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Author Topic: Total knee replacement  (Read 8961 times)

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Offline doctorb

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Re: Total knee replacement
« Reply #20 on: May 28, 2015, 01:45:54 pm »
Lee-

Here's a little Q&A I go through with my patients.  If you want to skip it, the take-home message is that while exercise can help you lose weight, you don't need to turn into a gym rat to do so.

"How many calories in one pound of fat?"  Answer:  "I have no idea"

The answer is that there are about 9 cal/gram of fat....and there are 454 grams in a pound.  Roughly speaking, that's about 4000 calories in a single pound of my spare tire (I usually grab it now to make the point.)

"How many calories do you burn if you run a mile?"  Answer: "I have no idea."

The answer about 100 calories.  And it doesn't matter whether you run a mile or walk it, it's still about 100 calories.  The calories burned seem to correlate with distance, not speed.

"How far is Washington DC from Baltimore?"  Answer:  "I have no idea."

The answer is about 40 miles.  So I show them that walking from my office to the Washington Monument would burn about 4000 calories.....only one pound of fat!  (40 miles  X 100 calories / mile = 4000 calories.)  They are shocked to realize that a 40 mile walk only burns one pound off their weight.

Now, let's look at exercise....If you walked 5 miles/day, How many calories would you burn?  Answer:  500  (5 miles X 100 calories / mile.)

If you walked 5 miles every day for a week, How many calories would you burn?
Answer:  3500 (7 days X 500 calories / day)

Doesn't that figure sound pretty close to the 4000 calories stored in a single pound of fat?  So....ideally:

If you could eat 500 calories less than you burn up every day (and that figure varies for each of us), you would be at minus (-) 3500 calories for the week.  If, in addition, you could walk 5 miles /day, you would be at an additional minus (-) 500 calories for the week.  Total those two methods and you would be at minus (-) 7000 calories for the week, and, using the 4000 calories per pound estimate, you would lose between 1.5 and 2 pounds per week.

The point is that you don't have to exercise to lose weight.  Many of my patients have injuries and disabilities that will not permit them to walk 5 miles per day.  But through a change in dietary intake, we can make a steady dent in our universal problem of being overweight.  But exercise does increase the amount of calories you burn, and exercise has tremendous other health benifits besides burning fat.  Many patients tell me they can not lose weight because they can not exercise. That's when they get this little lecture and hopefully they benefit.
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Offline LeeB

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Re: Total knee replacement
« Reply #21 on: May 28, 2015, 02:19:39 pm »
Thanks doc. I know a change in my dietary intake is the biggest factor in losing weight. It's hard to change a lifetime of bad habits. I also know I have to get some kind of exercise since my job is now pretty much administrative now and I spend about 12 hours a day behind a desk. Got to keep the ticker going and keep down the edema somehow. So, with cardio health in mind, is a bicycle any easier on the knees than walking/running? This getting old is not easy, but I like the idea better than not getting old.
'98 LT40HDD/Lombardini, Case 580L, Cat D4C, Ford 851 tractor, JD 3032 tractor, Husky 346, 372 and 562XP's. Stihl MS180 and MS361, 1998 and 2006 3/4 Ton and 2005 1 ton Dodge 5.9 Cummins 4x4's, 1989 Dodge D100 w/ 318, and a 1966 Chevy C60 w/ dump bed.

Offline pabst79

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Re: Total knee replacement
« Reply #22 on: May 28, 2015, 03:07:59 pm »
doctorb,
 
 I appreciate your advice, and yes I could stand too lose 30lbs, I got down to 175 a few years after my accident and surgeries by walking 3 miles daily and cutting out carbs. I now have too much pain and swelling to do that much walking and I'm trying to keep a better diet. I had the accident in 03' so I've made it okay but recent xrays show bone spurs and moderate arthritis in both my hip and knee, my hip was also broke so there are what look like deck screws holding it together, besides the nail which travels the length of my femur. I had the screws in my knee removed in 05', I assume all the hardware will have to come out at some point?
P.S If I had been wearing my seatbelt like my father was, I wouldn't be having these issues. I won't even ride in a parking lot without my belt on now. smiley_sidelightbulb
4th Generation Plumber/Fitter who moonlights in too many hobbies to master any, 2 little girls are a blessing and ensure that a new mill may be a few months...years away.

