Apprehensive about upcoming bilateral PKRs (Sept 18th)

[TKAA]

OK - here goes. Hope at least a few of you will bear with this long post.

I've been lurking here for a while and am beyond grateful to all of you for what you've shared about your experiences and your advice to one another. Here's my story - any and all advice will be extremely appreciative of any advice or suggestions.

I'm 59 years old. 5'6", 160 lbs. And I love to play baseball. I mean - really love to play.

At age 40, I was diagnosed with severe osteochondral arthritis in my right knee. At that time I underwent an osteochondral autograft (mosaicplasty). It worked incredibly well and I was back to playing baseball within about 15 months.

At age 54, the other (left) knee became unbearable, and my surgeon said the defect was too big for mosaicplasty. So I had an osteochondral allograft (thanks to the kindheartedness of some grief-stricken family to whom I will always be grateful). That didn't work as well - I suspect based on my surgeon's comments that the graft didn't knit well with my own bone and the interface went, in his words, fibrous. It took a couple of years, but eventually I returned to the ballfield, although my performance is greatly degraded.

(BTW I have also done Synvisc, PRP, and stem cells - all with mediocre results. Recently I've started cortizone injections every two months which help temporarily. When I play I take a hydrocodone before games which also helps.)

Five years on, with continued pain which has now begun to include hip-related issues and nerve pain, along with increasingly bowed legs, I thought it might be time to face the inevitable. I had learned from prior doctor's visits that I might be a good candidate for PKR as my arthritis appears to be only in the medial compartments on both legs. I felt that was good news as I hear they feel more natural, and preserve the cruciate ligaments which I imagine improves stability.

I sought out the best local surgeon I could find for that procedure. It's now scheduled for September 18th - both at the same time because A) he felt that I'd have a good outcome given my level of fitness and strength of ligaments and B) I'd much prefer to avoid two procedures and rehabs. (FWIW he only does Oxford UKRs).

As the date approaches I'm getting cold feet. While my pain is pretty much constant, it's not unbearable. Daily activities are tolerable, though I can't walk my dogs anymore because the destabilization when they pull on the leashes causes me a lot of pain. I am still able to play ball (albeit only with elaborate pre- and post-game routines). A couple of guys on my team have had replacements (TKRs) and seem to be able to play ok, but I know that's not advisable and it's totally possible that I won't be able to play after replacements, which would be pretty devastating for me.

I'm also concerned about the depth of my auto/allografts being an issue in the PKR process. In my one and only consultation with my surgeon back in May, he was kind of cavalier (even though he had my x-rays and MRIs close at hand he chose not to consult them) and just said "Well, if we get in there and it's a problem we'll just do a TKR instead."

I also read that the cementless Oxford UKR had more promising results for active people, but when I contacted his office about that possibility I was advised those are not FDA approved in the US so it's not an option for me.

I'm also considering radiofrequency nerve ablation as a pallative procedure to further extend my baseball playing and defer the inevitable, but haven't been able to find much in the way of unbiased reviews of that procedure.

Given my apprehension I contacted my surgeon's office to schedule a pre-op consultation. (Frankly I was a little surprised that wasn't standard operating procedure, especially since my initial consultation was 4 months before my surgery date.) Today I heard that I *might* be able to get in to see one of his physician assistants before my surgery date, but that seeing the surgeon himself would be impossible given his schedule. Naturally I declined the appointment with the PA and asked that they recheck with the surgeon to see if he could squeeze me in.

Anyway, with all that, I'm currently stuck firmly between postponing and just trying the nerve ablation to see if it would let me play for a while longer, and biting the bullet and just going through with the surgery. Any advice appreciated. A few specific questions in case any of you have any insight:

Is my concern regarding the depth of my auto/allografts a legitimate one? Has anyone had experience with a PKR after auto/allograft?

How worried should I be about the recent development of bowleggedness and hip/nerve involvement?

Do any of you have experience with nerve ablation for osteoarthritis pain relief that you could share?

As I consider postponing replacement, should I be concerned about further erosion of knee joints that might make future replacement surgery more difficult?

