Knee Replacement Preparation

So you're thinking about a new knee. I know I certainly have, and I've been looking at that now for a couple years since I've been suffering from some pretty moderate to severe knee pain. And again, with my tenacity, I am looking at everything, just like I did for my hip, to understand it better. And I hope that in this lecture, that I can give you some more education and insight, maybe gleam something for my studies and my research that might help you or help you with your clients when they're trying to consider if they're right for a knee replacement. To start off this lecture, I wanna talk about being prepared.

I want to talk about some questions that we can ask ourselves as it pertains to a total knee replacement, and the first question is, is it time for me to take the next step, that of a total knee replacement? I've asked myself that question. And again, one of the things that I always think of is what will life be like after a total joint replacement? And of course, I see the best and the worst of both. As a physical therapist, I've seen those who have had amazing results with a total knee replacement who were completely incapacitated to prior to surgery, and have completely returned to their life, doing everything from even skiing and hiking and dancing with a new knee, so that's the kind of question we're putting out there.

And one of the things I always want to say to my clients is that you are the consumer. You are the one that is gonna be making that decision as to what is right for your body. Now, to understand that, you need to be educated, you need to do your research. You need to get multiple opinions sometimes. I'll give you a good example.

Recently, I had a patient who came to me to get ready for a knee replacement surgery. And as we started evaluating her and looking at her, it seemed like her symptoms were more patella femoral than they were degenerative knee problems, and so I sent her to another surgeon who I trust very much, and he did a full workup, and he came up with the same conclusion that she was not a total knee replacement candidate, but that she had patella femoral pain that was not being addressed. And so that made it a easy for me then to address the patella femoral alignment as the physical therapist, and we started doing Pilates and other activities and got her back walking and participating in life without a total knee replacement. So again, she as the consumer was able to evaluate, to talk to different practitioners, different surgeons, different therapists to be able to see really if she was a proper candidate for that surgery. And that leads to something I talked about in a earlier lecture of false positives.

Sometimes if we, again, go through all the trouble of getting an MRI, seeing a surgeon, x-rays, maybe multiple surgeons, we have to remember that surgeons do surgery, and so their tool is a hammer, everything looks like a nail. And thank goodness we have great surgeons out there, and when it's time for that surgery, that we have somebody that can do an excellent job of that surgery, but I have noticed a lot lately that there are people who are getting total knee replacements that maybe didn't need a total knee replacement. I I'll give you another example of this. I had a patient who was complaining of severe lateral knee pain. It was acute after she had had a fall.

She had sprained her ankle, and the ankle seemed to have gotten better, but her knee got worse and worse and worse. She went to a number of surgeons. She ended up being told she needed a total knee replacement. She got the knee replaced, but the pain never got better. This lateral knee pain continued to bother her long after the total knee should have been improved, so when she came to see me, what I looked at and realized was that she had the fibula was not moving in relationship to the tibia or the ankle.

And when I was able to mobilize the fibula, she was like, oh my goodness, that's the pain that I've been feeling all along over the last four years. So she ended up getting very upset, and saying that she got a surgery that she didn't need when all she had to do was have a manipulation of her fibula. So you could imagine how upset she was with the idea that she might have had and suffered the pain from a total knee replacement for that six month period of time, and still have the residual pain that she had from the very beginning, and that's my point is that doesn't always happen. Like I said, I have many patients who have true degenerative changes that are very painful and life inhibiting, and they get a total knee replacement, and they're restored to full function in their mind, and are super happy, my mother being one of them that has done incredibly well with the total knee replacement. So, it's a matter of doing your research, seeing enough practitioners that don't see everything as a total knee replacement, trying everything, trying your rehabilitation.

And if you still are not getting better, and it is impairing the quality of your life at that point in time, it is time to move forward. And what I can tell you, and I went through this with my own experience with the hip, when I wasn't able to do 50, 60% of what I believed I should be able to do in my 50s, I knew it was time for a total hip, and I had tried everything. And literally, the day after my hip surgery, I felt so much better. The pain of the incision was nothing compared to the pain that I'd been dealing with for over 10 years. And I think this is sort of the story that I hear over and over again from my patients that I now understood is that I was dealing with incapacitating pain on a daily basis in my joints that was interfering with the quality of my life.

