TKR Brownie's Good, Bad, & Uglies

[trailspud]

This is sure interesting about Los Angeles and Orange County drs not doing the MIS or my not being able to find one!

I know there is some hesitancy among some surgeons to advertise what has been termed MIS. I also know of others who tout it in their work. The following is from my surgeon's web site: I put in bold the line about this being a choice that should be made by each surgeon.

Minimally Invasive Total Knee Replacement: Recently there have been attempts to do this operation through a smaller incision. Many surgeons use a 10-12 inch incision. My standard incision is approximately 6 inches; however the opening varies with the size of the patient. It is possible to do the surgery through a 3 inch incision! Recent studies however, have shown there is a high complication rate, higher incidence of poor component alignment, and no significant advantage to the patient. Some still advocate this approach. However, experience has taught me I can produce a more reliable result through a 6 inch incision. This is a decision I believe should be left to the surgeon. The fact that your incision is a couple of inches shorter will offer little pleasure if your knee fails prematurely or does not work as anticipated.

 

[Brownie51]

Thanks everyone! Well I had to reschedule my April 9 appt at the last minute because I had an issue with a kid at school. I try to have all these appts at the end of the school day (so I don't have to take time off which I've used up anyway) but then if something happens I can't leave. But I got in to see Dr Klapper on Tuesday. It was so different from Dr. Spitzer's office. His office is old, his sculptures and paintings all over it. Old xray machine. But super nice office folks! So small compared to my other doctor who must have Cedars providing the office/staff etc.
Anyway, I like him. He said my flex on my new knee was 90! I have to agree it's less since I finished PT but gosh..90! So now I am working on that again. But the next night I had a kidney stone again, but went to work (no sick time) and urine took awhile to clear up. Must have been a tiny one like the first one I had. I was sure dehydrated, I really think that's whats happening. I just don't drink much so working on that. So I have to decide whether to switch or not. Dr K would do left knee June 21, Dr. Spitzer would do it June 19. I hope Cedars hasn't figured out I'm on for 2 left knee replacements while I decide. I would stop seeing Dr. S completely. Dr. K said he would put in the same knee unless he sees that my ligaments can't handle it. He thinks I shouldn't have had the mobile bearing and that's why I am losing the flexion but I am not sure I really understood what he was saying except that he will try to use the same implant but if he gets in there he may change his mind. I think I am losing flexion because I haven't done my exercises since I went back to work! Not because of my implant! I ride the bike just fine, no issues but had just been in my car for an hour and hadn't stretched. Wish I had done that before going in to his office! I hate for any decision to be made based on that one try at bending my knee! Anyway, he does the quad sparing procedure as a routine. "I just push them to the side". And he showed me how much shorter my incision would be, which is 2 or 3 inches. I assume he doesn't have trouble with alignment or he wouldn't be doing that. And HOPE that's true!!!
My new knee started hurting more this past week and is stiffer than ever before I don't know what's going on except that I haven't been doing my exercises. I wonder if this is a life long process? Will I/we have pain and stiffness forever? It's pretty depressing thinking about that. I thought I would get this fixed and be able to return to long walks, light hikes, shopping trips etc.
If you google Dr. Robert Klapper, images for him will pop up and you will see that he is does the Weekend Warrior show for ESPN. Never heard of it before I googled him after my surgery. (The nurses told me to switch to him!)
I will try to spend more time on Bonesmart. Going back to work fulltime has kept me busy and tired. I am trying to catch up on my gardening. Oh and flew to Las VEgas, all my kids and their SO's met there after Easter for a few days and I rode an elliptical for only 8 minutes, it's hard! Did the bike and then sort of played tennis. My youngest son hit the ball right to me and we did that for about 20 minutes. It felt so good to do something like that.
Soooo not looking forward to another surgery but just hoping this will give me back my life. I know you all relate to my feelings!
Love to you all!
Marianne

 

[Jacky48]

Marianne, nice to see you again! I'm glad that you're getting everything sorted out for LTKR, you'll be so happy when that is over and you can start planning for a better pain free lift! You're only 5 months out for your right knee so it's not uncommon to be experiencing pain or discomfort occasionally and as far as stiffness you may still be experiencing some swelling still. It will get better my friend, I promise!

