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So, how is my new metal knee working out?

Dakine

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I have three days on the snow now with my new Smith-Nephew Legend total knee replacement.
A bit about how it is going.......
I took a year off to heal, rehab, train and learn new balance skills.
Yesterday I skied with an old buddy who is heavily certified in both the Austrian and PSIA systems.
He has been watching me ski on 1 1/2 legs, in pain for a very long time.
After ski yesterday, he told me he has never seen me ski better!
I'm gradually learning my new body and building confidence.
I don't have any idea where my limits now are so I'm skiing my SL skis and keeping it under 25-30 mph.
Things getting better at 72....?
Totally amazing, good thing I donated my speed suit and race gear to our local ski academy.
I got game!
If anyone wants to hear more this give this thread a like and I'll fill in some details.
"You have to grow old, you don't have to grow up"
 
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Dakine

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OK, there seems to be some interest in the subject.
I'll do this in a few posts as my thoughts develop.
This one is about the subject.......Me.

Born 1945, 5'6", 165-175 pounds.
Not particularly an athlete but very competitive.
I wrecked my left knee in a series of motorcycle crashes, ski racing crashes and general redneck stupidity by the time I was 30.
Nevertheless, I could get the joint to function over a limited range of motion and on a really good day could run a NASTAR handicap in the 10-12 range.
But every turn hurt and the mechanics of my left leg were so bad that I had bad crashes sometimes from things like crossing tips.

Two years ago it looked like this, bone on bone and no ACL.
Bone spurs everywhere, lots of floating bone chips and a big piece broken off the end of the femur that you can't see in this view.
ET Knee X Ray Crop.jpg

The right knee (on the left) is pretty decent for a geezer.

I have researched knee replacement technology ever since I saw an article on it back in the '70's in Scientific American.
Early joints were crude and lacked functionality.
Second gen joints worked better but had limited life.
Current technology joints got to the point where, at 70, I concluded I would not wear one out and have to have it replaced.
Than I had some real problems with my knee while surfing and knew it was time.
Crawling up on the beach is not a good way to impress anyone.

The single most important part of this drill is finding the right surgeon.
Most ortho guys slam the joint into old folks with knowledge that it won't really be tested because of lack of athleticism.
Find an orthopedic surgeon who works on athletes and specializes in knee replacements.
The guy who did mine does 4-500 per year and expects his patients to live strongly after replacement.

Then there is preparatory training.
I have had several lesser knee procedures and they ain't fun.
The stronger and lighter you are going in, the better it will go as you try to recover from essentially having your leg cut off.
I have always been a gym rat and I was in decent shape for the surgery.
Selfie 3-5-17.jpg

My left calf was about 1" smaller than the right and the quad was about 2" smaller in circumference.

Because I was in good shape and am married to an Ortho RN, my doc put me on an experimental protocol for same day surgery.
Eleven hours from walking into the hospital to being rolled out and on my way home.
Then it is no fun for a while but I have a good tolerance for oxy which makes things much easier.
Simple rehab started immediately and soon I had a recumbent exercise bike and I was pedaling for flexibility and endurance.
Later, much harder rehab than back to the gym for overall training.
Surgery was November 1, 2016 and I skipped last ski season so as to not stress the joint.
The finished product looks like this...
ET Knee at 2 mo 12-21-16.jpg


ET Knee at 2 mo 2 12-21-16.jpg


I spent last summer working and training and biking but not really pushing things at all.
My strength seemed good and my sense of balance was returning.
If this was going to be a fiasco, I wanted it to be on skis which brings this story to two weeks age......
 

Tricia

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We have a few members who've undergone knee replacement. Perhaps we'll get some activity on it.
@Bob Peters has some experience with knee replacement, which put his long ski streak to a stop a few years ago.
 
