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Saturday, February 27, 2016

I Kneed a New Knee..... so Here's the Plan!

The long anticipated ultimate demise of my left knee happened.....

At the first of the year.

This image of x-rays shows the "good" right knee on the left and 2 x-rays of the "bad" left knee on the right - one from June 2015.... one from January 2016.

What was bad got worse.  Looks like the last little bit of cartilage is gone and the knee has displaced even more to the inside.

So, as alluded to in a previous post -, I scheduled an appointment with Dr Gregory Stocks of the Fondren Orthopedic Group in Houston Texas -  - flew into Houston and had a long discussion / evaluation on a TKR - Total Knee Replacement - for my left knee.

Without a whole lot of embellishment, here's the information and plan that was generated from that visit with Dr. Stocks:
  • The surgery is scheduled to be performed Monday, April 4th, at the Texas Orthopedic Hospital.
  • If everything goes as planned, I will be discharged from the hospital the afternoon / evening of Wednesday, April 6th.
  • Am awaiting pre-approval of the procedure by the insurance company so schedule is contingent on that.
  • As far as recovery / rehab goes, it goes in stages.
  • Immediately following wake-up from the surgery, they will have me up and on a walker.
  • It depends on the individual patient but it is reasonable to expect that I will be walking under my own power, i.e. without a walker, crutches, etc. within 2 - 4 weeks of the surgery.... and that will be my first goal.
  • External physical therapy / rehab begins the day after discharge from the hospital, so Thursday, April 7th.
  • The plan is to do it a Brazosport Rehabilitation and Wellness in Lake Jackson Tx - - a place I have used for past knee and Achilles Tendon rehab.
  • Rehab will be 2 - 3 times per week.
  • I plan on staying with my daughter for a few days immediately following discharge from the hospital.
  • If the recovery goes as planned, I will stay in the Lake Jackson / Houston area for 3 - 4 weeks following the procedure, again, with the goal being to walk under my own power, go up and down stairs and be able to drive a car.  Then I will return to Santa Fe and finish my rehab there.
  • The structured physical therapy / rehab plan takes anywhere from 2 - 3 months following the surgery but the knee continues to progress / grow stronger over the course of a year or more.  As I have presented in several prior posts, there are 4 - 3 month cycles in the process of complete soft tissue repair.... so it's reasonable to assume that nerves and blood supply pathways will be continuing to reroute and reconnect for at least 12 months.
  • As far as the hardware, surgical procedure and techniques go, Dr. Stocks and I spent a lot of time on that so here's what we came up with.
  • The hardware will likely be a DePuy Attune Knee System....
  • Technology for the joint itself and the poly spacers has gotten a lot better over the last 10 years as the demographic / age for knee replacement patients has moved to a younger, more active population.  "Cross link" polypropylene has vastly increased the durability and life of the bottom shelf of the joint with the main failure element now still being the methyl methacrylate cement that glues all the hardware to the tibia and fibula.
  • We discussed rotating platform or not and Dr Stocks said there is no data to support that patients have greater mobility or knee rotational or torsional dexterity with a rotating platform and the failure rate for rotating platform is greater so it will be a fixed platform.
  • Dr Stocks does not use "computer navigation" in his surgery as was done in the 14 minute video link before.  Per Dr Stocks, it introduces a lot more hardware into the wound and the risk and documented rate of infection for this technique is much higher.... so all the cutting and sawing will be done manually by Dr. Stocks.
  • The next question on surgical procedure was "Posterior-stabilized vs Posterior Cruciate ligament - retaining".  The patient's ACL - Anterior Cruciate Ligament - is removed during the procedure but there is an option for Posterior Cruciate Ligament removal or retention.  About 80% of TKR procedures are done with removal of the PCL but after discussion with Dr. Stocks on my past and future planned activity level, i.e. hiking, biking, weightlifting, etc., he recommended a PCL retaining procedure because it accommodates a more natural movement of the knee, i.e. the artificial knee works more like the original knee.  I was actually kinda surprised that he went out on a limb because there are more risks to this type of procedure - it is more technically difficult - but done correctly - does have better performance results.
