Age 54: PKR or TKR?

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I’ve had arthritis developing in my knees over 20 years or so and I’m now on the waiting list for a left knee replacement in the UK.  My consultant tells me I could go for either a TKR or PKR as my osteoarthritis symptoms are on the cusp:  4th stage (bone on bone) in the medial compartment plus some (but much less) damage in the lateral compartment and at the patella.  The expectation is that I will need a TKR eventually but a PKR could delay this.  I’m tempted by the PKR as I have read that people can have better function and that it can feel still like a ‘normal’ knee.  I’m still (relatively!) young for this, at 54, and I want to be able to get back to activities like kayaking and therefore want to be able to squat, kneel etc.  However, as we know I do have osteoarthritis developing in the other compartments of my knee, I am also concerned that a PKR might not provide me with the relief I am hoping for and I might have to go through a TKR sooner rather than later.  Thoughts?  

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  • Posted

    I had a partial in Sept 17 I don't feel it has worked I am still in a lot of pain my knee feel like it just needs to snap into place was told I will need a total at some point I am still walking with a limp and it still feels very tight I was 52 at the time of op

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    • Posted

      Hi Denise

      This is my first time posting on this forum and I am blown away by how helpful people are and the balanced views and approaches from folk.  I am sorry you are still having these difficulties.  This my fear too.  I hope you are still getting reviews.  Is there a plan for what to do next for you?  

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  • Posted

    Hi Annette, I am just over 7 weeks post TKR, I am 52 and training to be a yoga teacher. I was really worried before my op as I am young but I had really deteriated the last 7 months begins my op and my activity levels went way down. I still have quite a lot of pain, stiffness and swelling but already I can feel the benefit, my knee is much stronger and I’m already able to do some things I couldn’t do before. I am working really hard to get as much back as I can. I am glad I made the decision to go ahead with the op. Good luck with what ever route you take x 
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    • Posted

      Hi Louise

      That’s great to hear you are feeling the benefit already and that by working hard in your recovery you are finding yourself able to do some of the things which you couldn’t manage before the op.  As a yoga teacher you will want to be flexible!  Like you I have had a rapid deterioration recently; for me this was after years of knowing there was an issue but being able to manage by thinking of alternative ways to do things.  Over the past 18 months the pain has been much worse and has stopped me from doing so many of the things I enjoy in life.  It’s definitely time to do something, worrying though that prospect is. 

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  • Posted

    There is no correct answer to this especially since you cannot know in advance how you will be AFTER either operation.  We have a few partials on the Forum but a lot more.  The partials seem to indicate that recovery is similar to a total...painful and long.  If that's truly the case and you know you will need a full TKR down the road a bit, why go through all of that TWICE?

    Consider a second opinion but we've heard stories of different docs recommending different ops on the same patient.  Another idea is to engage a doctor who is a "Patient Advocate".  A lot of older docs retire from active practice but still consult on difficult, multi-disciplinary and/or cases involving conflicting diagnoses and treatment recommendations.  Since they have no profit motive behind the decision, they can help give you an unbiased evaluation of your choices.

    With you, there are pros and cons to each approach.  Have an expert guide you.  I would not recommend making a decision based on personal anecdotes on the Internet.  Engage a pro to help you.

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    • Posted

      Hi Chico

      It would be so much simpler if there were a correct answer though, wouldn’t it?  As you say, pro’s and con’s. I take your point about getting alternate views from professionals.  In a way that is what has been happening as my first consultant referred me on to a second one who has expertise in osteotomies and unicompartmental replacements and he has done lots of investigations to get us to this point.   I do agree I need to keep talking to the professionals as well as reading about people’s experiences.  We are all have individual needs and circumstances after all.  A patient advocate is a new idea for me.  Will give it some thought!  