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Dakine

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I doubt that anybody reading this is doing it for fun.
Yes, it's true, you have a knee replacement in your future and you hurt.
Two important points.
1. I no longer hurt or worry about my knee acting up at a bad time,
2. If you are going to get a good result, you had better take charge and learn all you can so as to assist your surgeon in a desirable outcome.
You need to know about knee replacements and here is some easy reading.
https://www.peerwell.co/blog/2016/10/03/different-types-of-knee-replacement-implants/
My Doc, who correctly observed my tendency to do stupid stuff, went with what he considered the best.
The Smith Nephew Legion is made of zirconium superalloy which is surface oxidized to zirconia ceramic for wear resistance.
They call it Verilast technology and claim it can last for 30 years (based on only about 15 years worth of data).
It is more expensive than the nickel superalloy joints made by Stryker, etc but should take more abuse.
It is even possible to get patient customized bone cutting templates for this joint system.
Bone cutting...now we are getting to the good part.......
Go read your homework assignment from above while I make a sandwich and give me some likes if you want me to keep on with this tale.
Warning...I'm an engineer, not a surgeon so always get professional advice, etc.
 

crgildart

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WOW that X-ray of your left knee..:eek: I can't imagine how painful skiing on that must have been. My little bad toe and bad thumb seem pretty trivial in comparison! My back, on the other hand? I've been afraid to allow myself or a legit specialist to take a good picture of what's going on with that. Every other month something goes POP and I'm hobbled a little or a lot for several weeks when it's a bad spasm..

Surgery could also be in my future, but I don't have the money or coverage to make that happen this decade..

I had no idea you didn't ski at all last season. Hoping you make up for lost time this season though!

Glad to hear you are back on solid footing!

:yeah::daffy:
 

Fishbowl

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General question.............should you wait until replacement is the only option, or are you better off electing to have the surgery whilst you still have reasonable functionality? I'm asking based on reports that better prehab produces better long term results. This never used to be an option when knee replacements lasted ten years at best, but if they are now lasting thirty.......
 

Monique

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I have a question. Looks like you still have the original patella. Wouldn't the hardware wear down the patella from the inside?

... Inquiring minds! I'm so glad it's going well for you.
 

Living Proof

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Thanks for a very well detailed report. My 71 year old right knee is bone-on-bone on the lateral (outside) side, and, it has sucked the fun out of skiing for 2 years now. With the exception of skiing pain, I live mostly pain free, it is not as stable as last year. I've always stated that when I start to limp or feel pain on a regular basis, that will be the trigger for the surgery. Fortunately, Philly is a major center of Orthopedic surgeons, I fully agree with your thoughts about selecting a specialist who wants to get athletes back into their sport. Yes, your preconditioning physical work and weight management are the best way to get well fast. I play a fair amount of golf in the summer, and, am able to walk not ride. I'm beginning to think about have it done in the fall of '18, so that I can play and ski in '19. I will read up on the specific knee joint you used.

Again, thanks. There is a (too) large contingent on Pugski of people with knee issues. Most are too young to consider full replacement, It sucks to need it, but, I got many good years and am thankful mine lasted this long.
 

Living Proof

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http://info.conformis.com/image-to-...=cpc&utm_campaign=MDCPPC&utm_content=national

The above link describes another knee replacement option, ConforMIS. This was the replacement knee that a well known Colorado ski technique guru selected. Interesting to see how CAT scans prior to the replacement result in better alignment of the hip, knee and ankle. For sure, it seems wothwhile to have a custom designed product rather than off the shelf. Check out the video.
 
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Dakine

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Back at the keyboard.
First, the above questions than a little about the surgery itself.
In further installments I'll address post op, rehab and conditioning, skis and boot alignment and then how it actually feels.

@crgildart
My xrays from 30 years ago look nearly as bad.
It was amazing what I could do with a joint that was really only strong when flexed from 30 to 60 degrees.
The pain was always a factor as was the unreliability, I never knew when I might cross some line and spend some days laid up.
For the chronic pain, aspirin and pot worked much better than other stuff.
Backs are a whole different subject and I'm very grateful that mine is solid.
Let me know if you are going to be around.

