TKR - a couple of Qs

[Seramount]

after several decades of tolerating a deteriorating knee, have a consult in 2 weeks with an orthopedist to discuss the total replacement procedure.

obviously, my first concern is how long after the op can I expect to throw a leg over a top tube?

anyone have issues with resuming pre-op mileages and speeds...?

fwiw, I'm 67 (well actually turning 68 next week) and rode 10K miles last year.

just wondering if I should start adjusting expectations...

[teleguy57]

Subscribed. Turned 66 earlier this month. Knees have been on/off for a number of years; 11 years ago ortho said "come see me when you're ready to have surgery" as there was bone on bone back then. Had a series of prolotherapy injections in one knee; not much difference longer term.

Talking with my PT yesterday (good friend, cyclist/nordic skier pal) and I mentioned "yeah, not too bad this week, I could walk almost a mile before I had to stop" and then I thought what I just said and figured time to think more seriously about R&D for a good surgeon. I remembered reading about this article (https://www.webmd.com/pain-management/knee-pain/news/20200113/all-in-the-timing-many-get-knee-replacement-too-late-or-too-soon#1) and pondering that too....

FWIW, I found this gave me some optimism. (https://www.uphillathlete.com/new-knee-running-again-total-knee-replacement/) If you haven't searched here there are a number of threads/reports from those who have gone TKR.

[djg21]

I had a TKR 7 years ago at age 49. My OA was horrible and my knee was totally unstable as a result of of stupid sports injuries. My TKR was a complete disaster landing me in the ICU after I developed a compartment syndrome that required multiple fasciotomies. Then I was found by a nurse in my hospital bleeding out of the fascitomy incisions and near dead. I received 6 units of blood. Then I developed clots in my leg. I was literally the 1 in 1 million to develop real complications.

Even so, I was on my trainer within a few months going easy, and I was outside shortly thereafter. Within a few more months, I was riding outside and getting pretty long and relatively hard miles. My orthotic knee isn’t the same as my natural knee when it worked, and it still gets achy from time to time. I can’t do high impact stuff any longer, and I haven’t skiied since my TKR. But I feel fine on my bike and still get lots of miles in and regularly time trial.

Talk to your surgeon, and prepare to work your ass off in rehab.

[Ralph]

My wife is not particularly athletic, and she is especially not a cyclist. However....she does ride her bike on the local trails 15-20 miles at a time. several times a week.

And after numerous knee surgeries, bone on bone last few years, and living with almost constant pain, she decided it was time.

She is 69 and had a TKR last October. She took PT very seriously....and worked hard. Her goal was to get her life back.....without pain. Go walking, go to the gym (soon I hope) for all around work outs, shopping, ride bikes moderately with me, etc. She didn't necessarily work hard just to go bike riding.

7 months later....I am happy to say she has succeeded. She is now pain free....and has been for several months now. And can do those things pain free she likes to do. So it worked out for her just fine. Her cycling is actually way better now than it has been for many years, although she doesn't train for it. She is expecting to continue to recover for at least 4-5 more months. Her surgeon said to expect it to take up to 12 months for complete recovery.

So....I bet you can have a great outcome. And be back riding soon. My wife had this terrific PT, and his ideas are to work for all around fitness, not just cycling, or running, rowing, weight lifting, etc. Strengthen all the muscle groups. Doing that might also improve your future cycling and prolong your cycling life. And don't rush it.

My wife's surgeon makes the incision down middle of knee....and says he gets best outcomes that way. If he does a side incision, initial pain is slightly less, and recovery for first few weeks might be a tad faster, but after a few weeks it all evens out...."he says". Also.....he says the side incision works best for skinny knees, but can see better what he is doing on a middle incision. And statistically speaking...."he says" there is less problems with a middle incision overall. Not an expert here, just quoting wife's surgeon. And we think he's pretty awesome. I know some surgeons are advertising side (called lateral) incisions is why I mentioned.

[mbrtool]

I had my knee replaced two years ago; I was 71 and typically rode about 7200 miles per year. I was given permission by the surgeon to start riding two weeks after surgery. I only rode a few miles the first time and just increased the distance as long as I felt no unusual pain. Choose the hospital with the best reputation for TKRs and do the physical therapy religiously.

Ray

[SoCalSteve]

I had my partial knee replacement about 5 years ago ( at 57 ). I wrote about my journey from before, during and after on here. You may want to search for these threads.

I can tell you it was a long and painful road to get to a place where I had 95% range of motion. It took a couple months of PT and religiously following my physical therapist.

It was all worth it. I can ride at about 85% of where I was when my knee was normal. This is not to say that I am pain free, I am not. But it’s much better!

