Dale Says

I am in the midst of recovering from total knee replacement. It’s been slow and painful, as everyone said it would be, but I’m gradually gaining strength and mobility and I now know it will be worth it in the end. My situation isn’t uncommon, as an increasing number of people are choosing knee replacement as a way to ease pain, increase mobility, and get back to a more active life.

What is surprising is how much I didn’t know before I had the surgery.

This article is meant to help readers who are considering knee replacement prepare for surgery, and for a successful recovery.

Make plans before surgery
There are a number of things that should be done before knee replacement surgery. Here’s a checklist:

 Have a physical examination to ensure that you are in good enough health to have the surgery.

 Check with your health insurance company to determine your coverage and responsibilities, and to complete required paperwork.

 Arrange for care after surgery (at home or in a rehab center) that includes meals, medicine, laundry, shopping, and transportation to and from the hospital and physical therapy.

 Re-arrange your home to allow you to get around on a walker or crutches without climbing steps or lifting or carrying things.

 Find and schedule an appointment with a qualified physical therapist that has experience with knee replacement patients.

 Lay in a supply of food, clean clothes, linen, medicine, and cash.

Mentally prepare for your hospital stay
Typically, knee replacement patients spend three nights in a hospital. During that time you will be in bed nearly full time (except for brief periods to do physical therapy). You will likely wear a catheter, have an IV attached to your arm, and be poked and prodded every couple of hours around the clock. There’s not much you can do about it – except to be mentally prepared for it. Take a couple of good books with you, ask friends to stop by with special treats, and pick out a few good TV programs or movies to watch.

Arrange for caregivers
Helping you through recovery is a big job and you should make sure you have arrangements with people to spend time each day with you for at least two weeks. You probably won’t be able to drive, cook, shop, do laundry, buy medicine, or clean house, and you will need someone to take care of those tasks for you.

Make sure your caregivers are well rewarded because helping you (at least at first) is probably going to be a pretty thankless task.

Pick a qualified and trusted physical therapist
A good physical therapist is crucial to recovery. Few of us have the discipline on our own to do the painful and tedious work required to recover from knee replacement and it helps to have a physical therapist as instructor, coach, disciplinarian, and cheer leader.

Find a physical therapist you trust who is experienced with knee replacement and willing to spend the time and energy to help you through recovery. Do everything your physical therapist tells you to do. If he or she doesn’t measure up change therapists until you find one that does.

Plan for pain
You will likely experience pain for several weeks and pain pills will only dull the pain, not eliminate it. Prepare to deal with two types of discomfort – pain during therapy and night pain.

The therapy of re-gaining flexion (bending the knee) hurts. After awhile you will get used to it, but the pain will still take your breath away. You can relieve the pain by taking pain pills before therapy sessions, and by massaging and icing your knee afterward.

You may also experience night pain – a sharp ache that wakes you in the middle of the night. You can ease night pain by taking anti-inflammatory pills (ibuprophen, for example) before you go to bed, and by gently massaging the knee, then icing it.

Get your knee back
Getting motion back in your knee involves increasing the flexion (bending) and extension (straightening). Immediately after surgery you will have difficulty with both functions and improving them will become your focus during recovery.

There are a variety of exercises to increase flexion, with the goal of gradually increasing the angle you can bend your knee to 110 – 120 degrees. Your physical therapist will teach you the exercises, and you should do them every day. At first, they will be painful, but your knee will gradually warm up and they will become easier and more rewarding. Two useful tools to improve flexion include a Continuous Passive Motion (CPM) machine, which slowly bends and straightens your leg, and a stationary bicycle, which helps increase mobility in your knee.

Be forewarned, there are no days off during recovery and you will have to do exercises every day for up to six months. Consider it your full time job to recover and push yourself, even on days when you don’t feel so good.

The payoff: a new start and a new knee
There are a lot of things I didn’t know about knee replacement. But looking back on it, I would have had the surgery even if I had known them. For me, it’s worth the pain and effort, because in the end I know I will have a new knee and a fresh start.

