Need to decide between PKR and TKR

[sk44tyler]

I am a 42 year old male with a long history of right knee problems and overall pain. Here is my story / history:

I remember having pain in my right knee, beginning in 5th/6th grade. I saw a doctor and without doing an X-Ray or MRI, he simply diagnosed me with tendonitis. I believed this diagnosis and tried various things to manage the pain while playing sports (I played basketball and lacrosse in high school) - this included taking much Ibuprofen and wearing a Cho Pat knee strap. Finally when I was 16, the pain got so bad, I convinced my parents to take me to a new doctor. The first thing this doctor did was take an X-Ray of my right knee. The X-Ray revealed Osteochrondritis Dissecans (OCD) - specifically a small piece of my medial femoral condyle had broken off. In 1999, when I was 16, I underwent surgery where the doctor affixed the broken bone to my femur utilizing a screw. After a lengthy recovery (non-weight bearing for an extended period), I actually felt very good and was virtually pain free. The bad news is, that the pain slowly began to return in subsequent years. Finally in 2012, the pain was so bad again I decided to see a new doctor. Here is an overview of my surgical history from that point until present:

2012: Microfracture surgery performed because of significant cartilate loss. The screw from the surgery in '99 was protruding slightly. The Dr. attempted to remove the screw but it broke off beneath the surface and remains in the bone today

2016: Autologous Chondrocyte Implantation (ACI) Surgery (medial and patellofemoral compartments treated)

2020: Euflexxa Injections (Hyaluronic Acid)

2021: Subchondroplasty Surgery

2023: Bone Marrow Aspirate Concentrate (BMAC) Injection coupled with five shockwave treatments. Prior to the injection, I had an MRI which revealed significant cartliage loss in the Femorotibial and patellofemoral areas (lateral compartment is fine)

Unfortunately none of these procedures worked for me... I am still in pain - pretty much daily. If I am on my feet a lot (standing or walking), I will always develop pain that starts out slight and gradually increases to where it hurts to walk and I am limping, My max distance for walking (until I am badly limping and in pain) is approximately 1 mile. Sometimes if I turn the wrong way or step wrong, I get a shooting pain that sometimes is brief, while other times hurts me for the rest of the day. In addition, there are times where my knee hurts for no reason at all (seems to be weather related). The pain is always felt on the medial side of my knee, as a deep aching sensation. Also, going down stairs is challenging for me.

Anyways, I've tried all conservative treatments known to mankind (TENS machine, RICE, Ibuprofen, Diclofenac, wearing an unloader, wearing an Incrediwear sleeve, etc.) - while some provide brief relief, nothing is long lasting or really makes the pain maneagable.

At the end of the day, I want to be able to run around with my kids (at least a light jog), shoot hoops, go on long hikes, walk around at Disney World all day, etc.... I feel very limited by my knee and I am fed-up with the constant pain.

From my research, I feel like my best bet at this point is a Mako Partial Knee Arthroplasty. Mako seems to be the way to go because of the high degree of accuracy, precision, and fit of the hardware. I am thinking a partial would be good in my situation for two reasons: 1) All my pain is on the medial side (always) 2) Since I'm relatively young (42), it seems that when the partial knee replacement inevitably fails (in approx 20 years), I stand a much better chance at having a successful TKR, as compared to if I had a TKR right now (revision success rates seem to be much lower).

I would love to hear from the community and what people think my best course of action is at this point. Thanks in advance!

 

[Ziggy100]

I am no expert on this at all (my TKR is May 14, only had arthroscopy of knee and hip before), but I'd be inclined to go for a total knee. I read info that some knees are good for 30 years now. I would hate to see you needing treatment for the lateral side of the knee in a few years. I would also be afraid that the partial replacement would somehow throw your leg height off on one side and therefore make your gate uneven.

Have you seen an Ortho or 2 and what do they say?