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    • Posted

      My cousin Greg was a doc for 50+ years but didn't want to totally retire.  So he went on his own and called himself a Patient Advocate.  Took on difficult cases where multiple docs were involved or where people were confused by conflicting opinions.  Job: 1. Help the patient separate the good advice from the bad; 2. Recommend a good course of action making sure that the therapies fit together and do not cause conflicting problems; 3. Coordinate the multiple therapies that were decided upon; 4. Monitor the results and suggest adjustments when required.  Most of all, he translated all the medical gobbledygook into language a patient can understand.

      I think you can use someone who will review your case, explain all the pros and cons, and then help you reach a decision on which path to follow.  Each doc is going to push for the treatment based on their expertise; I think you need someone neutral who can give you an honest appraisal.

      This is a big decision.  It is a brutal op, whatever you choose.  Recovery from either a TKR or PKR is not easy.  Going through it twice would require a double recovery....on the same knee.  Then again, I have no clue how many PKR patients end up with a TKR later.  Here's a list of activities you can and cannot do after a TKR...don't know what a PKR list would look like...

      https://patient.info/forums/discuss/do-s-and-don-ts-after-a-tkr-a-typical-list-541794

      Post-op, the rule of thumb for a TKR is that you cannot do anything that will pound the knee (running, jogging, etc.) or twist it in any way.  You would need to make sure you avoid whatever activities that are similarly classified if you end up with a PKR.  Docs will tell you that ignoring the "rules" will reduce a 25-year knee to 3 years operational time.

      PS:  Do you remember the TV show "House" from a few years back with the real ornery doc?  Greg's business cards have the tag line: "Just like House...only nicer."

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  • Posted

    Hi Annette,

    I did not have a TKR, only a partial knee replacement - but the principles of recovery are the same - even though we are all different in how we recover.

    Understand one thing - this is butchery - 1st order butchery !

    Mine was right knee, medial compartment. I had a general anesthetic. I have a pre-existing medical condition, a heart arrythmia. I am on Warfarin (Coumadin) for life. I was operated on and cared for by a surgeon as an NHS patient in a private hospital. I just give you this background as an outline to show the challenge I presented my medical team.

    ?I was operated on on 6 Nov 2015, home after 3 days, stitches were the staple self disolving type. Dressing removed on 19 Nov 2015, return to hospital for PT review on 21 Nov 2015. Driving my car again on 29 Dec 2015 and on 26 Jan 2016 back at work driving a bus.

    ?The only PT I had was during the 3 days in hospital and that was intensive  - it was more like (boot camp) training in all the exercises I'd have to do at home. At discharge I was given a booklet explaining what had happened and what exercises had to be done, when, and their frequency. Surgical and hospital policy was that the patient had to achieve a 90 bend in the knee before discharge.

    ?The most significant thing you can do as an act of self help is what I did - get the leg muscles strengthened, lower and upper leg, prior to surgery. In other words present to the surgeon a leg with the best possible strength in it as you can - all ready for him to butcher. YOU WILL need those strong leg muscles to work for you during recovery and rehab. I went once a week to my sports injury massage therapist for her to work on my leg.

    ?NEXT - as soon as you have the dressing off and it is confirmed there is no infection I went back to my massage therapist for her to start breaking up the scar tissue. She did this by gently massaging the incision line itself and all around it. THIS IS VITAL. She showed me what to do myself at home and recommended I use an Aloe Vera Gel.

    The point is this - if the scar tissue forms it will make your exercise program very painful and maybe even nearly impossible for you to get the bends and flexion you need to walk properly again.

    ?I decided to dedicate myself time at home exclusively to exercises and rehab. I did all my exercises exactly as instructed every day - WITHOUT FAIL - you have plenty of time as I'm sure you will realise. I was at it 5 times a day. I was on crutches continuously up until 29 December, very, very gradually weaning myself down to one crutch and then none. Then as soon as I could drive I tested myself along the (I live in Cornwall) South West Coastal path, hilly, rugged and very uneven. Very tiring, very uncomfortable and mildly painful but good exercise.

    ?I am one of those who likes to know things, yes, I knew why I was doing exercises and rehab PT but I wanted to know what it was doing to the inside of my leg. I went onto YouTube, and typed in the search box something like " exercises after knee replacement". there were shedloads of short videos which explained it all and gave me much more confidence in what I was doing.

