phase. Just make sure your doctor is OK with the on the road by May deal.

[djg21]

Made it through with no hitches. My surgeon says that's the OA was really bad, and told me I really needed the procedure done. That made me feel better about my choice not to put this off further. I still have a femoral block so the pain is minimal, The passive motion machine sucks, He says he is going to get me back on the skis and bike soon. It's all relative I guess.

Thanks all.

[gasman]

Speedy recovery !

[SpokeValley]

I had bilateral TKR in 2010 and it's just been a blessing. I have Styker devices.

It's definitely the surgeon that makes the difference, I absolutely agree.

Do your physical therapy! I was back in the gym in less than 90 days.

Good luck!

[Louis]

Great news that it all went well, and good luck with the rehab.

[schneiderrd]

If you are having problems with the CPM machine, have the hospital folks make sure the alignment is correct. When it is lined up correctly, it is great. I used to fall a sleep with mine. This machine is critical in helping you get your range of motion so hang in there.

[djg21]

If you are having problems with the CPM machine, have the hospital folks make sure the alignment is correct. When it is lined up correctly, it is great. I used to fall a sleep with mine. This machine is critical in helping you get your range of motion so hang in there.

I've had it checked a few times, and all is fine. I think I'm just tired of having my ass glued in the same position on the hospital bed since this morning, and I will not be moving until I start PT tomorrow.

Thanks again.

[djg21]

Well, things turned really ugly for a while, but seemingly have turned the corner.

The evening I last posted, I developed compartment syndrome and had to undergo emergency faciotomy surgery to relieve the pressure in my calve and quad. As I already was on blood thinners, I then managed to bleed out, and had to be transfused with 5 units of blood. Then, on top of it all, clots were found in my lower leg when an ultrasound was done.

I've now had multiple additional surgeries to install a filter in my femoral vein and to close the faciotomies wounds. I was released from the hospital after two weeks on Sunday night, with lots of stitches and staples, and drains attached to my leg.

The staples from the original procedure come out on Friday, and the stitches in my calve and quad are being removed on Monday.

My PT thus far has been minimal at the hospital, and self-guided at home. PT is supposed to visit me at home on Thursday. At this point, I have good extension, but almost no flexion. I can't tell how much of the tightness is caused by all the stitches, and how much from the swelling around the new knee joint. I am slowly gaining the ability to do leg lifts. I can bear some weight and walk very short distances with a walker or crutches, but I get fatigued even when I walk 20 feet.

The good news -- the plastic surgeons were able to line up the tiger tattoo on my left calve that was cut up during the faciotomy and told me that it won't look horrible. I figure that when this all passes, I'll have to do something to fix the tat.

As of last night, I stopped taking pain killers. I was on some pretty heady stuff that rendered me unable to read or think. I also had been waking with bad night sweats which I think we're caused by the painkillers. At this point, the pain has become relatively tolerable, and I prefer lots of ice.

I'm still hoping to ride my bike this summer!

[thwart]

The evening I last posted, I developed compartment syndrome and had to undergo emergency faciotomy surgery to relieve the pressure in my calve and quad. As I already was on blood thinners, I then managed to bleed out, and had to be transfused with 5 units of blood. Then, on top of it all, clots were found in my lower leg when an ultrasound was done.

I've now had multiple additional surgeries to install a filter in my femoral vein and to close the faciotomies wounds. I was released from the hospital after two weeks on Sunday night, with lots of stitches and staples, and drains attached to my leg.That is major ugliness. Losing half your blood from the fasciotomies and then having clots as well, in spite of the blood thinning med... yikes.

Never good to be getting the last rites after elective knee surgery. ;)

Glad to hear things are doing better.

[Louis]

The good news -- the plastic surgeons were able to line up the tiger tattoo on my left calve that was cut up during the faciotomy and told me that it won't look horrible.

Good to hear that they had their priorities right!

Best of luck with the healing process.

[djg21]

It's 8 weeks, and my final procedure to remove an umbrella filter from my femoral vein (put in because of the clotting in my lower leg) is tomorrow. My hemocrit level has been restored to normal range without me getting to experiment with EPO. More importantly, my orthopedist OKed me getting outside on my bike, so long as I avoid hills and hard efforts. I've been on my computrainer or a stationary bike since week three. I will be outside Saturday.

[weiwentg]

It's 8 weeks, and my final procedure to remove an umbrella filter from my femoral vein (put in because of the clotting in my lower leg) is being removed tomorrow. My hemocrit level has been restored to normal range without me getting to experiment with EPO. More importantly, my orthopedist OKed me getting outside on my bike, so long as I avoid hills and hard efforts. I've been on my computrainer or a stationary bike since week three. I will be outside Saturday.

Floyd Landis 'won' the 2006 TDF on a total hip replacement + lots of EPO + a few transfusions. You can do it too.

[Keith A]

djg21 -- Glad to hear you are progressing and I hope you enjoy your ride on Saturday. I've had ACL reconstruction myself, so I understand a little about what you've been through and it felt soooo good to finally ride outside again
:banana:

[mnoble485]

I had bilateral TKA about two and a half years ago and a similar situation. I developed a deep muscle thrombis that totally derailed my re hab. All ended well with my first ride at 3 1/2 months. First ride was scarey, fun, hurtfull, and feel good all at the same time. Didn't clip in for awhile because I didn't want the experience of unclipping or not being able to unclip and falling. Keep up the good work.

Mike

PS As we the forum get older I predict a wealth of knowledge on these types of threads.

[schneiderrd]

I had bilateral TKA about two and a half years ago and a similar situation. I developed a deep muscle thrombis that totally derailed my re hab. All ended well with my first ride at 3 1/2 months. First ride was scarey, fun, hurtfull, and feel good all at the same time. Didn't clip in for awhile because I didn't want the experience of unclipping or not being able to unclip and falling. Keep up the good work.

Mike

PS As we the forum get older I predict a wealth of knowledge on these types of threads.

Yeah, this getting old isn't for whimps