I hope you will feel the same way, and I wish you well in your recovery!

At my pre-op checkup x-rays showed a substantial deterioration of my right knee joint since the last examination nearly a year ago. After considerable debate, we decided the arthritis in my knee is too far advanced for allograft OATS surgery.

The inside portion of my knee compartment is now nearly closed and I have a lot of arthritic growth in the knee joint and under the kneecap. After studying the x-rays and my knee flexion, Dr. King believes the allograft OATS procedure would only alleviate some of the pain, and that I would be dissatisfied with the results and would be back in an operating room within two years for a knee replacement. Also, there was the question of the donor tissue — is it appropriate to use the tissue for a marginal surgery, when there are more suitable candidates waiting for it?

So we decided to cancel my surgery and turn the tissue back to the donor bank, to be used by someone else.

Now I will look for an alternative surgery.

The phone finally rang, and I’m scheduled to have knee surgery tomorrow (Wednesday, June 13).

The procedure will be an allograft OATS, a surgical transplant of good cartilage from a cadaver knee into my right knee, which has lost cartilage from osteoarthritis.

During the surgery, my knee will be opened up to expose the affected area. Measurements will be taken of the damaged areas of the knee to confirm the size and extent of the lesions. Once the appropriate size is determined, a cylinder-shaped dowel of bone and cartilage will be removed from my knee, and replaced by the same size dowel of bone plus cartilage from the cadaver knee. In my case, this will likely involve several dowels, since the inside of my knee is missing most of the meniscus cartilage. Once the “plugs” are inserted, my knee will be closed.

Dr. King will also perform an osteotomy, which is a realignment procedure that unloads the vulnerable or arthritic side of my right knee and puts more weight on the outside of my knee (which still has good cartilage). The osteotomy will be done by wedging open the tibia (shin bone) and adding bone graft putty to create new bone growth into the wedged area.

I expect to be in recovery for four to six weeks; in bed for a week, then on physical therapy and crutches for around a month.

Following is a link to an excellent description of the allograft OATS procedure, with images that help explain it. It was developed by Dr. King, who will perform my surgery.

http://www.pamf.org/sports/king/osteoarthritis.html

Be sure to check with your health care insurance company before you agree to have this procedure done. Some cover it; others do not; and still others have stringent criteria that must be met before the procedure is covered.

My insurance company (CIGNA) will cover it if several conditions are met:

CIGNA HealthCare covers osteochondral allograft transplant as medically necessary when ALL of the following criteria are met:

Symptomatic and debilitating focal chondral lesions of an articular surface of the knee are present. Previous medical and/or surgical management has failed. The patient is not currently a candidate for total knee replacement.Other insurance companies have different criteria. Some specify the site and size of the damage to the knee, and some even specify that the patient’s age and even body mass index.

Osteoarthritis is a common cause of pain and disability in the knee joint. In the knee, the end of the femur (thigh bone) and tibia (shin bone) are covered in smooth articulate (surface) cartilage. Between the two bones sits a second type of cartilage, called menisci, which acts as a shock absorber. Joint fluid also adds lubrication to the knee joint. Osteoarthritis (OA) starts when articulate cartilage is thinned or missing, which results in areas of exposed bone, and then progresses into surrounding bone, tissue, and synovial fluid.

It has been estimated that 12% of Americans aged 25 years and older have osteoarthritis, which increases to 80% of people older than 75. Symptoms of osteoarthritis include joint pain with activity, night pain, morning stiffness, limited motion, joint inflammation, crepitus or noise from the knee, and deformity. There are several options in treating osteoarthritis, both surgical and nonsurgical. All options are not always appropriate for every patient. Information gained from X-rays, MRI and knee arthroscopy all are helpful in determining an appropriate treatment plan.