A few words of advice: get off the pain meds as quickly as possible. Ice, ice and then ice some more. Use ice instead of pain killers. And, of course, follow the PT religiously, even if you are in horrible pain. It will be worth it.

Good luck!

[djg21]

I had my partial knee replacement about 5 years ago ( at 57 ). I wrote about my journey from before, during and after on here. You may want to search for these threads.

I can tell you it was a long and painful road to get to a place where I had 95% range of motion. It took a couple months of PT and religiously following my physical therapist.

It was all worth it. I can ride at about 85% of where I was when my knee was normal. This is not to say that I am pain free, I am not. But it’s much better!

A few words of advice: get off the pain meds as quickly as possible. Ice, ice and then ice some more. Use ice instead of pain killers. And, of course, follow the PT religiously, even if you are in horrible pain. It will be worth it.

Good luck!


I would modify this advice slightly. Stay on the pain meds initially, and use a timer to make sure you stay on a schedule. That means setting an alarm in the middle of the night so you can take your meds at regular intervals. Otherwise, you will wake up in excruciating pain. I used an app called Dosecast on my iPhone to schedule my meds. https://apps.apple.com/us/app/dosecast-my-pill-reminder-app/id365191644. I hate opioids and they make me miserable. I do everything I can to avoid them. But if you don’t stay on them at first, you won’t be able to complete your PT that you start almost instantly, and the pain can be horrible. Once you exhaust your initial supply of opioids, you can talk to your doc about alternatives. But do not rush it! You are having parts of your leg amputated. The other thing that helps is a cold therapy machine like a Donjoy Iceman. Load your freezer with ice ahead of time. I used mine almost around the clock, and it really helped with the pain management.

[SoCalSteve]

And I’d like to modify this advice slightly...:)

Ok, so this is really personal...but, after taking strong pain meds for 2 days, I was constipated for 4 days. Unbelievably uncomfortable! But, seriously, everyone handles pain differently. If you can handle the pain, sleep and do PT, then get off the drugs!!!

I would modify this advice slightly. Stay on the pain meds initially, and use a timer to make sure you stay on a schedule. That means setting an alarm in the middle of the night so you can take your meds at regular intervals. Otherwise, you will wake up in excruciating pain. I used an app called Dosecast on my iPhone to schedule my meds. https://apps.apple.com/us/app/dosecast-my-pill-reminder-app/id365191644. I hate opioids and they make me miserable. I do everything I can to avoid them. But if you don’t stay on them at first, you won’t be able to complete your PT that you start almost instantly, and the pain can be horrible. Once you exhaust your initial supply of opioids, you can talk to your doc about alternatives. But do not rush it! You are having parts of your leg amputated. The other thing that helps is a cold therapy machine like a Donjoy Iceman. Load your freezer with ice ahead of time. I used mine almost around the clock, and it really helped with the pain management.

[djg21]

And I’d like to modify this advice slightly...:)



Ok, so this is really personal...but, after taking strong pain meds for 2 days, I was constipated for 4 days. Unbelievably uncomfortable! But, seriously, everyone handles pain differently. If you can handle the pain, sleep and do PT, then get off the drugs!!!



Opioids do that! I was put on a laxative with the pain meds. I never could understand the allure of Heroin or opioids.

Since we’re being personal, you probably will want to purchase and install a toilet seat riser in advance. You won’t be able to bend your knee to sit for a while. Also, have a set of crutches around if you have stairs in your house. It is difficult to navigate stairs with a walker. It is more manageable if you can use crutches.


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[2LeftCleats]

Had my TKR 16 mos ago and same side hip 12 mos ago. Hit the rehab hard and back spinning on the trainer within a couple of weeks. I wasn’t bothered with the pain, except some at night, but only took a couple of the opioids as they weren’t very helpful and it’s hard enough going to the toilet without the constipation. A sleeping pill worked better for me. I’ve stuck with the exercises and believe I’m stronger now than pre-op. Best wishes.

[semdoug]

Being a bit of a smart ass here. You need a knee replacement and managed to ride 10,000 miles last year; wish I had such luck.

[Dave]

I can't imagine riding 10,000 miles on a bad knee either. The most I ever rode was 6500 miles, but living in Colorado, the number of good days is limited.

I quit cycling at age 57, because my left knee got too bad to keep cycling. I got both knees replaced 7 years later, at age 64. I started riding again at age 65, after almost 8 years off the bike. I'm about to turn 67. I used to ride 5000 miles per year, but I've cut back to 4000 or less now. I'm still increasing my strength, since I've been back to cycling for less than 2 years. I'm also riding some really challenging terrain with grades up to 12%.