While I've seen some success stories regarding return to somewhat vigorous sports activities following TKRs, any testimonials out there re PKRs that might buoy my spirits?

Can anyone confirm or refute the assertion that cementless PKR truly isn't available in the US?

Thanks to any of you that made it this far. And thanks for being a great community and supportive resource.

 

[DEL2019Aug-6]

I had a partial on my left knee last year and was back competing in my sport(dog agility) 3 months after the surgery. Traveled around the country for a month competing at big events. This year I had a total replacement on my right knee 6 1/2 months ago and spent this past weekend competing at a regional event I was really hoping I would be ready for. My surgeon said I would be ready and he was right. Ran 10 courses over 2 days. Came in 2nd overall. The partial was easy to recover from. The beauty of a partial is that you get to keep your acl and pcl. Or at least I did. And it just feels like a normal knee. The total is great, better than what I had but not as normal as the partial. No more acl or pcl. Ive had to work a lot on my proprioception on that leg. Lots of variation in my workouts and a focus on building lots of muscle in my legs. I would describe the total as having a bit of an information delay compared to the partial. But I can still run agility, I can hike!, and walk on the beach for hours all without pain.

 

[TKAA]

Thanks! That's encouraging.

 

[Jaycey]

Do any of you have experience with nerve ablation for osteoarthritis pain relief that you could share?

Frankly I would not go anywhere near this and I doubt if you will find someone who will do it. Pain is a signal that something is wrong. Trying to mask that pain with ablation seems downright dangerous to me. You risk totally blowing out that knee.

should I be concerned about further erosion of knee joints that might make future replacement surgery more difficult?

Yes, if the joints are worn further or worse yet - collapse recovery from any procedure will be longer and more complicated.

Find a surgeon you trust and let the experts guide you through this. They will use the procedure and implants that they are most familiar with given your own medical situation.

 

[rosieNZ]

Its 3am in NZ Im awake after a hard day yesterday and Im reading your post.
Life is a progression. Sooner or later basketball wont be something you do. With knee replacement surgery you will swap the pain and disability for a new horizon of possibilities.

I had TKR x2. I wonder if partials just put off the inevitable? Personally I would find a surgeon I could trust who has an excellent reputation and then I would trust them to be an expert. You have alot of prep to do.
I get that you love basketball but its not all life has to offer you. Do your best to see other opportunities and move forward.
I personally have just started a little tennis (if it ever stops raining). I do strength programme in the gym as well plus I work 60+hrs per week
I can walk 10k per day but tend to stick at about 5k because Im so busy and need to have time for my husband, kids and grandkids. Being active is a gift that TKRs bought me so dont worry about having them rather than a partial. Your current situation doesn't sound encouraging!. I think you want to be able to focus on your future life and all it could be and kick your worn out knees into history xxx

 

[TKAA]

Thanks for your thoughtful advice rosieNZ. I understand that aging will eventually require me to stop playing baseball (which fwiw is considerably less knee stress than basketball would be). I just don't want to give it up prematurely. I'm sure you can understand that.

I'm so glad that your TKRs gave you such an improvement in your quality of life! That's certainly encouraging. Thanks again.

 

[TKAA]

Frankly I would not go anywhere near this and I doubt if you will find someone who will do it. Pain is a signal that something is wrong. Trying to mask that pain with ablation seems downright dangerous to me. You risk totally blowing out that knee.
Yes, if the joints are worn further or worse yet - collapse recovery from any procedure will be longer and more complicated.

Find a surgeon you trust and let the experts guide you through this. They will use the procedure and implants that they are most familiar with given your own medical situation.

Thanks so much Jaycey for reading my lengthy post and offering your advice. When I first heard about nerve ablation my first reactions were much like yours. However, since I've been researching it I've learned that it's an approved treatment for knee osteoarthritis in the US based on positive outcomes supported by clinical trials, and is covered by most medical insurance. As profit-motivated as the insurance companies are here, they're unlikely to cover a procedure that is likely to generate more expensive claims down the road. And as hard as I've looked, I haven't found any cautionary tales that confirm the concerns you cited.