 

[sk44tyler]

Thanks for the reply! I’ve seen one ortho so far who said I could really go either way (TKR or PKR) but eventually settled on thinking a PKR would be better for the reasons I previously stated. This doctor is only experienced with Mako TKR however, so referred me to a different doctor with Mako PKR experience. I see this new Dr. on Thursday, so we’ll see what he says.

 

[mendogal]

Our general recommendation is that the individual surgeon's skill is more important. than the robotic or computer system they use.
And with partials, the number of successful partials on your compartment is critical knowledge to have.

I agree that a partial may well be your best choice. Many of our members have done great with partials and I'm sure some folks will chime in re theirs!

The important thing that isn't often mentioned is that recovery time *might* be just as long with a partial as with a total - a few of our partial members had remarkably fast recoveries, but that's not the norm.

 

[sk44tyler]

@mendogal - Thanks for the reply! At my appointment on Thursday I’ll be sure to ask the doctor how many medial partials he’s performed. Also, I’m looking forward to hearing about people’s experiences with PKR’s on this forum.

 

[EalingGran]

I agree with @mendogal that partials can be very successful ( I have a lateral PKR) but they are slightly more complex surgery and it is really important to get a surgeon who does lots of partials.
Medial partials are the most common partials and the most straightforward. I know some people with Medial partials who have had speedy recoveries but it is definitely not necessarily faster in terms of recovery time than a TKR.

 

[sk44tyler]

@EalingGran - Thanks for the comments.... that definitely makes me more confident that the PKR will actually work for me and relieve my pain. I'm cautiously optimistic though, seeing that nothing has worked for me so far.

 

[hhilltop]

@Lcjudge gave a report of Dr. Gauruch in Gallatin, TN, that uses computer assisted surgery to resurface rather than totally replacing knees. The reports of his patients are nothing shy of amazing. TKR's are rarely short rebounds. I'm still rebounding after 13 months from my last one. You've been doing your research, I recommend this as one more avenue you should consider. I wish I'd known of this surgeon 2 years ago. This is not an endorsement, but a recommendation for your consideration.

LCJudge was due for having a second knee done almost two months ago now. I wonder how that went. I'm sure others would like to hear it, too - including sk44tyler.

 

[sk44tyler]

@hhilltop - thanks for the comments... Very interesting... So from my limited research (See Southern Sports Medicine Institute), it appears the "Southern Approach" utilized by Dr. Gauruch is primarily different in that the incision is done from the side (as opposed to the front of the knee). I am assuming (although not positive) that the entire computer-assisted navigation mentioned on the website, is no different than the Stryker Mako procedure (perhaps that same?). I briefly looked on YouTube for a technical video showing the "Southern Approach" in action, on live patient, but could not find one. If anyone knows of one, please post the link.
I am in the Charleston, SC area, so I probably won't be traveling out of state if I have a PKR done (it wouldn't be covered by my insurance). I am not currently finding any Charleston Ortho's who employ this "Southern Approach" for knee replacement.

 

[hhilltop]

Glad you are checking it out. If any, anywhere know of the "Southern Approach" being used, I'd like to hear more about it. I understand the insurance limitations. It means we need to advocate in each state for new methods to be researched and encouraged - or for insurances to allow at least access to neighboring states as warranted.

 

[lrj]

I had mako patella femoral PKR and am 37. I also needed an osteotomy to fix my knee alignment. I'm 8&5 months post surgery and it has given me my life back!
One thing I've experienced and have heard many others say about knee/hip replacement: you can walk great and no pain, but standing in one spot for even 10 minutes can still be a challenge years later. Fortunately, my job involves walking around and sitting. No need for standing in one spot.

 

[sk44tyler]

@lrj - I’m happy to hear your PKR and osteotomy were successful. I hear you on the challenge of standing after a hip/knee replacement. For me though, I’m not too concerned because I have problems standing as it is. A couple years ago I went to a music festival and was standing a lot that day (intermediate sitting)… by night, I could barely walk and my entire leg and foot had swelled up.