Offline doctorb

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Re: Total knee replacement
« Reply #23 on: May 28, 2015, 03:20:34 pm »
Lee-

Exercises that load the knee in flexion are hardest on the patella / femur joint, and not the weight bearing surfaces of the femur / tibia portion of the knee.  It may depend how hard you push when you pedal a bike whether your arthritis flares or not.  In general, smoother, non-impact loading exercises like a stationary bike or an elliptical are better for knees than running.


"This getting old is not easy, but I like the idea better than not getting old."  Amen, Lee.  Amen.

Pabst - without seeing you x-rays, I would bet that most, if not all, the hardware will need to be removed if further reconstructive procedures need to be done in the future.

There's an old thread around here about seat belt use.  I have pretty strong opinions, backed up by a ton of scientific investigations, that seat belts save lives and lessen injuries.  Some still stick to the "I have a right to do what I want to do..." philosophy.  It always sounds like the motorcycle helmet debate to me.  Others state that "Thank God I didn't have my seat belt on in that crash, or I would have been trapped."  While that may be true in selected and very rare instances, the number of drivers and passengers that get ejected from vehicles is astronomically higher without seat belt use.  If you want to see the vehicular death rate climb, get thrown from a vehicle during a crash.  Ejection of an occupant is much, much, much more common that the depicted "trapped by your seat belt" scenario.  Finally, I hear, "The paramedics told me I would have died if I had my seat belt on."  That is absolute horse hockey, IMO.  I've known hundreds of paramedics and had them describe thousands of vehicular accidents to me, and I've never heard one say that.  So I tire of the justifications to not wear them.  Click them every time.  I am glad you learned your lesson and are here to tell the tale.  Sorry about the rant that has nothing to do with the topic!
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Offline LeeB

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Re: Total knee replacement
« Reply #24 on: May 28, 2015, 03:29:35 pm »
It would have to be on the exercise bike here at work. Not much place to ride a real bicycle here on the rig.  :D I get a little exercise when I'm at home, just not too much when I'm on the rig.
'98 LT40HDD/Lombardini, Case 580L, Cat D4C, Ford 851 tractor, JD 3032 tractor, Husky 346, 372 and 562XP's. Stihl MS180 and MS361, 1998 and 2006 3/4 Ton and 2005 1 ton Dodge 5.9 Cummins 4x4's, 1989 Dodge D100 w/ 318, and a 1966 Chevy C60 w/ dump bed.

Offline pabst79

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Re: Total knee replacement
« Reply #25 on: May 28, 2015, 08:08:47 pm »
doctorb,

 I completely agree with your comments, in my opinion everyone repeats the story about the guy who got burned up in a car because of a belt, but never consider or talk about the tens of thousands that die because of ejection or bouncing around like a pinball. A 2 ton bucket truck pulled out in front of my Dad and I, we were going about 65 and Dad had no time to hit the brakes. He was wearing a seatbelt, I was not, the airbag saved my life. He had bruised ribs, I had a broken hip, femur and cracked ribs. I tell the story as often as I can to the anti seatbelt crowd. Its so easy to wear them, why risk it!

 I would like your opinion on the cortisone shots or steroids? I'm supposed to be going to a pain management clinic, but haven't had time to get in. I have been on 200-300mg of Tramadol for 4 years and use Voltaren gel and they seem to help enough that I can still work, but not sure how long they will continue to be effective? I have heard that sometimes the shots can do more harm then good? Again I appreciate your advice.
4th Generation Plumber/Fitter who moonlights in too many hobbies to master any, 2 little girls are a blessing and ensure that a new mill may be a few months...years away.

Offline doctorb

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Re: Total knee replacement
« Reply #26 on: May 28, 2015, 09:53:32 pm »
Cortisone injections are a mainstay of reducing the inflammation and pain of arthritic joints.  Usually given 4 X / year maximum, most often only twice.  They really help some people and I would not hesitate to use them.  Given too often then can have a deleterious effect on joint cartilage, but your doc should keep you away from that.  I think the risks are very, very low compared to the benefit, especially if you are running out of meds to try. It may not work, but usually they do.  The unanswerable question is for how long.
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Offline Brucer

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Re: Total knee replacement
« Reply #27 on: May 30, 2015, 01:54:23 am »
No point in repeating doctorb's advice -- he's the expert on the medical side. Here's some advice from the patient side (patient's spouse, actually). EDIT: I added a few comments in blue after I first posted this.