And within days after my surgery of the hip in particular, I was able to do almost everything that I couldn't do before. Within six months, there was nothing that I couldn't do with my right hip. So now I'm facing that same decision that maybe you're facing, or a client of yours is facing with the knee. And the knee to me is a little more challenging because I know there's a sacrifice with the knee, right? I know that the knee is going to end up with losing a little bit of range of motion because of the new prosthetics that they're using, so we'll come back to that in a little more detail.

So we're gonna talk about things like how do I pick the procedure? What's the best prosthesis? What is minimally invasive? How do I find a surgeon that does minimally invasive surgery? What's the long term outcome comparison between procedures with short term outcomes.

I know that with my hip, I chose an anterior that was minimally invasive that didn't cut the muscle, but I know that the research shows that those that have a posterior approach have the same now success rate six months out with pretty much the same level of no limitations of movement. And then the last thing we'll talk about in this section is how do I pick my surgeon? So that first question, is it time for me to get my knee replaced? Typically what I ask my patients is, do you have a limitation of more than 50% of the activities that you desire to participate in? Do you have poor tolerance with things like transfer from sit to stand or getting in and out of cars?

Are you able to squat, or are you not able to squat? So when you gotta pick something up, do you tend to have bouts of low back pain and other problems that are because your knees aren't bending? Are the non-steroidal anti-inflammatories no longer cutting it for you? Meaning that you take your Aleve, you take your long lasting anti-inflammatories, and you're still having pain most of the day. Do the x-rays confirm the symptoms, right?

We're gonna avoid false positives, but the symptoms you're having long term, does it really show the degeneration on the condyles of the femur and the tibia? Is it really bone to bone? Has the space been lost? Is there scarring around the edges of the tibia, and and the condyles of the femur where there's loss of cartilage? You've done all the therapies you can do.

You've tried everything, and then there is a test that you can do. It's called the SCORE, S-C-O-R-E that also is out there that says whether or not you're ready for a knee replacement. So these are some of the questions and some of the hoops that we jump through to be able to understand if we're ready for a knee replacement. So this is me being told why my surgeon, that there's no other way to fix my knee other than a total knee replacement. Of course, I stick my bottom lip out and pout when people tell me those kind of things.

And the big question that I always have for myself is to be whole or not to be, that is the question, right? So, what I have to come to the grips with is that to be whole, to me, could be whole function. Doesn't mean I have to have all of my original body parts to be whole, although that would be nice if I could. And I wish now, as an older adult that had played very aggressive sports, one of my main sports was pole vaulting, and I pole vaulted in high school college, and as an adult as well, that had resulted in many severe traumatic injuries. And even though we sort of think of it like metals that we wear on our coat of being an athlete that has these injuries, as we get older, we pay the price for those, and I certainly feel that now.

I look back and I think of my children who were raised to be very mobile, very supple, that they're very in control of their body. They have great awareness. They grew up on the Pilates equipment, and they just don't have the same set of injuries or degenerations or surgeries that their old man has. So that's the question, to be whole or not to be whole, for me? And I chose that whole function is more important than whole body parts, and so that's what allowed me to go forward with the hip replacement, and it's allowing me in my mind to start preparing for a total knee replacement probably in the next year.

So if we look at this set of x-rays, you'll notice that on the left hand side there, that there is no cartilage. There is no black space between the femur and the tibia. This is a good example of something that would tell you that we've lost the cartilage, and the knee is starting to collapse. It no longer serves its purpose fully, but I've seen these type of x-rays with people who don't have any knee pain. So the question has to always come back is do the images and the tests and the consultations match the dysfunction?

And remember that belief can create dysfunction. So when a doctor says, he looks at this x-ray, and she says, "That's the worst x-ray I've ever seen of a knee. You need a total knee replacement," and the person that goes, "That's funny, I wasn't here for my knees, I was here for my ankle," that they weren't really complaining of knee pain, but now all of a sudden in their head, they're recycling this statement that the doctor said, where she said, "That's the worst degeneration I've seen a long time of that knee." So we have to be very careful of how we influence. If you're looking at me, standing here, you can see my left knee is in another county, right? So, I've lost the alignment of that knee.

Doesn't matter what I do. I wear a brace when I play sports to be able to minimize more damage, but people all the time that I have no idea who they are come up to me and tell me, when are you gonna get that knee replaced? That knee looks really bad. So we often put this information into our clients a lot of times that could be harmful to them, when in reality, their knee isn't bothering them that much. And we have to be careful of diagnosing the x-ray or the static posture, and not looking at the function.