It sounds like you had a great time in Vegas with you kids! I love Vegas, it's a fun place!

I wish you the best for you left knee replacement, before you know June will be here and you'll be we'll on your way!

 

[Brownie51]

Thanks Jacky! I am actually 6 months out from tkr but you are right. So glad I mentioned the pain and stiffness because I was/am getting pretty discouraged. Also still can't take a decent walk without causing pain and swelling both knees so I am hardly doing anything. Pooped when get home from work, happy if I can just keep my garden areas alive with water and tending!
Oh and Trailspud, the doctor who did my surgery does the long incision and cuts through the quads because he feels it gives better alignment. But the new doctor just routinely does the quad sparing and does not use a tiny incision but not as long as the 10", so I think his work is similar to your surgeon. I wasn't concerned about the length of the incision but I was concerned about cutting the quads. It seems like many docs have adapted to that procedure but I could not find one in LA. One of our Bonesmart friends said something about finding someone who isn't still doing the archaic procedure!
I hope my decision to change doctors works out okay and I have proper alignment.
I hope everyone is enjoying a beautiful Sunday. Overcast here but mild and delightful in sunny cal.

 

[Creeker13]

What your new dr. says sounds like what my OS did.... not worrying about the insision (but it was shorter) and not cutting the Quads. Good luck Marianne.... try icing and elevating before and after exercise... it may help some.

 

[trailspud]

Surgeons have their own preferences but so do we patients. I was talking with my veteran sales rep friend. He has told me about surgeons who believe they get their best results using the alignment rods and will not use or rely on computer navigation. Those rods are pushed through your bones into the intramedullary canal causing a lot more bleeding and trauma. While I read a study showing no long term differences in outcomes, and I'm sure others show similar results on quad and incision choices, I prefer less trauma over more all things equal. My LTKR went as planned in roughly 40 mts. Less bone resection. Minimal blood loss. And, hopefully faster recovery as my sales rep friend, surgeon, and his PA all have predicted. You having a choice in the matter is a good thing. I think you will have a better recovery and outcome going with your new doc.

 

[Brownie51]

Wow that is interesting and might explain something I was wondering about! The new doctor only took 3 xray views using the old kind of xray machine, not the new which goes onto the computer. So my new doctor does quad sparing but must use the old way/alignment rods. And the doc who did my right knee cuts the quads but uses the newer/computerized way of alignment. I will never be able to make this decision!

 

[trailspud]

I would check with your surgeon. Some use computer navigation w/o the scans used to create custom cutting guides. One of the surgeons I consulted last year, and my second choice, uses computer navigation with only a few x-rays prior. He is a Stryker surgeon, but he relies on his system to get a proper alignment within surgery (w/o Stryker's cutting guides). My sales rep friend says this is common as some implants have better custom cutting guides than others and surgeons all have their own preferences. Some use the traditional rods plus computer navigation (as my 3rd choice does). I suspect the doc you described uses compute navigation, but with or w/o using the rods...you would need to ask to find out.

 

[KathyH]

Good to hear from you again, Marianne. Sounds like your new doctor is good, but is also good that you have a choice of doctors

At six months, it's not unusual to still get a bit of stiffness every now and again. I still get it at seven and a half months. It just gets better as time goes on. Slowly but surely.

 

[Brownie51]

Hi Kathy! How are you???
Trailspud oh geez there is so much to think about. The thing is I dont feel like I know enough to make a decision between doctors when I have no idea which technique is best. I wanted someone who was more up to date so I met my guy who spares the quads, but then he didn't seem to be doing anything cutting edge with alignment. I didn't ask the right questions! I guess I will try emailing the new guy with my questions.

 

[pdx]

Stryker cutting guides have been recalled -- Class 1 recall. The original recall was voluntary; the FDA just last week raised it to a Class 1, the most serious. Just FYI.