Barb had her second knee replacement 8 years ago, and the first one 6 months before. She really didn't want surgery and did everything she could to avoid it. Finally her GP told her it was the only option left -- she had advanced arthritis in both knees (no cartilage left).

At that point she had trouble getting up and down the basement stairs, trouble walking up and down hills, trouble getting in and out of the car. I was doing a lot of fetching and carrying so's she could avoid all those difficult places.

When she finally decided to go with the surgery, there was no fooling around. It was going to happen. As it turned out, her GP recommended one particular surgeon and he had a 6 month waiting list. Fine. In the meantime, I started researching on-line. Here's what I learned.

Your new knee will never be as mobile as your original (when you were healthy). The longer you can put off getting a replacement, the more satisfied you will be with the result.

This is not a "plug and play" scenario. When your new knee is in place, it only has the potential to be better than your worn out one. You have to make it better. It's a lot of hard work and no one can do it for you.

Prepare yourself physically. When your knees are that bad, you may not be able to do a lot for weight loss. Doesn't matter. Go to the gym and work on your upper body, your core muscle strength, and your aerobic fitness. Get some advice from an experienced trainer. You will find it a lot easier and safer to move around if you can take a lot of the load off your legs. Good cardiovascular condition will reduce possible complications. If you're a smoker, quit now. Three months in the gym just before surgery is a good target. Longer is better.

Prepare your house. If you think you might need handrails in the bathroom, get them installed. You might need to raise your bed. You can check some of these things out ahead of time by trying to move about with your bad knee straight and putting almost no weight on that leg. You don't want to find out that your bed is too low to get out of easily when you have to go the bathroom urgently.

You'll want a chair you can get in and out of easily, and you will want to be able to keep your leg raised for a good deal of the time. At the same time, you will want to move about as much as you can. That means in and out of the chair a lot.

Plan for all the things you will need to do if there is no one there to help you. You won't be able to kneel on your new knee for a very long time, and you won't be able to flex it enough to kneel on the other knee. Is there anything stored in low cupboards that you won't be able to reach? Be sure to have a wireless phone (or cell phone).

You will probably need a walker for a week or so. You might need crutches as well. Barb used a cane for a month or so after surgery (she bought one with molded handles and adjustable length).

Have people you can call in an emergency. Rethink your ideas about what an emergency is -- small, simple stuff can become much more important if you aren't mobile. What happens if you slip and fall? How are you going to get back up (even if you don't hurt your knee in the process)?

Your spouse/partner will have to be prepared to do a lot more work around the house for a couple of months. If there's no one living with you, arrange for someone to come in and help out.

You won't be able to drive for several weeks. Make sure you'll be able to get to appointments after the surgery. You will need a lot of physiotherapy -- 2 or three times a week. You may need to see a chiropractor.

You will need medication -- meds for pain, and blood thinners (blood clots are a big concern after surgery). Someone will have to fill those prescriptions for you. Someone will have to inject those blood thinners if you aren't able to do it yourself.

The biggest thing that will lead to a satisfactory outcome is knee joint flexibility. You will need to work hard on this (that's why the physio) and it will hurt (that's why the pain killers). You need professional advice so you pace yourself properly, but you also need someone to keep pushing you.

Barb discovered one of the greatest things for working on flexibility at home was a recumbent exercise bicycle. We got a cheap one that was adjustable for leg length and resistance. Barb was able to keep adjusting it so she was always pushing herself just a little. After both knees were good (about 1 year after surgery) we gave the bike away to someone else who was having knee surgery.

Finally, the outcome. Two years after her second surgery, with both knees in good working order, Barb and I became grandparents. When I watch her playing with the grandkids, taking them for walks in the woods, hiking through the snow, scrambling up and down hills, I think of what it would be like for her if she hadn't had her knees replaced. She thinks about it too.
Bruce    LT40HDG28 bandsaw with two 6' extensions.
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Offline LeeB

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Re: Total knee replacement
« Reply #28 on: May 30, 2015, 02:15:52 am »
Excellent post Bruce. A lot of good food for thought.
 