@Fishbowl
I'm not a fan of partial knee replacements, I haven't seen many that have worked out well for long.
Your knee can only take a limited amount of surgery before the build up of scar tissue and poorly vasculated areas becomes problematic.
If they can do something useful with an arthroscopic procedure that will give you some good years, go for it.
If you are younger than 60, TKR is a conundrum.
Your joint will need to be replaced and that procedure is a nightmare that surgeons hate.
Hint: Most good ortho guys have a surgical assistant that looks like a linebacker and replacement procedures usually require the use of a slide hammer to get the old stem out.
My choice was to grit it out until 70 (actually 72) but the joint tech keeps getting better, keep studying.

@Monique
What you see on the side x ray is about 1/3 of my old patella with a plastic patella attached underneath (can't see plastic on xrays).
The patellar tendons attach to the old cap and they use that portion with tendons attached to locate the plastic patella.
You can also see the bone chips from my old joint that the surgeons didn't dare to remove because of their proximity to "big red".
Big Red is an artery that runs behind the knee and if it is knicked you just might lose your leg.
The leftover chips can be felt but don't seem to be any kind of a problem.

@ Living Proof
I waited about two years too long according to my surgeon.
That made his job harder and my rehab harder because correcting my skeletal alignment was a bigger chore.
The custom joints are, in most cases, not really better if you are a fairly normal scale human.
All joints come in sizes and mine is a 6 1/2.
I have seen two cases where the surgeon chose a "too large" joint that required total rework and led to unsatisfactory results.
Size really matters and I'll have more to say about this in the following installment.
 
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Dakine

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OK. now about the surgical part.
Some folks might want to skip this and the pics are in as thumbnails, click at your own risk.
There are a lot of vids on YouTube about TKR, don't watch them...you will have nightmares.

A TKR requires near total dissection of the knee including disconnection of the patellar tendon so they can get the patella out of the way.
The dissected knee is bent to expose the bone ends and now we get to the part where you want the best surgical talent.
The bone ends are sawed, chiseled and ground into an exact shape to fit the joint parts.
The shaping is guided by templates that come in the TKR kit but it is still artful work.
Eventually, this part of the op will be done by CNC robots but not yet.
Some of the joint systems allow for the manufacturer to provide individualized templates based on your xrays but this is still hand work and a lot depends on the skill of the surgeon.
After the joint is prepared, the stem is shimmed for length (more art) and the pieces are glued in with super glue.
Then the patella is reshaped or discarded and a correctly sized UHMW polyethylene patella and meniscus disc are placed and the patellar tendon is re-attached,.
The joint is then dusted with strong antibiotics and a anesthetic cocktail is added to the joint space then everything is buttoned up.
If you really care about a tidy scar, sometimes a cosmetic surgeon can be called for closure (like if you are a movie star).
Next, off to recovery and your room as consciousness returns.
Takes an hour to two in complicated cases.

On waking, it is customary to get a visit from your surgeon.
Ortho guys are typically arrogant jerks and you love them for it.
Mine walks in and says:
"We should have done that sooner, the joint was as bad as I have seen in a while, it made surgery complicated so I really enjoyed it, thanks, bye"
The bottom line was about $54,000 but with Medicare and co-insurance I paid about $2000.
That's why you have been paying into the Medicare trust fund your whole life only to have our government steal all the cash!
(Oops, that's another story)

I was on an experimental same day protocol, I had to pass two hurdles to get out of jail.
First, I had to get up and show them (literally) that I could pee.
And then, I had to pass a short course on using a walker, crutches and getting up and down stairs.
Fixed on my goal and having enough dope in my system to make an old hippie think he could fly, I aced the tests.
11 hours from walking in, I rolled out with crutches in hand and my wife (aka Big Nurse) drove me home.
What does it look like, I naturally wondered.
You don't get to find out right away.
The wound is sealed with a silicone rubber bandage that you can shower with and take off in about a week.
At the end of that week, a tech came by to pull the bandage and inspect things.

IMG_0098.JPG

The scar follows an old surgical scar, if you have a clean knee your scar will be on the midline.
At the end of a month things looked like this.

IMG_0119.JPG

Next up, post-op, pain management and early rehab.....keep those likes coming.
 

Monique

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Fixed on my goal and having enough dope in my system to make an old hippie think he could fly, I aced the tests.