 

[Brownie51]

Glad I didn't have a Stryker! Zimmer had an implant recall in the past. Ugh always something!

 

[KathyH]

I'm really good, thank you, Marianne. I miss my chums when they go AWOL

 

[trailspud]

Stryker cutting guides have been recalled -- Class 1 recall. The original recall was voluntary; the FDA just last week raised it to a Class 1, the most serious. Just FYI.

I sent a note to my sales rep friend to get some insight, but I know that when I told him the Stryker doc (who is incidentally the friend of my friend) did not use the custom guides, he said that is because they were not very good. A lot of companies have these cutting guide systems, but some are better than others and the docs all have their own preferences plus stuff is always changing.

 

[skigirl]

Marianne, I would go with my gut on this one---which doc do you like best. Didn't you say that the nurses recommended Dr. Klapper? That is high praise in my opinion since they see the results. My surgeon who uses a Stryker knee used computer navigation for the alignment. I went with results---can you ask your pt for instance about the results he sees from Dr. Klapper?

I am not impressed with your surgeon using an old technique--cutting the quads giving a 10 inch incision and if I remember correctly, you suffered with lots of problems. My doc uses a four inch incision and I had a much easier recpvery with a rom of 148.

Try not to worry so much about specifics---what surgeon do you trust more? And try to find someone who used him before you---are they happy? Even call the office and ask if they can hook you up with some of Dr. Klapper's patients. Kelly

 

[Brownie51]

Kelly-Cathy/Beachmomdk and her friends used Dr. Spitzer. Her PT in Venture love his work. My PT was very happy with his work as well. I was very happy with his work on my knee. I sure don't understand why there is such a variance between doctors/procedures! I feel that Dr. Spitzers alignment process is probably alot more sophisticated than Dr. Klappers. But Dr Klapper does the MIS and Dr. Spitzer does not!
I read medical articles...check out PubMed/NCIB for all kinds of medical articles from books and journals. Just "google" your issue into the search window. I have read way too much! But there is some evidence that there are more late complications with the smaller incision. No one on here has had that problem. Maybe the doctors in the study were not skilled enough to be doing the MIS! Anyway, I don't like Dr. Spitzer's office and he can be really rude (and was in the hospital). BUT I trust him to do a great job on my knee even if there is more pain than with someone who can do the MIS. Dr. Klapper's office is weird but the people are really nice. I had so many problems getting my tests done and other stuff with Spitzer's office. But I have to live with these knees forever and it's probably smarter if I go to Dr. Spitzer who I feel gave me perfect alignment. I have gone back and forth. But Cathy had such a good result as well. After all it's not a personality contest and most surgeons have difficult personalities. There is reason surgeons are stereotyped, it didn't start with my knee!
Thanks to everyone's help I think I am getting there. I see Dr. Spitzer on Monday afternoon and I figured that I need to make my decision that evening and then not look back.
Sorry Kathy H! I know everyone is busy! Since I went back to work I feel like I can't catch up with my house and yard and paperwork! Didn't get filed (tax day) last night but by next weekend I MUST have it done!
Did anyone see the photo of the man(in wheel chair) at the Boston marathon who's legs were literally removed by the blast? His tibia was completely stripped of muscle/skin/fat...no foot at all. I believe that both his legs were traumatically amputated. Anyway it sure made me feel lucky and grateful. A 3 year old girl lost a leg and she was an irish dancer! It was her 8 year old brother who died, and their mother has a bad brain injury. All the stories are so sad. Makes me feel pretty self absorbed for getting so wrapped up in my knee problems.
I hope everyone has a good night! Thank you all!