'98 LT40HDD/Lombardini, Case 580L, Cat D4C, Ford 851 tractor, JD 3032 tractor, Husky 346, 372 and 562XP's. Stihl MS180 and MS361, 1998 and 2006 3/4 Ton and 2005 1 ton Dodge 5.9 Cummins 4x4's, 1989 Dodge D100 w/ 318, and a 1966 Chevy C60 w/ dump bed.

Offline doctorb

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Re: Total knee replacement
« Reply #29 on: May 30, 2015, 09:32:56 am »
Brucer's post should be a must read for any patient considering knee replacement.  Excellent.
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Offline Brucer

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Re: Total knee replacement
« Reply #30 on: May 30, 2015, 02:32:26 pm »
I added a couple of comments to my previous post (in blue). Good cardiovascular fitness will reduce potential complications during and after surgery. Smokers should try really hard to quit as part of preparing for surgery. I know that's hard -- try to convince yourself that it will make your new knee(s) even better. Remind yourself that once you're past the surgery you can always take it up again (but maybe you won't want to by then :)).
Bruce    LT40HDG28 bandsaw with two 6' extensions.
"Complex problems have simple, easy to understand wrong answers."

Offline Gary_C

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Re: Total knee replacement
« Reply #31 on: May 30, 2015, 03:40:53 pm »
After being in the dairy business, I have been around many people that have had knee replacement surgery and I can say you can expect results to vary widely depending on many factors. The obvious factors are the skill of the surgeon and hospital in making the right cuts and avoiding infection.


This is not a "plug and play" scenario. When your new knee is in place, it only has the potential to be better than your worn out one. You have to make it better. It's a lot of hard work and no one can do it for you.


What Brucer said is an extremely important point. The best outcomes are with the people that can push thru the pain during the immediate post-op period and beyond. You must get that new knee in motion right away or there will be unwanted scar tissue that develops and will make your rehab more difficult and the final outcome not as good. During that immediate post-op time, it truly is as the saying goes "no pain, no gain."
Never take life seriously. Nobody gets out alive anyway.

Offline petefrom bearswamp

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Re: Total knee replacement
« Reply #32 on: May 30, 2015, 05:20:58 pm »
My experience.
My knees were hurting for  the past several years.
i heard about a new partial compartmental replacement called MAKO plasty and researced it further .
Had both knees done last June 9th.
the recovery was slow and I am an impatient sort so quizzed the last surgeon I consulted with in October.
He said I tell my patients that a bilateral is not twice as slow, but about 5 times as slow recovery.
Almost a year now and at 77 yrs the knees are great.
No problems
I just finished marking about 70 acres of timber some on a very steep slope with no problems.
worked at the mill alone today carrying heavy slabs, planks and boards with no discomfort.
My unprofessional advice is to look into this procedure.


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Offline Brucer

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Re: Total knee replacement
« Reply #33 on: May 31, 2015, 01:35:45 am »
You need to get a diagnosis on your condition before you do too much research. A partial replacement would not have worked for Barb -- her knees were too far gone. For other people in other situations, a partial would be an excellent choice.

Barb's first meeting with the surgeon was interesting. His first comment (before looking at her file) was, "You're awfully young for a knee replacement." She told him she'd been diagnosed with "advanced arthritis" (which is a technical definition, not a generic description). He pulled out her X-rays, took one look, and said, "Right, new knees."
Bruce    LT40HDG28 bandsaw with two 6' extensions.
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Offline petefrom bearswamp

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Re: Total knee replacement
« Reply #34 on: May 31, 2015, 08:46:19 am »
Brucer, glad all went well for your wife.
I appreciate everyones comments especially Docs medical insights and brucers advice regarding post op.
I did do a consult with xrays and cat scan with the surgeon before doing my extensive research over several weeks.
I also looked into blood platelet enrichment injection which is touted as very non invasive and will supposedly rebuild cartilage.
This is not covered by any insurance and would have required a trip to NJ or CAL and was very expensive for out of pocket for a fairly new and somewhat unproven procedure.
regarding Mako, I found a 45 minute utube by a surgeon in Clearwater FL who claims to have done more than 500 of these.
Very interesting and set my mind at ease.
At 77 I doubt that i will wear the knees out, but i am too stubborn to stop working.
As an aside, I ruptured  my left ACL in 95 and had it replaced with a piece of patellar tendon.
The surgeon wasnt sure he could save this repair but thankfully he did.
Also have had a total on my left hip in 99 and a dry revision in 2006.
thank goodness the prosthesis is modular.