Just curious - do you have direct knowledge of this procedure, and/or are you a physician? Knowing that would help me to evaluate your perspectives more fully. Thanks.

I especially appreciate your advice to "Find a surgeon you trust and let the experts guide you through this." Sadly that's harder than you'd think here in the US. The specialization is so intense and the business is so profit-oriented that getting unbiased advice is difficult to downright impossible. My surgeon is motivated to cut, my pain doctor is motivated to prescribe pain-relieving procedures ... the good old days of having a medical professional whose sole focus is on what's best for the patient seem to be long gone here. </whingeing>

 

[Jaycey]

Just curious - do you have direct knowledge of this procedure, and/or are you a physician?

No I am not medical. However I was offered this procedure as I have many issues with my lumbar spine. It was not a fit for me. But sounds like you have done your research and it might be a better fit for you.

I hear you about finding a surgeon. It's not that easy here either. But what we do recommend is finding someone who does high volume surgery. It's always good to ask how many procedures you surgeon does annually. If the surgeon waves off the question - find another. Good surgeons are proud of their numbers and are usually up front with them.

 

[Tykey]

This is an interesting question, I had no idea that ablation was an option, to be honest I'd never even heard of it. However, doctor Google knows a lot about it, and I'm now an expert(not!)
Bearing in mind the comments about the American health care system, it's actually available in the NHS system in the UK, so we can be pretty sure it's a real alternative to consider, although I've never known it to be offered for knees this side of the pond.
Would I choose it?
I realise this depends on non medical factors to a huge extent. It's a lot to do with our personal attitude to risk etc.
I would have a choice between an option (ablation) which is likely only temporary and allows the wear and tear to continue, or an option (new knee) which is far bigger a procedure, but will almost certainly solve the problem for 20+ years.
I'd go for the new knee as my personality tells me to get it properly sorted ànd not leave the problem purely masked by ablation until some future date, when my knee may well be a lot worse. That's a risk I'd choose not to take.

But I'm not you, you have your own personality, so I can't advise.

You pays your money and takes your choice

 

[TKAA]

No I am not medical. However I was offered this procedure as I have many issues with my lumbar spine. It was not a fit for me. But sounds like you have done your research and it might be a better fit for you.

I hear you about finding a surgeon. It's not that easy here either. But what we do recommend is finding someone who does high volume surgery. It's always good to ask how many procedures you surgeon does annually. If the surgeon waves off the question - find another. Good surgeons are proud of their numbers and are usually up front with them.

Yes, in fact that's what drew me to the Dr. I selected. The downside is that he's so busy with surgeries he doesn't have time for consultations!

 

[TKAA]

This is an interesting question, I had no idea that ablation was an option, to be honest I'd never even heard of it. However, doctor Google knows a lot about it, and I'm now an expert(not!)
Bearing in mind the comments about the American health care system, it's actually available in the NHS system in the UK, so we can be pretty sure it's a real alternative to consider, although I've never known it to be offered for knees this side of the pond.
Would I choose it?
I realise this depends on non medical factors to a huge extent. It's a lot to do with our personal attitude to risk etc.
I would have a choice between an option (ablation) which is likely only temporary and allows the wear and tear to continue, or an option (new knee) which is far bigger a procedure, but will almost certainly solve the problem for 20+ years.
I'd go for the new knee as my personality tells me to get it properly sorted ànd not leave the problem purely masked by ablation until some future date, when my knee may well be a lot worse. That's a risk I'd choose not to take.

But I'm not you, you have your own personality, so I can't advise.

You pays your money and takes your choice

Thanks Tykey for taking the time to read this and reply. I agree these are all highly personal choices and how we consider all the factors might lead to different decisions.

The thought that I might be able to "solve the problem" via surgery is one I can't really get my head around as I don't anticipate it will ever truly be fixed. In my mind it's just the tradeoff between one set of circumstances for another. I'm sure for some it's a no-brainer to have surgery because the pain has become intolerable but I'm not there yet.