 

[sk44tyler]

Well I just saw my new Dr. (referred by my previous Dr.). After looking at my case, he was intially inclined to recommend a high tibial osteotomy (HTO). He thinks an HTO can help realign my knee to take pressure off the damaged side (medial) by wedging open the upper portion of the tibia to reconfigure the knee joint. NOTE: My alignment right now is perfectly straight. In addition, he said he would probably do some kind of cartilage treatment (e.g. Osteochondral Autologous Transfer Surgery (OATS).

I told him that after having ACI surgery in my 30s and being non weight bearing for several weeks (followed by extensive PT), that this really did not appeal to me - it was a long a slow recovery. I have 3 kids who keep me busy and being non-weight bearing for 6 weeks is something that would be extremely hard for me to do. In addition, it seems a bit counterintuitive to me to purposely put me out of alignment just to alleviate medial pain. Couldn't this cause other problems such as gait and/or hip issues? Also, this option does not seem like a sure fire way to eliminate my pain... I will still have some load on the medial side and its not a guarantee that any cartilage restoration procedure will actually work (as I've found out through the years).

Anyways, he understood why I was reluctant to proceed with the HTO, but said he would not be doing his job if he didn't offer it as an option - I can appreciate this and like the fact that he's trying to preserve my joint as much as possible in a conservative matter. He told me to research the HTO procedure and talk it over with my wife.

I specifically asked him about how much experience he had with doing Mako partials - specially with medial partials... he said he has done many over the years, so I don't think experience is a problem. He ordered a Mako CT scan for me which I will get scheduled shortly. After the CT, I will make another appointment with him and choose an option going forward.

Anyways, do any of you have any opinion on which option I should choose? (e.g. Mako partial (medial) vs HTO w/ cartilage treatment). Thanks

 

[EalingGran]

In addition, it seems a bit counterintuitive to me to purposely put me out of alignment just to alleviate medial pain

That seems counterintuitive to me too.
As someone who became increasingly out of alignment ( naturally knock kneed but got much worse due to lateral arthritis collapsing that side)- this led to severe back and hip pain which massively improved with straightening my leg with a PKR.

 

[sk44tyler]

@EalingGran - Thanks for the comment... It's nice to hear from someone who's experienced alignment problems and the impact this has had on the rest of your body. Your comment further increases my preference for a PKR as opposed to an HTO.

 

[sk44tyler]

For those that are interested... I found this study pertaining to HTO's: https://www.nature.com/articles/s41598-023-44051-4

This section was particularly interesting: "However, the location of the aimed weight-bearing axis is still controversial. If varus deformity is insufficiently corrected and the alignment is not shifted outwardly, compressive loads of medial compartment will not effectively redistribute; meanwhile, overcorrection always leads to an accelerated degeneration of the lateral compartment and patellofemoral joint. Therefore, total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) remain the gold standard indication in patients with end-stage degenerative KOA which affects multiple or single compartments of the knee."

 

[EalingGran]

High tibial osteotomy versus unicompartmental knee arthroplasty for Kellgren–Lawrence grade 3–4 knee osteoarthritis in younger patients: comparable improvements in patient-reported outcomes, adjusted for osteoarthritis grade and sex - Knee Surgery, S

Purpose Previous studies comparing high tibial osteotomy (HTO) with unicompartmental knee arthroplasty (UKA) have seldom accounted for differing patient characteristics between both groups. This study compared patient-reported outcomes (PROs) of HTO and UKA patients, adjusted for preoperative...

link.springer.com

Had a look at some of the literature and this paper is interesting.
There does still seem to be debate about HTO versus PKR but this paper is very recent.
I think some of the older literature reviews found PKRs were more challenging and had higher revision rates.
This paper suggests better results with PKR and also shorter recovery than for HTO.
HTO seems to be used more for younger patients who want to return to very high activity levels.