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Offline doctorb

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Re: Total knee replacement
« Reply #35 on: May 31, 2015, 09:42:19 am »
Platelet rich plasma (PRP) injections have been touted for a whole lot of conditions.  Tendonitis, arthritis, bursitis, fracture healing, nonunion repair, meniscal repair, assisting total joints in adhering to the bone.....Yep, it's a hot topic right now with very little science behind it.  Sure, they can see that the high amount of growth factors and cells in these concentrates, but we are not sure how they identify what your specific problem is and how they focus in to repair it.  In the future, we hope to be able to give you a specific cocktail of cells and growth factors to stimulate the repair that you need.  We are not there yet.  So, while PRP is big business, and very much a sexy medical topic, I'd wait a bit before climbing on that bandwagon.  I had a friend of mine get 6 different PRP injections over a 9-12 month period for patellar tendonitis.  Heck, the darn thing would have healed by itself in that amount of time!
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Offline Gary_C

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Re: Total knee replacement
« Reply #36 on: May 31, 2015, 12:07:32 pm »
Doctorb, what's you opinion on this computer guided surfacing to get the precise angles needed for best positioning of knee joints? Is this just another fad or is it going to be the new standard?
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Offline doctorb

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Re: Total knee replacement
« Reply #37 on: June 01, 2015, 12:02:40 pm »
At this point, my joint surgeons have tried it and no longer use it.  It's currently more of a marketing tool, in their opinions, than something that improves your outcome.  Here are the controversies.....

1.  It takes a long time to set up, slowing the procedure significantly.

2.  Dependent upon placement of markers and calibration, it can be no more accurate than what is currently done.  Most surgeons currently use guides within the bone to align the femoral and tibial components, not computers.

3.  Everything is experience dependent.  An experienced surgeon places these components within the acceptable range of position the vast, vast majority of the time.  A younger surgeon with a computer is not necessarily better, and could be a lot worse, than an experienced arthroplasty surgeon .

4.  What we have found is that we are all built a little differently.  There is no one perfect position of the components for all patients.  So the allure of the computer assisted guides is that machines are more accurate than humans, but the computer does not necessarily make the adjustments required for your specific anatomy.

There are lots of computer guided surgeries being done.  Many involve brain surgery.  I don't think these techniques are a fad.   I think that they need to be refined and tested.  Further, I think we need to prove that these computer assisted techniques improve long term outcomes in joint replacement.  For the majority of knee replacements performed, the critical factor in their longevity has not been shown to be an absolute requirement of position, as long as the components are close to the acceptable range.
My father once said, "This is my son who wanted to grow up and become a doctor.  So far, he's only become a doctor."

Offline petefrom bearswamp

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Re: Total knee replacement
« Reply #38 on: June 01, 2015, 05:58:08 pm »
So doc,
Am I understanding you?
Replacement and other ortho surgery is not an exact science?
I imagine that the surgeon in any case is an artist and I can relate to that as I have had a lot of ortho done.
both knees as stated above, both rotator cuffs and they are acting up again, my fault.
Both bicep long tendons blown no surgery at the insistence of my surgeon again my fault.
Left hip, duputrons on both hands the left one twice, Carpal tunnel both wrists,
Maybe brain surgery to correct my late life accident proneness is in order.
LT40SHDD51
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Offline Gary_C

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Re: Total knee replacement
« Reply #39 on: June 02, 2015, 01:16:37 am »
Thanks for the update Doc. Around the Twin Cities the smaller medical facilities are always sending out a news release touting some "new and better" medical procedure, mostly to compete for patients with the Mayo Clinic. Since Mayo never participates in the hype of the "new and better" it's sometimes difficult to know what is a better way. Your insights are exactly what is needed by those who are facing a decision on knee surgery and it seems like it still more important to find an experienced surgeon than someone touting a new method.
Never take life seriously. Nobody gets out alive anyway.