Nonsurgical Treatment Options

There are several non-surgical treatments for osteoarthritis; most of them start with weight loss.  Each pound of weight can put up to six pounds worth of pressure on the knee joint during activity, so heavier people tend to develop arthritis at an earlier age and to a greater severity

Muscle strength  is also vital in combating osteoarthritis. The muscles surrounding the knee joint act as shock absorbers for the pressure that daily activities and sports place on the joint. The stronger the muscles around the knee, the more stress they can absorb for the knee joint. Exercises that will increase quadriceps, hamstring and calf strength include ¼ squats, leg press and leg extension. These exercises should be pain free and done with limited flexion or bending of the knee, not greater than 45 degrees. In addition, cardiovascular exercise such as cycling, elliptical, rollerblading, and swimming will also be beneficial. Strengthening exercises should be done at least 3x/week to build muscle strength.

Knee braces are available for treatment of medial compartmental osteoarthritis (arthritis on the inside of the knee joint). These braces work by unloading the medial (inside) portion of the knee. These braces need to be custom made and therefore can be expensive.

Anti-inflammatory medications may also help decrease symptoms. Aspirin, Ibuprofen (Advil) and Naprosyn (Aleve) are all examples of over the counter anti-inflammatory medications (NSAIDs). Prescription strength NSAIDs include Indocin, Daypro, Relafen, Celebrex, Lodine, and Mobic. Acetaminophen (Tylenol) may also be taken for OA pain but it is less effective for inflammation than other medications. Supplements such as glucosamine sulfate and chondroitin sulfate are widely used but not regulated by the FDA. Glucosamine, an aminomonosaccharide, is a primary component of connective tissue (including cartilage). It is not know however, if taking glucosamine orally has any effect on the knee joint. Chondroitin sulfate is found in proteoglycans which contribute to the stability of cartilage. In supplementation form, chondroitin is derived from bovine and calf cartilage. Several clinical studies are in process to evaluate effectiveness, efficacy, and to monitor long term adverse effects of glucosamine and chondroitin.

Lubrication or Hylagan injections provide extra lubrication and shock absorption, as well as decrease friction or rubbing within the joint which may slow the progression of osteoarthritis. However, of all the patients who receive Hylagan injections, only about 50% have symptomatic relief. One injection is given into the knee each week for three weeks and may be repeated as soon as 6 months. Up to five injections may be given, but studies have shown no difference in symptom relief after 3 or 5 injections.
Injection of cortisone into the knee joint has been shown to be effective for ‘flares’ of arthritis symptoms, as they are a direct acting anti-inflammatory medication. However, research has also shown deterioration of articulate cartilage after repeated cortisone injections. Therefore, these injections are only used with caution in the knee joint.

Surgical Options

Artificial joint resurfacing involves capping the end of the femur (thigh bone) and tibia (shin bone) with plastic and or metal pieces. These pieces are glued in place to form an artificial joint surface. This procedure can be very effective in eliminating painful and severe OA, but it is limited by the fact that the articular components (plastic and metal) will eventually wear out and need to be replaced. In active people early loosening of the components can occur. For these reasons most orthopedic surgeons try to delay artificial resurfacing procedures until late in life

Unicompartmental Knee Replacement
Another option for patients with osteoarthritis in one area of the knee- usually medial or lateral is an artificial resurfacing of the cartilage surface, called a unicompartmental knee replacement. This procedure is successful in relieving symptoms from osteoarthritis if the arthritis is limited to one compartment or area of the knee

OATS Procedure
Osteochondral Autograft (or allograft) transplant (OATS procedure) can be performed for small to moderately large area of surface cartilage loss. This procedure involves first removing a cylinder shaped dowel of bone which is lacking surface cartilage and replacing it with a dowel or cylinder of bone with intact surface cartilage. Both dowels are the same size so when they are switched there is a press fit and no hardware is needed to secure it in place. The replacement dowel of bone (with surface cartilage) can either come from a non weight bearing area of bone and surface cartilage from your knee (AUTOGRAFT) or from a cadaver (ALLOGRAFT). If the lesion or area lacking surface cartilage is less than 20mm an autograft OATS may be performed, using either one or a few bone and cartilage plugs. If the lesion to be resurfaced is larger than 20mm, taking tissue from a cadaver or an allograft is needed.