  • In connection with this, I asked Dr Stocks how many TKR's he had done.... pretty mind boggling.... about 5000 with about 1000 PCL retaining TKRs.
  • The incision starts at the top of the knee capsule and extends to the bottom of the knee capsule but does not cut the quad muscle above the knee.
  • He will install a plastic button on the back of the patella (kneecap).
  • As mentioned above, we discussed in detail what I could / should do with the new knee and again, I was surprised.  Dr. Stocks said "I tell people to go do what they want to do".  Again, pretty amazing coming from a guy who has a vested interest in having the knee last.  He provided some more details on high risk activities of which he named only 2 - long distance running and jumping.  He says he has patients that ski, play soccer, tennis, do aerobics, etc.  Unfortunately, there are no studies on the effect of weightlifting, or the amount of weight that can / should be lifted with a TKR.  He did say "I think it's unreasonable to assume you can or should do a 350# squat" which I agreed with.  I haven't squatted 350 for over 20 years and don't plan or didn't plan on doing it even if I had 2 good God given knees.
  • But I am interested and concerned with overall health, fitness, strength and body muscle mass so I asked him what was reasonable - can I squat up to 225# which at 170# bodyweight is all I need to be squatting anyway and about the most I had recently squatted with.  We agreed 185 - 225# was not unreasonable for a TKR.
  • Total flexion post procedure is typically what you had before the procedure.  I had full extension of my left leg but I have never been able to do butt to heel with my left leg, having about 120 degrees of flexion so that will be a reasonable goal / expectation post procedure.
  • Post operative pain management has progressed a lot in recent years and is critical to a speedy recovery.  They put you on 4 different medications immediately - Celebrex, a blood thinner (to minimize blood clots), antibiotic and an opioid pain killer.
  • The big risk for a TKR is infection.  If that happens, they have to go back in, remove all the hardware and replace it with a antibiotic saturated cement and keep the knee completely immobile until the infection is eliminated.... then they go back in and re-do the TKR.
  • If the TKR fails in the future, Dr Stocks will do a revision.
  • I will likely buy a stationary bike for my SF condo and have it in place before I leave for Houston for the procedure.  I will likely buy one for my 4 weeks in Lake Jackson also.
  • Goals post procedure are in the following chronology:
  1. Walk without crutch.
  2. Walk up / down stairs.
  3. Drive a car.
  4. Attend my daughter's nursing graduation ceremony on April 29th and walk without a limp or assistance.
  5. Ride a stationary bike.
  6. Complete standard / recommended physical therapy / rehab.
  7. Walk 1 mile.
  8. Begin body weight exercises such as squats, lunges, etc.
  9. Get back into stretching and non-impact group exercise classes such as PIYO.
  10. Ride a regular bike.
  11. Start hiking.
  12. Start light weightlifting.
  13. Resume a modified CrossFit style workout with no impact and reduced weight exercise.
  14. Do a "long distance" bicycle tour in the New Mexico / Colorado area - probably will likely do the "Enchanted Circle" loop - Taos, Red River, Eagle Nest, etc.
  15. If I can do long distance walking with a light load without pain, I want to plan to do some backpacking probably along the Continental Divide Trail - in 2017.
There's probably a lot more I could put in this post, but, as with all other things in my life, new information and data will come in and I will update and document the process as it becomes available.

After talking with Dr. Stocks, I felt a lot better about the whole process and, frankly, it can't come too soon.

I'm tired of limping around in pain and dealing with all the negative aspects of this left knee and I'm ready for the challenge of the procedure, the rehab and life with a new knee.... whatever that life is.

As with all things, I will adapt, modify and overcome....

Because that's what I do.

And it's not like something a lot more complex than this hasn't been done before....

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