My first TKR was difficult to get enough range of motion to pedal a stationary bike. It took about 3 weeks. The second was much different. I was pedaling after a week, but spent 16 weeks getting that leg to fully straighten. The rehab was not fun at all, but I had no unusual complications. I got off the opioids after 10 days, but I had to get a stronger dosage than initially prescribed. I'm not prone to opioid addiction. I still have leftovers in the medicine cabinet.

I used to ride 3-3.5 hours, but now I'm only doing 2.5-3. I have several routes with varying difficulty that I can complete in that time. I usually take one rest day between rides.

[Seramount]

good info, appreciate the responses...

as far as riding with a bum knee, strangely, it's about the only time it doesn't bother me. I can be on the bike for 3 hrs/day with only minor discomfort, but lately, even trying to walk a half-mile is a daunting prospect. I can do it, but it's gonna hurt.

have had issues with the knee forever, blew out the ACL 50 yrs ago and then diligently did as much damage as possible after that...serious amounts of basketball, high-mileage running, backpacking, etc.

but, the days of just taking some anti-inflammatory meds and using an ice pack to deal with pain are past. lately it takes 20 min each morning before the knee will bear full weight, getting in and out of the shower is a serious chore. have to pick up the leg up with my hands to clear the rim of the tub...

was told by two previous orthopedists that I'd 'know' when it was time for major repair work. pretty sure that time is now...

if my knee was a bike tire, the cords would be showing...

[Seramount]

oh, another Q...

I understand there's a 'robotic' version of TKR...anyone had that?

[2metalhips]

The most important factor in this is choice of surgeon. Due diligence is your friend, the wrong choice and you could be in for a life time of pain. The right one and you will as good or almost as good as new. Travel for the surgery if you must. Good luck.

[mnoble485]

I was either smart, dumb, heroic, masochistic...pick any when I had TKR on both knees the same day. My Ortho and I talked it over several times but we both felt that because I was fit and not over weight we could do it. I cussed him like a sailor for several days afterword. I was 61 and it was 10 years ago. Rehab was a bitch but I think total time was less than if I had done them separately.

Best thing I ever did. I used pain meds as prescribed especially an hour before therapy. Good luck with yours.

Mike

[Dave]

I'm not sure how you'd identify a bad surgeon. Mine had a good reputation in my area and he was in his 50's, so he had done hundreds prior to mine. I was surprised by the intense pain, the first night home and had to up my meds quickly.

I had both knees done the same year, but one in January and the other in November, so I could rehab during the winter. Getting both done in one calendar year saved me a lot of money. I paid my out of pocket maximum of about 6k for the first and the second was free. It would probably have been cheaper if I had waited until age 65, but Medicare might dictate where and maybe who did the surgery.

[biker72]

It would probably have been cheaper if I had waited until age 65, but Medicare might dictate where and maybe who did the surgery.

Medicare won't dictate who does the surgery. Finding a surgeon that will accept medicare is the problem.

[el cheapo]

Seven years ago my mom died from ALS. Two years before she was fine except for a bad knee. Decided to go with a knee replacement and the surgery went great until she began having symptoms like slurring words and difficulty walking. To this day, even though I can't prove it, I believe it was linked to the trauma of the surgery on her body. Yes each situation is different but I will never have surgery unless my life depends on it.

[Seramount]

I've had numerous surgical procedures...eyes, throat, hand, foot, tonsils, lumbar discectomy, and 3 on the knees (one radical, two scopes)...

there are excellent, good, and average surgeons...but, even great ones have bad days in the OR. so, it's a crapshoot what you get for results.

the hand surgery I had after being in a hit/run on the bike has left me with a totally numb thumb. the doc who did it was supposedly 'the man'...

the guy I've scheduled a consult with did a friend's TKR and he gives the doc his 5-star rating. said everything went flawlessly. the guy has reportedly helped develop some of the latest improvements in techniques, so that seems like a positive.

when I called for an appt, the office person said the usual wait-time was ~4 months, but there was a cancellation and I'm in for June 4.

guess I'll either get a warm fuzzy about the dude or I won't...have a list of questions to pose and will be interested in his responses.

[Spoker]

guess I'll either get a warm fuzzy about the dude or I won't...have a list of questions to pose and will be interested in his responses.
Excellent surgeon with terrible bed manners, or terrible surgeon with excellent bed manners?

[Plum Hill]

I’m going through issues with mine.
Worked on my feet, ladders, uneven surfaces, lots of squatting and kneeling. Lived with shot knees much longer than most would.

