Quad Sparing vs Traditional Surgery

[Gringo]

Are there internal sutures involved in the TKR? I really don't know much about that aspect of it. For example, is the quad moved aside or cut and then reattached? What are done with the ligaments? My ACL was removed and grafted to the inside of my knee to become a replacement medial collateral ligament thirty years ago, so I have long been accustomed to walking with two completely different feeling knees.

And the one that was just repaired felt like it had been originally made of glass and had been broken and never replaced. And now, even with the pain and soreness of the quadraceps, it feels amazingly stable and secure. I love it.

 

[stives]

Re: Jamie's Year-After Knee Blog

Hey, that's brilliant news Gringo. A nice strong, stable knee - yeah!

Don't know about the medical side - I was told that I had lots of internal stitches but that they would gradually dissolve.

 

[Jamie]

Re: Jamie's Year-After Knee Blog

Are there internal sutures involved in the TKR? I really don't know much about that aspect of it. For example, is the quad moved aside or cut and then reattached? What are done with the ligaments?

And now, even with the pain and soreness of the quadraceps, it feels amazingly stable and secure. I love it.

Jo has told us there are in fact sutures inside that eventually dissolve. It is my understanding that there are two different ways to approach knee replacement surgery. In one, the quad muscles are cut and reattached. In the other they are not cut. Jo would have to explain the details of both these types of surgery.

Gringo, I think this is an excellent question and I'm going to move your questions to their own thread so that we can get some dialogue going on this topic.

I'm so glad to know that your new knee feels stable. That's exactly the feeling I had with mine....even through all the pain of the surgery, I KNEW it was gonna be a good thing.

 

[backbay38]

Gringo to add to Jamie's post the surgery many doctors have been doing for the last 5 or so years is called minimally invasive surgery. A smaller incision - 4 to 6 inches usually- and there is no cutting the quads. So healing and recovery are usually faster and less painful. But not every doctor is comfortable with the technique and not every patient is a candidate for it. I guess if your incicsion extends up your knee well into the quads -- you didn't have it. If it stops basically just above the kneecap... you probably did have it. You could also simply ask your surgeon tomorrow by phone what he did. I had the minimally invasive surgery and had no quad pain except what I would expect with a weaker muscle being asked to work harder. And pain at the right upper corner just under the kneecap -- which still comes back now and then when I do heavier weights at the gym.

 

[Josephine]

All incisions, knees, hips etc., are 'closed in layers'. For that matter they are opened in layers too. This means that, far from cutting straight down from the skin into the joint, it goes like this ..

1st layer: skin incised
2nd layer: fat
3rd layer: fascia lata which is the tough gristly layer over the muscles
4th layer: muscles which are not actually cut but opened by blunt dissection which is to say the muscle fibres are spread open with blunt instruments or even fingers
5th layer: capsule which is cut

Closing goes
5th layer closed with strong absorbable suture
3rd and 4th layer also closed as one with strong absorbable suture
2nd layer, fat, closed with a fine absorbable suture
1st layer, skin, closed with a fine absorbable suture running just under ther skin and topped either with staples or Steristrips. Or occasionally it can be closed with traditional sutures which may be either absorbable or non-absorbable material.

The issue of quads cut/sparing is a technical one, usually employed in a so-called minimally invasive approach. In this, the access to the joint is restricted and some surgeons choose to give themselves more room by making a small oblique cut in the quads just above the patella. It's a technique that is happily losing favour for the very reason that it hampers rehab and actually doesn't give all that much extra room during the op.

Cruciates can be preserved or sacrificed according to their condition. And either or neither the anterior or posterior can be preserved. If they are preserved, a slightly different tibial prosthesis is used that has a notch for them. Otherwise, they are removed along with the bone that is cut off.

 

[Jamie]

Thanks, Jo! What great, easy-to-understand information!!!

 

[backbay38]

You know, Jo, reading the medical explanations you write is like attending an online lecture. Only you write so clearly and illustrate so well that laypeoiple like us can actually visualize what you're talking about. What you write is so much better than anything I have read before..... That's really fascinating about the layers; I knew there were some but not that many.

 

[Gringo]

Thanks for that explanation. Certainly explains why my thigh is so damned sore. I haven't started any serious physical therapy yet. Is it advisable to start working the muscles while they are still stitched up, or should one wait for them to heal a bit before seriously flexing them?

 

[backbay38]

Gringo -- didn't your doctor give you post op instructions and say something about exercises and PT etc? Most surgeons have protocols they want patients to follow and they vary doc to doc . If not -- maybe you should ask him?

 

[Jamie]

Yes, Gringo. By all means contact your doctor and see if he agrees before getting too crazy with PT while the staples are still in. At your early stages, I had home therapy 3 times a week (some doctors do, some don't that early), but we didn't do a lot of strenuous activity until the staples were out. Even then, we kind of worked up to it.

Find out when and how you will be doing some therapy before you head back home. That would be important to know.

 

[Josephine]

Well, thank you, backbay! and others. I love doing it, you see, and it shows.

As for the exercises, some you should be doing right off like the straight leg raises, the flexions - though not too much, the quads flexions which is leg straight and clenching quads and the extension, leg straight and press back of knee on bed. These can be done before the wound heals though some surgeons don't mind if you take the first one or two weeks off and then do it when the staples are out, for no other reason than that it hurts! But check with him.

Also, if it's your thigh that is sore, Gringo, that's tourniquet pain. Mine was indescribable and lasted for 4 days! I could hardly lift the leg to take a step when walking. I had no idea tourniquets caused such excruciating pain.Some people's last even longer.

 

[stives]

Perhaps that's why my thigh's a bit tender then! It's where I would imagine the tourniquet would have gone, and I'm only aware of it if I touch it. It feels as if it should have a visible bruise, but I can't see anything!

I would feel wary about doing too much bending before the scar looked as if it was healed. I'd be worried that it might open up! Hopefully with no other problems (I think I'm a good healer, and have no other medical problems) then once the edges of the scar look as if they've knitted together then it's OK to stretch as much as possible? I don't know the answer to that!

Gringo, all I was told to do before the staples came out was the simple exercises that Jo has described. Every little bit helps. I'm still finding the straight leg raising to be very hard though - but it is definitely getting easier.

When do you get your staples removed?

Val

 

[stives]

Jo's description of all the cutting and stitching has got me thinking.....why is it that surgeons don't want to do knee replacements on people who are very overweight? I have three friends down here who are desperately trying to lose weight as they have been told they won't have the op until they do.

Is it because there is a lot more of that fatty layer to cut through, which presumably also means that access to the joint is limited? Or is it that there could be complications in other ways if people are overweight, such as under the anaesthetic, or more risk of heart problems or strokes?

Val

 

[Gringo]

All I have is a prescription for outpatient physical therapy, 3x a week for four weeks. Gait and ROM. Nothing else. Pretty sketchy.

 

[stives]

That's more than I've got, which is nothing but a little booklet!

 

[Jamie]

Gringo, that sounds like a typical PT prescription. They know what to do after taking an assessment of your particular situation on the first day. When do you start that? Is that going to be something you can continue when you get back home?

 

[Gringo]

Just now set up the PT for Wednesday. It will be three times a week until I screw up my courage and defy the doc and get on an airplane back to de island, mon.

 

[Josephine]

Jo's description of all the cutting and stitching has got me thinking.....why is it that surgeons don't want to do knee replacements on people who are very overweight? I have three friends down here who are desperately trying to lose weight as they have been told they won't have the op until they do.

Is it because there is a lot more of that fatty layer to cut through, which presumably also means that access to the joint is limited? Or is it that there could be complications in other ways if people are overweight, such as under the anaesthetic, or more risk of heart problems or strokes?

Val

That's the case for an awful lot of ops, Val. There are various reasons. Sometimes, yes, it does increase the risk of cardio-respiratory problems due to the extra load on the system. It can also be because some think it shortens the longevity of the prostheses which it does. There's also the Health and Safety factor for the staff who have to lift the patient on and off the table and then nurse them afterwards. From the surgical team's pov, it's tough work having to lift the leg and hold it up (especially in THR). Remember, each leg weight approximately one third of a person's total body weight!

However ... there are less and less surgeons that hold to that view and won't factor it in. I weigh 19 stone yet my surgeon never mentioned it at all, bless him! None of the surgeons at Sunderland factor it into their decision for joint replacement. It's their view that if a person has mobility problems, denying them a joint replacement is only going to make matters worse.

I nursed a lot of hip and knee patients who were in the morbidly obese category. They all did just fine. The last lady weighed over 28 stone! (400lbs), had a spinal and her op and recovery was perfect! My sister was in the same ward when she was done so I would stop by and have a word. She did great and was up and about really quickly. Lovely lady.

My suggestion for you to pass on to your friends is to ring around other hospitals and ask if obesity is a problem with surgeons there. They'll find someone who is willing to take them on eventually. And remember, we can go where we like now. There's no more restriction on going to your local hospital. You could even go to Bath, Bristol or Bournemouth, all of which have excellent joint reconstruction units, I believe.

 

[stives]

Thanks for that Jo.

I'm wondering if it could be one particular surgeon down here who is anti doing the ops on larger people!! Two of my friends have the same consultant. Both are really trying to lose weight - but when you can't exercise 'cos of the pain, and all you can do is sit and comfort eat, it's a vicious circle. Another lady, in fact one of our church ministers, is really huge - must be well over 20 stone. (She looks miles bigger than you do in those nice photos!) She has real mobility problems, waddles around with two sticks, her legs are very badly bent outwards - worse than mine were - and can't stand for long at all. But, she is hoping to go on the list shortly and hopefully can have both ops before the end of the year. She has a different consultant. But....I can see it would be a huge (!) problem to lift her - she is massive! And if each leg weighs a third of the body weight - that is a lot of weight.

As you say, it seems to make sense to try to get the knees sorted out, whatever the weight, as there is more chance of losing the weight post-op if the person is able to move!

I'll certainly mention to my friends about thinking about going elsewhere. Of course, it might be an excuse for them to put off the (evil) day !

 

[Gringo]

some think it shortens the longevity of the prostheses which it does.

Thanks, Jo. I think you just gave me the little bit of extra oomph I need to seriously tackle this weight gain I have allowed to happen to me over the past couple of years. Yeah, I have the bad knees, but gaining weight just made them worse, and brought me to this point a few years earlier than it would have otherwise. I gave up smoking a month before this TKR after reading some of the studies on smoking's effect on healing.

And now, thinking of maybe having this knee taken out and replaced someday because I continuously allow myself to be too fat....well,this might just do it for me. Keep the weight off and delay the revision for as long as possible. I am 58 now...if I could stretch it to another 30 years I might just slip by it entirely!

This will be my new goal: Make it to 90 on this knee and ride in a chair after that! Of course they will have all kinds of new technology by then, but I would sure hate to have to go through this again at 70 if I don't have to.

Isn't it amazing how much easier it is to stay in shape than it is to get in shape?