Rehabilitation after an OATS procedure includes using crutches and partial weight bearing activity for 3- 6 weeks.

Osteotomy – Tibial and Femoral
Often patients with knee osteoarthritis may have more arthritis on either the inside (medial) or outside (lateral) of the knee, causing the alignment of the knee joint to shift towards becoming bow-legged or knock-knee. Unfortunately once alignment is no longer even activity and pressure on the knee joint can cause an acceleration of wearing of the vulnerable side of the knee as more and more weight is now transferred onto that area. An Osteotomy is a realignment procedure that unloads the vulnerable or arthritic side of the knee and puts the majority of the load of the knee joint onto the underutilized cartilage on the other side of the knee.

An Osteotomy is performed by wedging open either the tibia (shin bone) or femur (thigh bone) and adding bone graft putty to create new bone growth into the wedged area. After this procedure patients are on a home motion machine for one week, then progress to physical therapy.  They use a brace and crutches for the first 4-6 weeks after surgery until the bone is well healed. This procedure is very successful in relieving symptoms and preventing or delaying an artificial knee in many. 

From Treatment Options for Osteoarthritis in the Knee, Warren, King M.D. 

Allograft OATS is a surgical procedure for transplanting good cartilage from a cadaver knee into a knee that has lost cartilage from osteoarthritis.

During allograft OATS, the knee is surgically opened up, to expose the affected areas. Measurements are taken of the damaged areas of the knee to confirm the size and extent of the lesion.  Once the appropriate size is determined, a cylinder-shaped dowel of bone is removed from the knee.  It is replaced by the same size cylinder-shaped dowel of bone from the cadaver knee.  In my case, this will likely involved several small dowels, since the inside of my knee is missing most of the meniscus cartilage.  Once the “plugs” are inserted, the knee is closed.

My surgeon will also perform an osteotomy, which is a realignment procedure that unloads the vulnerable or arthritic side of the knee and puts the majority of the load of the knee joint onto the underutilized cartilage on the other side of the knee.

The osteotomy will be done by wedging open the tibia (shin bone) and adding bone graft putty to create new bone growth into the wedged area.

After the allograft OATS and osteotomy, I expect to be on a home motion machine for one week, then will undergo physical therapy for around a month, while using a brace and crutches for 4-6 weeks after surgery.

Following is a link to a good description of allograft OATS with images that help explain the procedure:

http://www.pamf.org/sports/king/osteoarthritis.html

The phone’s not going to ring today.  It’s Saturday, and my doctor’s office is closed.  But each weekday I wait for the phone call that will tell me donor tissue has been received and I’m to report to the surgery center.

The cartilage is missing from the inside of my right knee.  It’s been a long-term process, involving several surgeries, lots of pain, and the realization that I need to take more drastic action to “fix” the problem.  Allograft OATS seems like the best solution for me.

Osteochrondal transplant (OATS procedure) is performed on knees that have suffered large areas of surface cartilage loss (grade IV chrondromalacia).  The procedure involves removing a cylinder-shaped dowel of bone from the knee and replacing it with a dowel of bone with good cartilage.  Both dowels are the same size so when they are switched there is a press fit and no hardware is need to secure it in place.

The replacement bone with good cartilage can come from a non-weight bearing area of the patient’s knee (autograft) or from a cadaver (allograft).  In my case, it will come from a cadaver.  That’s why I’m waiting for a phone call.  A tissue donor with good cartilage will die, my knee surgeon will receive the cartilage from the donor’s knee, and it will be transplanted into my knee.  It’s gruesome, but a remarkable alternative to knee replacement, which is not a good long-term solution for someone my age (55).  Knee replacements tend to last 10-15 years, then a second replacement needs to be performed.  The second one is much more difficult than the first, as less bone is available to work with.

So I’m waiting for the phone to ring …