Had first TKR in 9/2014; second 7/30/2018. Never extremely satisfied with first; second problematical.
Surgeon said “let’s redo it”. Got second and third opinions; told I was overdoing it, termed a “slow healer”, TKRs aren’t meant for active people, and...get an E-Bike. I requested MRI, CT scan, or ultrasound for diagnosis and was refused by all three. No pain meds, no pain management.
BTW great palmares on all three.
Turned down twice by Mayo Clinic for review.
Turned to a doctor I researched. Took his PA to get my foot in the door. Saw him Monday. MRI Wednesday. Phone call Thursday informing me of large fluid pockets indicative of prosthesis loosening due to cement failure. Told surgeon would recommend replacement of replacement or living with it.
I asked about the possibility I had the problem on the other knee. “Same surgeon; same brand of replacement; same method. Probably same diagnosis.”
Recommend non-cemented joint.
He added I showed no typical signs of loosening (pain on pressure applied around knee).
I might add I can kneel on both knees and ROM is at least 135 degrees (less than what I started with but better than average).

To your research, add https://www.cedars-sinai.edu/Patients/Programs-and-Services/Imaging-Center/For-Physicians/Musculoskeletal-Radiology/Exhibits-and-Presentations/Knee-Arthroplasty/Aseptic-Loosening.aspx .

https://ryortho.com/2018/04/whiteside-v-callaghan-the-cementless-tka-its-about-time/

I saw Whiteside after first TKR and he mentioned then that he was against cemented prosthesis.

The people I know that are the most satisfied with TKR are sedentary. Fellow cyclist had one done 11/2018; said never again, not happy. Female horse rider in town says TKR (by my surgeon) “destroyed” her life and got rid of her horses.

Definitely not wanting to paint doom and gloom, but stuff happens. You better be prepared.
And there’s more to life than riding a bike.

[metalheart]

I had serial TKR's in 2015, the first in January the second in August. Before the TKR's I was riding average 6k per year at a good pace and did a reasonable amount of climbing. However, in the year before surgery, rides were often painful and activities of everyday life were compromised. I decided that the surgery was more likely to help me on and off the back than not.

After the first TKRI did my first full revolution on the trainer just short of 3 weeks. I was back on the bike by late February riding easy. I rode up until the day before the August surgery and then was back riding again in late September. Rehab and opioids are a whole discussion.

I rode about 5k in 2016, 6k, in 2017 and 2018. My speed dropped some and although I climbed a reasonable amount, I developed an issue in the second knee that turned out to be a popliteal tendon issue: if I used a bigger gear on the flats or to big a gear on steeper climbs I would get sharp and debilitating pain in my left knee. Original and second opinion surgeons suggested on option was to "release" (cut) the tendon and see if that would resolve the problem. Short story is that there was no firm opinion about what that might mean for cycling. I decided to live with a slower pace on flats and climbs. Early season it is necessary to not overdue it or I have a sore knee for extended periods of time.

The surgeries definitely improved my cycling life and my overall functioning off the bike. No regrets, I would do it again without a second thought. The cycling compromises after the surgeries are acceptable given that prior to surgery cycling was becoming difficult and many activities of everyday life were problematic. I do know of folks who have had TKR outcomes that seriously compromised their cycling and others who have returned to pre-surgery cycling levels. Things can happen.

The docs I have seen emphasize that a TKR for active people is a developing area of knowledge. Find a good doc, do the rehab necessary, and get back on the bike and ride however your new knees allow.

[teleguy57]

I had posted earlier in this thread. Saw the ortho most often/highly recommended in my area, and the xrays showed significant deterioration in the last 18 months. Severe gr 4 osteoarthritis, bone on bone, large spurs, evidence of some historical ACL damage, the works. He was a bit surprised at what I had been able to until now.

Will likely get a second opinion, and doing TKR late Aug-mid Sep. Of course, he said "and your right knee looks suspiciously like your left...." so that may be downstream.

Have to do some more research on the implant he uses (Zimmer Persona Medial Congruent) which is cemented. I asked about cementless and he cited failure rates higher for those, even among active people. Need to figure out how to get a better handle on that choice.

[reuben]

The most important factor in this is choice of surgeon. Due diligence is your friend, the wrong choice and you could be in for a life time of pain. The right one and you will as good or almost as good as new. Travel for the surgery if you must. Good luck.

What he said. But there's another VERY important factor.

Do the PT. Religiously. Without fail. A 70+ year old friend started to ride across country a couple of years ago but one of his knees just blew up, and he had to stop about 1/3 of the way into the ride. He's also still an avid backpacker and skiier, so he ain't no slouch. He did the PT as prescribed and was amazed at how quickly he healed. He was skiing again in 6 months. Said he'd have done it sooner if he had known it would work out so well.

I have other acquaintances who've had knees/hips replaced, and they all say the same thing. DO THE PT. The physical terrorist/therapist is your friend. Really.

[teleguy57]

Yes. My PT is a personal friend/cyclist/skier and we've been working prehab for a couple months already. He's already "authorized" to come up with some new and challenging ways to push me -- and he'll likely partner with my wife to do so! :help: