Statistics and the decision for TKR

[BigGene]

As I ponder my decision to have TKR here a question I need to face.

I have come to the conclusion that the degradation in my quality of life is not what I want to accept. It is far different from it could be after a sucessful TKA. The number of people on this forum who are skiing, hiking, jogging, playing tennis or playing with their children or granchildren in ways they no longer prior to surgery is both inspiring and motivating.

However. the risks of this surgery, or any surgery, seem small, but they are not insignificant. In the final analysis TKR is an elective procedure.

There is a risk that the procedure does not go well and that we will never achieve the quality of life improvement we seek or that the path to get there is traumatic and painfull.

The numbers seem very small, 1%, 0.5% or even less. Good odds, right? But if 500,000 TKA are done in the US, a 1% failure means 5000 people who suffer or maybe never achieve the intended outcome.

Further, if it happens to me it represents a 100% failure rate for my TKR surgery.

I appreciate that everyone in this forum stress a positive approach to these discussions, but some seemingly very small statisical risks can become very daunting if I became one of those 5000.

I apologize for the negativite nature of this post, but I would appreciate an open discussion of this risk. Obviously, those of you who made the decision all faced these sane thoughts. Those of us contemplating the decision matrix need to be able to face it openly and evaluate it inteligently.

Thank you in advance for your thoughts and discourse.

 

[referee54]

You write of risks. There risks that we choose to take everyday. Every time we get into a car, I would imagine that the risk of getting in a car accident is higher than having a TKR surgery go bad, correct? If you have flown on an airplane, you have taken a risk, too. Horseback riding, basketball, raquetball, all have risks; a man was killed working at a golf course last week when he was struck in the head with a tee shot.

If we choose to participate in sports, there is also a chance that we could sustain an injury--perhaps even a catastrophic one. In the 38+ years that have officiated, I have seen more than my share of horrible injuries. the more you play, the greater chance you have of something happening to you. If you look at the NOCSAE Warning Label on the back of football helmets, hockey goalie masks, and catchers masks, you will know that there are risks with some very grave consequences.

When I decided to have my BTKR, I knew the risks; I also knew that my life as I was living it was not what I wanted to be. I couldn't sleep at night; it was if I was having gutter nails driven through both of my knees. I couldn't cycle , nor could I officiate; heck, I had a hard time walking up and down the hallways at school.

To me, the risk, while very real, was minimal and worth it. My question to you is this: When are you willing to take the risk---albeit a very slight one---to improve the quality of your life? If you are not, then you simply decide to put up with the pain and the possible debilitating effects of arthritis. That choice is yours. Is the chance of regaining your life and your level of activity worth the risk? If it isn't, you must then choose to accept the pain and the other negative impacts; if it is worth the risk, then---and only then---do you make the phone call to set up the TKR.

Tim C.

 

[Jamie]

You have made a very wise analysis, Gene. The risk of problems is small when compared with the successes. But if YOU are in that small percentage it is a really big deal!!

Life is all about choices and weighing risks and benefits. This elective surgery is no different. You have to decide what is right for you. But, I can tell you this....if you do nothing, you have a 100% chance that you will never get back the days you are losing to pain. No one knows what the future will bring and for many people it is just not worth it to waste precious days like this.

If it helps any, even when there is a problem with a joint replacement, there is almost always something that can be done to fix the situation. Jo can probably give you better statistics on this, but in the 2+ years I've been on BoneSmart, I cannot recall anyone who wasn't able to get a revision done.

You're right...there are no guarantees. It's life. No guarantees there either. This is the reason we stress the importance of finding the best surgeon you can....with the most experience in what you are having done. This ups your chances for success dramatically.

I hope my thoughts help you in some way.

 

[referee54]

One other interesting piece of data to consider. NSAIDS---especially COX-2 inhibitors---all have a risk of causing heart attacks. Celebrex has a lower risk---but it is still a risk. I was on Vioxx---that was pulled from the market. Again, even when one chooses to forgo the surgical route, there are risks.

(An interesting side note---I had just taken my two Vioxx pills and was just getting out of the car to ref a football game when I listened to the news about Vioxx causing heart problems. Whew...that was as interesting way to start a game...)