Not the same procedure, but I was not supposed to be weight bearing the first 24 hours after my ACL/meniscus surgery.

Guess who was hopped up on pain meds, hobbling around the house without those "inconvenient" crutches, in the afternoon after a morning surgery?

I don't actually remember this.

I later asked my husband why he and his parents (who were visiting) didn't stop me from doing this. He said that short of tackling me, they really couldn't do anything.

Of course, stubborn is good when it comes to doing the painful rehab ... sounds like you have more than your share of stubborn. Properly directed, that's the ticket!
 

Plai

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@Dakine post #11 surgical just took it from concerned thoughtful academic exercise to shocking reality. Thanks.

I've no clue if I'll ever need this or similar procedure, but given the active lifestyle, the thought is always in the background.

Thanks again for your generosity in sharing your story. The organization of details just make it.

I'm tuned in....
 
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Dakine

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,,,,this thread was interrupted because there was 14" of fresh stuff at Nub's yesterday AM.
In the spirit of scientific research, of course, I had to test out my new knee.
The knee rocked, my FX 94's rocked and I'm more stoked on skiing than anytime in a long time.
TKR has made me whole.

Back to the story, it ain't fiction.
This bit covers the first six weeks or so after surgery, the hard part.
When you can eat, pee, control the pain with oral meds and do some simple PT tasks, you go home.
Your own bed never felt so good.
The first two days are a blur.
PT comes and opens your case and inspects things and gives you a bunch of stuff to read.
You must keep moving and, initially, it doesn't hurt too bad because of the anesthetic cocktail left in the joint.
After two days, that wears off and reality bites....you just had your leg cut off.
I tolerate narcotics well but also respect them and try to get the most from each dose.
(My wife doesn't tolerate narcotics and when she had her knee done, she had to do it with aspirin and true grit. She had a traumatic time even if women tolerate pain much better than men. Don't be a Puritan, if you can take dope do it)
(Pot helps a lot too as does music, if you are so inclined)
For the first week, I could generally get four good hours out of 10mg of Percocet but sometimes had to take another 5 mg in between doses because I'm a pussy.
I learned to dope up just before the PT assistant made her visit for a good therapy session.
You should get 12 PT visits at home in the first month if you are on Medicare.
Give it your best and do your exercises on the "off" days as instructed.

More important than the narcotics for pain control and healing is cold.
Cold keeps the swelling down for faster recovery and cuts pain which also speeds healing.
There are two ways to go for cold application.
Some docs use the machines that circulate ice water through a cuff for long lasting relief.
I tried this but went back to old fashioned reusable ice packs because the cuff doesn't cool behind the knee and I got better relief with an ice pack behind my knee.
(http://www.coolrelief.net)
Be careful, you can get frost burns while doped up, always put some fabric between your skin and any ice thing.
I ended up using a big ice pack wrapped around the knee with a smaller pack inserted under the straps behind the knee.
This provides maximal cooling and requires you to get up every four hours to change out your ice packs.
My life for the first two weeks revolved around doping, icing and PT....and one more thing.

Food!
Lots of food.
My RN wife thought I wouldn't be hungry because of the dope and pain but that proved wrong.
I had bacon and eggs the first day and just kept eating.
Apparently, healing takes a lot of energy because I was doing 5000 calories a day and didn't gain any weight.
Iron is critical for healing and my Doc had me take lots of iron supplements before the surgery to build my hemoglobin to the max.
I'm an omnivore but developed a distinct craving for meat and lots of it.
After a month my appetite subsided and calorie control became part of my life again.

After 3 to 4 weeks you go into outpatient rehab.
That's when the true fun starts again.
More on that soon..........
 

Fuller

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I hope I never need such specific advice but thanks for putting it out there for us. Do you ever plan to surf again? I stopped a few years ago (I'm 64) because of the declining fun factor and too many UV rays.
 

Rod9301

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I have two friends that has tkrs and they started skiing 6 weeks after the procedure.
 