 

[pdx]

No, you're not being self-absorbed. You're rightly concerned about what happened in Boston. Yes, we're all lucky (and grateful). If you were self-absorbed, you wouldn't give a fig about them.
As for MIS, the studies so far indicate more complications, etc. I've never been known for my gorgeous knees, so I wasn't too concerned with the incision length. It's not 10 inches, by any means -- probably 6-ish. Until they make the implants smaller, I want to make sure the OS has enough room to get that sucker in there properly. (Or as a policeman friend once said, "I don't care if they give us compact cars, as long as we only have compact prisoners.")
Oh, as for self-absorbed: I now have one straight leg with a scar, and one crooked (knocked-knee) leg without a scar. Guess which one I obsess about?
One last thing: I don't know where California posts its infection rates, etc., but it's worth checking out the hospital(s) where these guys operate. And ask Dr. Spitzer: What's your infection prevention protocol? What has been your experience with infections? Good luck.

 

[skigirl]

I don't know about the complication rate of MIS---I have never really looked into it much.

I had an OS that I had worked with for years. But, during the first surgery on my right knee, after an injury, he decided in surgery not to reconstruct my ACL, despite the fact that I had said that I wanted it reconstructed even if it were patially torn. He did not discuss this with me at the time--instead just did what he thought best. I ended up with an unstable knee and a tkr.

When I met Dr. O, my current doc, he talked about MIS surgery--that was what he did most of the time---he changed if he needed a larger incision for easier entry, size of patient, size of knee, etc. I ended up with a four inch incision---which did not matter at all to me for beauty!! But, I did have an easy and fast recovery. I rode my bike 20 miles at 8 weeks. and I have a 150 rom on that knee.

But, most importantly, I respected and trusted him as a surgeon. I went with my gut. My husband was with me and both of us felt that he was my best bet----he knew my other surgeon as well. Ultimately, I decided to go with the person that I trusted and not with his staff, his x ray machine or anything else. (MY doc also does not have a new spanking x ray.). I trusted him and respected him. Also, he treated me as an athlete---not as an older woman he wanted to protect like my old doc. I have never waivered in my trust for Dr. O as a surgeon.

I think that you will find the answer to that question---Who do I trust the most? to be the solution to your problem. Kelly

 

[Brownie51]

Kelly The ancient xray machine concerned me. Not just because it's old. Dr. Spitzer took all kinds of X-rays including my hips as in relation to my knee. His computer got all the details, the angles and all of that for alignment. Alignment is his priority and it is mine also. Dr. K took 3 views of my knees with me holding the plate between my legs, balancing it myself. I asked Dr. K how he assures proper alignment and he wrote, "navigational tools that I created". He must use an inter-medullary rods? It seems like Dr. Spitzer was more scientific and engineered to me. I would prefer not to use either one of them. I would like to have a doctor who did MIS, was not rude, had a clean office and efficient, organized office workers who do their jobs without my reminder calls. My primary dr, my rheumatologist, GI, and gyn docs all meet that criteria! So it shouldn't be impossible but I have not found that yet.
I made an appt with Dr. Andrew Yun who is out of network for me. He was the first doctor I was interested in for my right knee but since he was out of network I didn't go to him. Going to find out how bad the damage would be if I should decide to use him.
PDX I tried to find out about hospital infection rates but I didn't get anywhere.
I checked with Kerlan-Jobe, loved my ortho there but he does not do the replacements. Today his office sent me the list of who they recommend, Dr. Spitzer was number one(and was recommended by several other doctors). They have a couple others on their list, which included Dr. Yun's group and one other Dr. Jason Snibbe.
It just seems so odd to me that so few LA doctors are doing the MIS. I have called several other ortho offices, who were recommended, who also do not do the MIS. UCLA does not have one and their best ortho is well known to be a real @hole.
I am driving myself and all of you nuts with my decision. We will be so glad when its over! I think the surgery will be a relief after all of this!

 

[Campervan]

Hi Marianne, what a dilemma you've got yourself into. Sometimes gut feel is the only way to decide on something like this. If I cant make a decision then I tell myself that I don't have sufficient information on which to base the decision.

Aren't MIS and computer navigated surgery two different things to be considered. I think Josephine has somewhere on the forum said that MIS is just another way of saying "its a smaller incision" and that nothing else is different?