    ?Yes, always adopt the RICE practice - Rest, Ice, Compression and Elevate, . Make sure your leg is raised, I went 2 pillows high and just used large packs of frozen peas. I never put a pillow under my knee, rather my heel on a pillow (or cushion), that way the knee joint stretches. Sleeping for me - I slept when I could, which wasn't often - not so much from pain but the toxins inside me from the GA made me continuously dizzy. Every time I put my head back I became dizzy. It wore off eventually. Because of the Warfarin I am severly restricted as to painkillers I can take - in hospital morphine and tramadol didn't do it for me - I ended up staying with CoCodomol 30/500. Plenty of constipation so a good fruit diet is advisable if you are that way inclined.

    ?Your exercises will all be different, all aimed at producing a different result. I found that sitting on a dining table chair (I have one with arms on ) and used that to practice my heel slides was excellent. also, from that position I was able to rest my heel on the arm of a lounge and press down on my knee just above the knee cap, and keep pressing it this helps you get flexion. ( a straight knee). Heel slides are illustrated on You tube and are vital to help you get the bend. to get anywhere near normal you have to aim for 130 degrees bend in your knee. Try it now, sit on a dining table chair, firstly sit with your bum right back then slide your leg back under the chair. Then sit in the middle and do it again and then sit at the front of the chair and do it again. Notice how in each seated position will give you a different bend in the knee. Another trick to help straighten your leg is to get a large towel roll it up, length wise, put your leg out straight, put the rolled towel under your foot and pull it back. This should have the effect of straightening your leg.

    These explanations are probably not very good - do go to YouTube.

    ?So, now - could I get into a kayak (I'm now 73) slowly, yes I probably could. Could I get out again - probably not !

    PKR or TKR ? - ask you surgeon a couple of questions 1) if I have a PKR, would I be able to have another PKR or TKR (in the same knee) sometime in the future if needed. If I have a TKR and found I needed another (in the same knee) in the future is it possible.

    ?Can I kneel now - no. Its not a case of discomfort from the medial implant but from the knee cap itself. Yes I can squat - but not like a gym freak aged around 30 ish ! Lol! I can still feel a change in the weather long before it is forecast and the knee stiffens up. BUT I AM PAIN FREE.

    ?In my view you gotta get at least a 135 degree bend in the knee, more if you can. If you are still kayaking at the moment why not get someone to video you (on your smartphone) getting in and out of a kayak focusing on the knee bend, squats etc etc and show it to your surgeon and ask him what he thinks. I mean there are so many aspects to this, your overall fitness, your weight, how pliable your body is etc.

    I got a big bonus from all this - because my leg had been out of geometrical alignment for many decades I was in a lot of pain from lower back and my right side Sacrilliac joint. My surgeon realigned everything when he did the PKR and I'm now pain free from those areas too.

    ?To the best of my knowledge - you will not legally be able to drive a car again for 8 weeks after surgery. You'll need to discuss this with your insurers. You will need to be able to confirm you have control over the vehicle and can do an emergency stop. Not just tapping the brake but imagine a kid chasing a ball and running out between a row of parked cars, you gotta hit the brakes or kill the kid.  That sort of stop.

    ?All I can say Annette is good luck, may the force be with you.

    ?John

     

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    • Posted

      Hi John

      I am so impressed you got back to a physical job in that time!  You clearly worked really hard to get that to happen.  You have motivated me to do another round of exercises right now...  my local hospital does an Enhanced Recovery Programme so I have already attended their Joint School and been given pre-surgery exercises and I am trying hard to do the required number of reps in the day.  I don’t always manage as it’s tricky to find four different opportunities to do them when also working full time.  But your story makes it sound worthwhile trying to do them all.  Another aspect of the Enhanced Recovery Programme is that the operation is done under a spinal rather than a general anaesthetic as this apparently speeds recovery.  That sounds worthwhile to me but I am needing to get my head round the idea of being awake for this...