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Dakine

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@Rod9301 Skiing right after you start to heal can be done but I'm way more cautious than that.
Right after surgery, the implant pieces are held in with superglue.
Superglue is brittle and many folks who used their joints as you suggest have broken them loose and had to face a nasty rework.
It typically takes two years for bone to fully grow into the implant's surface and lock the pieces in place.
This process is pretty much done after one year and I chose to not test things to see if I am lucky in my first year.
Most surgeons aren't happy with folks that want to ski at all, let alone at six weeks.
My guy would consider that six weeks advice malpractice.
He would also refuse to do the rework operation since I had shown so little regard for his work.
My strength and balance weren't nearly where they need to be to ski well even after three months.

@Fuller I did a little windsurfing last summer but our weather didn't produce many good days and mostly, it wasn't fun.
I did do a bunch of stand up paddling and kayaking.
I'm not a good surfer and won't chase it because I don't need the pounding.
 
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Dakine

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Now something about rehab and conditioning after TKR.
Everybody is going to have their own opinion about this subject and everybody's body is different.
My choice was for a slow and progressive rehab to minimize the chance of injury or joint damage.
Rehab is a huge business and in most areas you will have many rehab contractors to choose from.
You choose your rehab outfit before surgery and work with them until you are discharged, typically 12 outpatient visits under Medicare.

Rehab contractors typically have three types of clients:
1. Feeble elderly who may or may not have had serious surgery,
2. Workers trying to come back from occupational injury,
3. Senior citizen athletes who want to get back on their game.
You want to choose one that has Physical Therapists with experience and expertise in Type 3 humans.
Ask around, you probably ski with someone from the rehab community.
I chose mine because of the credentials of the lead therapist.
She has a PhD in PT and is a skier who knows I want to ski again at a decent level.

Your surgeon may provide the PT place with a preferred rehab schedule based on his experience.
Just show up and do what you are told, carefully, but with enthusiasm.
Good advice that I didn't follow, my competitive nature got the best of me and soon I was racing another rehabee on similar equipment.
It feels so good to be active after weeks of inactivity that it is easy to let your enthusiasm take you away.
I managed to put my spinal erectors in spasm which set me back for a couple of weeks.
Don't be as dumbass as DaKine!

Eventually, you are done and discharged.
From here on it is up to you.
Typically, you will have a two month follow up appointment with your surgeon to check things out and a one year follow up to see how the joint is wearing in.
(TKR joints need break in just like any other machine and this is one more reason to not push things early)
After my rehab, I went back to my typical gym routine with emphasis on quads and calves.
Because your body now has a completely new pelvic alignment, muscles and joints need to grow and stretch.
I spent many years limping without a heel strike on my left leg and that is all gone.
My left calf had to stretch out a lot which caused aches and cramps like I had never experienced.
Heat is your friend here and I came up with a routine where I iced my knee at the same time I heated my calf after a workout.
This and aspirin worked well to make me comfortable.
Naps are very good too as a way to shorten recovery time after a workout.

My favorite exercise became the inclined recumbent squat machine with two plates on a side @ 20 reps, 3 sets.
(I'm going to ask my surgeon next month if I can go heavier)
DO NOT...use machines where you flex or extend your knee without it being in a weight bearing situation.
These machines are bad for good knees and, unless you use trivial weights, they are dangerous.
For flexibility, I spent a lot of time on a recumbent stationary bike at light load with the seat adjusted increasingly closer to the pedals.
And lots of stretches in the hot tub and swimming when I could get in a pool.
After four months, it was spring and I started doing everything outside.
Lawn mowing, building new landscaping, etc. are all good training.
Mostly, I avoided anything that might result in loss of control or a crash for an entire year so the implant could grow in to the bone and get strong.
My surgery was in early November so I could rehab slowly and heal during the worst of winter.
This is also a good time to think about diet and adjust so that you get to an ideal body weight for your frame.
Weight and gravity are the main enemies of healthy older citizens, maintaining something like 15% body fat is highly desirable for fun and longevity.
There is no free lunch when you are trying to outrun the Reaper.

Next up, the last installment about boot alignment, bindings and what it feels like to ski on a metal knee soon.
 

Monique

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