 

[ruppbike]

Gene -

Totally understand your thought process as you ponder. I too am an analytical person. This may or may not have been part of your very sane process: you living with pain affects others. Slowly and steadily I believe that most people living with pain have a change of personality and demeanor - and these are not postive changes. It is natural. It also happens without YOU realizing, but the ones you care about most then also have to live with your pain. When I finally told my wife I no longer wanted to go with her on the daily dog walk she said, "good, you were a miserable grouch anyway." I began to think of how my interactions with people have changed with the increase in pain tolerance required. It was part of my decision process to take the risk and make the change for the better.

Hope this helps, Kurt

 

[cotton1958]

Good responses.

As far as risks, I saw a lot in not getting my BTKR's done. I was tripping and near falling because I could not lift my legs up high enough. One day, I was leaving the store I was working in, my knees had then suddenly become the worse they were going to be, and I almost walked into a thick glass window I thought was the door, I was feeling disoriented in my thoughts of trying to just get to my car safely w/out my knees giving out. That was one of my last days of work.

Then I was too scared to not do something about my knees. And there wasn't 2 ways about it at that point, unless I wanted to go into a wheelchair. And there are risks there too, like flipping out of one...well frankly didn't want to go into one. I just didn't have a choice any longer.

Hope you find peace in whatever decision you choose.

 

[skigirl]

Gene,

These decisions are so difficult--I also struggled with no wanting a tkr. I had so many issues--for one thing, i associated the surgery with age; for another, it felt like failure to me to have to replace my knees. I worried about which knee to use, I worried about my surgeon--who wanted to do both knees at once and i knew that I would not get the outcome that I wanted with him.

finally, we went to a knee specialist who does 300 knees a year--and both my husband and i were impressed by his explanations and his skill.

For me, I sat in ski school one day with my head hanging down, absolutely exhausted and several people said--Kelly, what is wrong. Also, I did not like what I was doing--this hurt and that hurt. I stopped hiking---because my knees hurt.
I was tired all the time--my rheumatologist said that pain makes you tired--and she was right. But, most of all, I stopped working in my studio--I could not stand up to quilt--my knees hurt--and I was so tired, I did not go to my studio to work.

So, for me the decision was easier---I could not stand the way my life was going. I did not want to wait until things were worse--and maybe miss a ski season because I had too much pain.

Once, i decided, I stopped reading all that stuff about risks and side effects---I decided to trust Dr. O and just move on. It was the best decision of my life. Today, I have the old, enthusiastic me back. I go into ski school and say hello to everyone, I am not grouchy, I don't hate people who are young and have good knees!!

So, today, I swam at 6 am for 45 min. I went to ski school, we were in training from 9 am to 4 am. We skied all day except for a lunch break of 45 min.

When I got home, I took the dog out for his 2 mile walk and now, i am sitting in my studio!!

I am not tired, I am working on a new painting and reading all the posts on bone smart.

Tomorrow, I am also in a training session and I will ski till four and then go to the gym for a spinning class--then, home, dog, studio.

Life is good----statistics are statistics. Kelly

 

[BigGene]

Thanks for your thoughts. They mirror many of my own and provide food for further analysis. In some ways what you are all saying is in the final analysis it may not matter that there are risks at all.

Suppose I asked each of you the following question: If after doing you due diligence finding the highly skilled surgeon and hospital you seek you are told that there is still only a fifty/fifty chance of the ourcome you have achieved. What would you do anyway?

I expect for most or all of you the decision is that continuing without the opportunity to improve is worst than failure and I guess that is probably where I end up. Do the research, interview the OS, check out the hospital and as the Nike add says "just do it".

I guess my only remaining question to the forum is directed at those member who have actually had a less than perfect result. The question may be unfair and pehaps not even relevant but I'll say it anyway.
Would you do it again having gone though your particular set of difficulties?