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    • Posted

      Hi Annette,

      ?On the matter of anaesthetic - they may well have given me a general on account of my heart issues. Can't recall that I asked the question. Maybe it was a joint surgeon/anaesthetist decision.

      My sister had a TKR a year or so after me and hers was spinal. She has no heart issues. No problems with the surgery, aware of noises 'in the background' but that's that. She did react badly to various meds after she got home and had a problem with getting the right pain relief without it making her ill. She won through eventually.

      ?For me, once home it took a while for the side effects of the GA to work its way out of my system. Just gotta go with the flow. Anyway, best wishes for a dream run for you.

      John

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  • Posted

    You could leave it to him or her to decide, as when they get in there they can see better how it is? Or as Chico suggests, get another opinion?

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    • Posted

      Hi Jenny

      Leaving the final decision to the consultant is an appealing idea which hadn’t occurred to me before.  I’ll definitely explore that possibility at my next appointment.  

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  • Posted

    Hi Annette. I am 46 and just had a partial knee replacement. My consultant was very reluctant to do a full at my age. The reason being that at my age it will probably only last 10 years. Yes you can have it done again, but each time it is more difficult and less successful. It is much easy to go from a partial to a full than from a full to another full.

    My surgeon was very good and said he will aim to do the partial but will have the full on standby. It would depend how the rest of the knee looked when he opened it up.

    Thankfully he was able to do the partial. The back of the knee does have arthritis but not at the stage where it needed replacing. He said it will definitely need a total at some point, but trying to hold out as long as possible.

    I am 4.5 weeks post op. I can honestly say it has been easier than I feared. The hospital were great at keeping on top of the pain. I'm still exceptionally tired, but even a partial is still major surgery and its to be expected.

    With a partial you do get better range of movement and it feels more like a normal knee.

    Personally I'm so glad I was able to have the partial. After all,at our age we would still need the knee replacing again after a total. So unfortunately either way it is still 2 surgeries. However much easier and more successful going from a partial to full rather than replacing to another full.

    Good luck what ever you decide

    X

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    • Posted

      Hi Debs

      Your situation does sound quite similar to mine.  They have been trying to hold off on doing a replacement because of my age and, as you say, it seems very likely that whatever type we have is going to need to be replaced some years from now.  I have also been told that they can both replace a TKR with another TKR or a PKR with a TKR but of course there is more bone being lost with each op.  This is part of what makes me think I’d prefer the partial.... and yet I don’t want to be part of the minority (10%?) for whom the partial fails really quickly and who therefore have to go through the total replacement soon after.   I’m really pleased to hear it’s working out for you so far.  Very encouraging!  

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  • Posted

    OK! Here we go. First off-good info from all, especially Chico, the current guru.

    3 1/2 years ago (at 64) I had a L-PKR. My surgeon also was prepared to go total or partial once he saw the lay of the land, as it were. He went PKR. A year later the arthritis attacked my right knee. Had a TKR. In reality, the recovery is about the same. A year later had a hip replacement ( this is getting really old!). Now a year later the PKR needs replacement due to bone loss and the other "half" has very little cartilage remaining. That knee has never been right as compared to the right knee. That left knee just never seemed right to me. Little joke there. At any rate, it's stiff, somewhat unstable, and painful at times and has always has some swelling. The r-TKR has been great, no pain, no swelling good range of motion (ROM). I'm really tired of being a member of the Joint of the Year Club. But some folks here have been through lots worse and come out the other side successfully. Not sure about that hockey thing...

    At any rate, yes, you are relatively young so Chico is right, try an additional opinion. Quite honestly the recovery is the same. Pain may be somewhat less, but by now I really don't remember. I had an aggressive PT outpatient regime that started within a week of discharge. Off the walker in a week and off the cane in another week. Carefully of course and I don't have stairs. Building strength before and after surgery is vital as well as RICE. For me at my age and arthritis and knowing what I know now, I would have opted for the total. But all our situations are different. And only you and your doc can finalize that. Best of luck!

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