 

[sk44tyler]

High tibial osteotomy versus unicompartmental knee arthroplasty for Kellgren–Lawrence grade 3–4 knee osteoarthritis in younger patients: comparable improvements in patient-reported outcomes, adjusted for osteoarthritis grade and sex - Knee Surgery, S

Purpose Previous studies comparing high tibial osteotomy (HTO) with unicompartmental knee arthroplasty (UKA) have seldom accounted for differing patient characteristics between both groups. This study compared patient-reported outcomes (PROs) of HTO and UKA patients, adjusted for preoperative...

link.springer.com

Had a look at some of the literature and this paper is interesting.
There does still seem to be debate about HTO versus PKR but this paper is very recent.
I think some of the older literature reviews found PKRs were more challenging and had higher revision rates.
This paper suggests better results with PKR and also shorter recovery than for HTO.
HTO seems to be used more for younger patients who want to return to very high activity levels.

That was a great article. Thank you!!

After reading it, I am still thinking that a Mako PKR is a better choice for me. With the HTO & OATS option, I’m just not convinced, due to the prolonged recovery time and lower chances that the procedure will even work to alleviate my pain. In addition I was reading somewhere that HTO & OATs may only last me 8-10 years before either a PKR / TKR would be necessary. It seems like an awful lot to go through just to get a knee replacement in the near future.

I’m hoping some people in their early 40s (or younger) who’ve had PKRs (Mako medial) can share their outcomes with me. If I proceed with a PKR, my goals after surgery are the following:
Minimum Goals (accomplish without pain): take the dog for a walk; walk 1 mile +; hike for a 1 mile +; mow the lawn; play basketball (light) with my son; walk around all day at a park
Stretch Goals: Do some light jogging (I haven’t ran in any form in 10 + years because of pain); go snowboarding

Are any of these goals achievable with a Mako PKR? I’d love to get some feedback to help me make my decision. Thanks!

 

[lrj]

Along with my patella femoral PKR, I had a distal femoral closing wedge osteotomy. My right leg was knock kneed. I wasn't yet bone on bone in the lateral compartment. So the osteotomy made sense for me. I can tell it's helping me. I was no weight bearing for 4 weeks and partial weight bearing for 2 more weeks. They did say I'll likely be looking at TKR in 15-20 years.
Apparently, no doctor near me does osteotomies, so no one even check alignment. It took me 7 years and 9 doctors to find one who really evaluated me well, listened, and gave me options. I'm glad to hear that your doctor did give options and explained well enough that you can make an informed decision. I hope everything goes well for you.

 

[EalingGran]

If I proceed with a PKR, my goals after surgery are the following:
Minimum Goals (accomplish without pain): take the dog for a walk; walk 1 mile +; hike for a 1 mile +; mow the lawn; play basketball (light) with my son; walk around all day at a park
Stretch Goals: Do some light jogging (I haven’t ran in any form in 10 + years because of pain); go snowboarding

Are any of these goals achievable with a Mako PKR?

I don't think the fact that a PKR is MAKO or not significantly affects the level of activity possible after PKR. It just helps the surgeon to ensure good alignment.
I can walk or hike now for pretty much any distance ( up to 6-7 miles/ day- but probably limited more by my age at 68 now than my knee). I walk around all day with my grandson in the park and it is just general exhaustion, rather than my knee that limits me!
I have been told not to run, but I also have an overstretched MCL and lax ligaments. I can run short distances ( for trains/ buses). I have never skied or snowboarded but I know others here with TKRs who go back to these activities. One of my grandsons other grandparents skis regularly after his medial PKR ( non- MAKO).
I think some of the restrictions were because no one was sure how long PKRs would last in younger people. My surgeon says that mine should easily last 25 years and see me out. My implant ( Oxford fixed lateral) apparently has a manufacturer lifetime guarantee- although not sure what that really means!