 

[jugornot]

Mark Twain once quipped "ther are lies, damn lies and statistics." Even if the failure rate was 10%, it would be a very successful operation. Carrying your logic into the absurd: With 50% of all marriages ending in divorce, why should you marry? 100% of all children die, why would you ever have children. But as a matter of life we continue in our lives despite the risks involved. Why should a 1% or even 10% risk keep you from living a full and pain free life. Its like my wife. Even after the last shuttle disaster she said she would love to go up on the shuttle regardless of the risk. I said it was much to risky. Risk must be weighed against what you want to accomplish with your life. Even just taking my dogs for walks was worth the risk to me for my knee. I put great value in small things that make life worth living.

Bill

 

[jugornot]

snip

I guess my only remaining question to the forum is directed at those member who have actually had a less than perfect result. The question may be unfair and pehaps not even relevant but I'll say it anyway.
Would you do it again having gone though your particular set of difficulties?

There are no perfect results. Not a single one. We all endured pain and suffering, swelling and PT to improve on what we had. I expect at a year out I will still be able to overtax my knee and know it is not the one God gave me. Of course I knew that 15 years ago when my pain started. Although I am fairly new to the forum I can only remember one who wished they never had it done.

I have a clunk. My friend has less rom. Natalie is going through a tough time. Read more and again. Look here Link He is on his third try and still positive. Follow these threads for a few months and see how they resolve.

You are asking the ones with a less than perfect result. Stick around you have time to ponder your situation. When the pain finally beats you into submission post here link about how you waited too long.

Bill

 

[Tykey]

This is a really good debate, and almost every post comes to the same conclusion, in that it is a risk worth taking. There's no getting away from the fact that there are failures, but what is the standard of life of those failures.?

In doing nothing, your problem will get worse (and your wife will go for longer walks:hehe and the risk on this side is that you will finish up bed-ridden and a real pain in the butt. (I'm talking American now, because butt is less rude than the English version)

Are those who have failed procedures better or worse than doing nothing in the long term??

If you consider what the future would hold for you in the long term, rather than the short-term statistics, you might find a bit of clarity.

So do a long-term balance of risks versus benefits

Personally, and it has to be a personal decision, the balance was well on the side of going ahead. But my attitude to risk is almost certainly different to yours.

 

[Josephine]

Gene, having worked in this field as long as I have (from the beginning!) I was surprised to find myself plagued with the very concerns you have voiced. But the "what ifs" of this life can drive you batty if you let them. What if you didn't get it done but decided to wait another couple of years? And then what if in some months time you got knocked down and killed in the street? You'd have wasted those months of quality life, with or without complications.

There's also the question of degree. In a recent studies where complications are discussed, they are invariably accompanied by charts logging the degree of the complication on the OKS (Oxford Knee Score) or the WOMAK (Westren Ontario and McMaster Universities) scores which define the question of degree.

So whilst a person might have a 'poor outcome' of say, a clunking knee, it might be defined as only of nuisance value or be extremely disabling. It also might be prevalent on a few days but absent the rest of the time.

So while you would be correct in saying almost nobody has 100% good outcome, it is still a question of degree and for most people, that degree will be worth the nuisance compared to the pain and disability they were suffering before the surgery.

An alternative to ponder!

 

[Max Wallace]

Minimize your risk by only choosing the best Surgeon (travel if you must) to get the best. Don't settle for an ortho DR. that does knees but one that specializes in this surgery. I went to the Campbell clinic in Memphis TN. They have a large pool of surgeons that all specialize in different areas. After you find one do some research about him in particular ask pointed questions it your knee and if they wont answer go to another one.

 

[DebR]

Wow, no wonder this site is called "bonesmart". These are by far, some of the smartest answers I have ever heard regarding this subject! Well done. I agree with what all have said. Only you can decide what you are willing to tolerate with your knee and for how long. I had a partial knee replacement done, did not have great results, and went on 1 1/2 yrs later to have a TKR with another surgeon. All of us have weighed the risks and benefits, and decided that it was so worth it to have our life back. As stated, there are risks with everything we do. The best you can do is make an informed decision. Research and find an OS that you trust, talk to physical therapists in your area for their advice. They, after all, deal with the other side of TKR. Ask about anesthesiologists, and talk to them regarding all the different options that are available to you, and there are many. Read ALL the information in the library here, and then do the only thing you can, choose how you wish to live the rest of your life!! Good luck to you in whatever choice you make