Thanks again

 

[kneeper]

There are tkrs that spare the PCL and maybe the ACL. I know my surgeon told me he likes to spare the pcl if it's healthy. (I'm actually not sure if he did that with me. ) It may require certain implants but I'm not sure.

 

[TKAA]

Thanks kneeper. I read about those cruciate-preserving replacements (Zimmer Biomet Vanguard XP Total Knee). They were recalled here a few years ago - back on the market now but AFAIK few surgeons are using them.

Given that I seemingly have little or no arthritis in my lateral and patellar compartments, for me the partials seem like a better way to go. I'm encouraged that people here who have had partials note that the recovery is quicker and easier.

 

[Jockette]

I'm encouraged that people here who have had partials note that the recovery is quicker and easier.

This was the case for those that posted. It is not always the case. Partials can take as long or longer than totals. It all depends on lots of things. Every knee is different.

 

[TKAA]

This was the case for those that posted. It is not always the case. Partials can take as long or longer than totals. It all depends on lots of things. Every knee is different.

Jockette, I'm so sorry you had a less-desirable recovery from your PKR. I have a friend who had one and said "whatever you do, don't have a partial" because of his experience. But I don't know which compartment he had done.

I do wonder whether medial, lateral, and patellar femoral PKRs have differing prognoses?

 

[marieltha]

I agree with those advocating replacing.
I have 2 lateral PKRs that I am very pleased with.
I put off the first one, partly because I had such good pain relief with Euflexxa injections and Celebrex.
I wish I had not delayed as it was wearing away the leg bones, became very unstable very quickly, and was causing hip bursa pain. I didn’t have a sense of how crooked my leg had become until I stood and walked on the new partial (day after surgery) and was shocked at how straight my leg was!
I didn’t procrastinate with the second PKR and everything about that was easier.
Hope this helps.

 

[Jockette]

Jockette, I'm so sorry you had a less-desirable recovery from your PKR.

Thank you. It really surprised me as I read wonderful things about partials before my surgery. So it really frustrates me now to read that partials have a quicker and easier recovery. You just don’t know how it’s going to go.

I do wonder whether medial, lateral, and patellar femoral PKRs have differing prognoses?

I wonder that, too, but I don’t know the answer.

I do believe the skill of the surgeon is important. He/she needs good skill in every procedure they do. Just because they do lots of successful TKRs does not guarantee that the few partials they might do will be successful.

At my one year check up I asked the front desk how many Patellofemorals my surgeon has done. Long story short, they wouldn’t tell me. What that tells me is, they don’t want me to know. I suspect that explains my poor outcome. For all I know I could have been his first, though probably not. But I will never know.

 

[kneeper]

Thanks kneeper. I read about those cruciate-preserving replacements (Zimmer Biomet Vanguard XP Total Knee). They were recalled here a few years ago - back on the market now but AFAIK few surgeons are using them.

Hmm. Well, I know I don't have that kind.

 

[marieltha]

I definitely agree with Jockette about the surgeon. Mine was the first to do partials in Florida and had done more than 20,000 when he did mine.
He also uses and is on staff at a hospital (all private rooms) that doesn’t rent nurses/PA’s, so he has his own PA for every operation and knows all the nurses and the anesthesiologists there. And he has a full time RN on call 24/7 for only his surgery patients. She calls you before and after; you can call her anytime; she can add you to his schedule from her home pc if an emergency occurs; she coordinates all your home care RNs (he uses only RNs), too.
I also personally like surgery Wednesday/mid-week. Away from the distractions of the weekends. And the office is still open for a day or two after your surgery.

 

[lennie]

I would go with the replacements ASAP. You are way past the point of needing intervention. I am your age and had TKR on both knees 9 weeks apart in the fall of 2016. My only question is why did I wait so long. I am a paramedic and went back to full duty 4 months after surgery. It has been a great decision. Usually when one door closes another one opens so maybe baseball will open a greater window. Trust your surgeon and go for it. It doesn’t get better. The pain is telling you something important so listen.


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