I still can do a full squat to the ground, and that's what I'm afraid of giving up. If I can still squat all the way down and come all the way back up, I won't be able to do that with a total knee, so those are the things that I have to take into consideration of sacrificing for the many things that I will be able to do. So here we're looking at a slide of a total knee arthroplasty. So what that means is that the surgery is going to take off the top of the tibia, and it's gonna take off the top of the condyles, and it's gonna replace it with hardware. There's many different types of hardware that are used, from plastic, titanium, porcelain, different types of compounds that are used.

Some use cement, some don't, but the idea is that whatever the prosthesis is, it's going to replace and try to be as smooth and shock absorbing as our normal cartilage and meniscus are in our knee. That's the challenge, that's the task, and the surgeon tries to preserve as much of the ligaments as possible in most of these surgeries. So if they can preserve some of the ligaments, they do. Sometimes they have to sacrifice depending on the prosthetic, the ACL and the PCL. Sometimes they don't, you'll have to talk to your surgeon about what you think is most comfortable for them, and what you're interested in.

Either way, the prosthetic is able to maintain most of the function, especially in the osteokinematic part of the knee, which we talked about earlier in the lecture. The osteokinematic part being flex and extension. So after a knee replacement, you can expect to have full extension with good rehabilitation, and you can expect to have about 125 to 130, 135 degrees of flexion. Now, to do the full squat that I did might require somewhere closer to 140. And that's what you would expect, like if you practice yoga or Pilates or dance, that it might be concerning to you to lose those 5, 10 degrees of knee flexion based on your choice of activity.

What I would challenge you with though is, are you able to do it now? Are you able to participate in those activities, or is that why you're considering a total knee replacement? And is the pain so bad now that it actually is interfering with simple things like getting in and out of a car, or going for a hike with your family, or being able to participate in other really fun daily activities? So here we're looking at the surgical approach, and typically you'll see a pretty good zipper that goes along the front of the knee, that goes from the mid thigh down to the bottom of the patella tendon, and that allows them to have the visibility that they need to be able to perform the surgery, and to have the exposure they need to basically shave off the end of the femur and the tibia, and to be able to fit the knee with the new prosthesis. The advances of science and of surgery have just jumped so drastically, and a lot of surgeons now are using robotic assisted surgery.

One in particular that I'm fond of, and one that I'm interested in is the Mako Stryker System. Mako was the robot, Stryker was the hardware. They typically go together, so if you find a surgeon that uses a robotic, whatever that robotic company is, is going to be paired up with the prosthesis that matches that surgery. And what the robot does is the robot actually is much more precise in the shaving and the alignment of the new knee, and let me give you an example of this. This is according to my surgeon, Juan Suarez, who I adore.

Because I'm already bow-legged, like if you look at my legs, I'm already there. You can see that I have sort of, I look like I was a cowboy since I was a kid, right? And even though the left side is much more severe, his thought is rather than trying to just straighten the knee up, so a lot of surgeons will come in and they'll try to straighten that leg so it's zero degrees varus, zero degrees valgus, it's just perfectly straight. The problem with that is that my leg has never been perfectly straight. I've always been a little varus, so if I'm three, four degrees varus, and you force me to be zero, it's going to cause a lot of tension and stress on the medial structures of my leg, and that is one of the reasons why people have such negative effects following a surgery is typically the surgeon did not line it up with what they were before, and therefore it puts an unnecessary stress on soft tissues that cause ongoing pain following the knee replacement.

With the robotics, they can go in and program it and say, look, Brent is eight degrees right now, so I'm about eight degrees varus, and my normal on the right side is about three degrees varus. So if we only bring his knee into three degrees varus, and his legs will look the same, and he won't have more stress on the medial structures than he would if we tried to bring him to zero. So there's some really good advantages now, and the other thing is the precision of minimally invasive, being able to have just the right amount of bone coming out so that the prosthesis fits perfectly. It's no more subject to the physician skillset, although it does require physician skill, but the physician will tell you as well that it really aids them in being able to do exactly how much bone has to be removed for the prosthesis to fit perfectly. Going back and talking about the prosthesis, so we just mentioned how, for example, for me, I'm choosing Mako.

I'm not endorsing it, it's just that the surgeon that I endorse, the surgeon that I like, that I've chosen, that I've gone around the country and interviewed a lot of surgeons for myself over the last couple years uses the Mako robotic system. That's what he's familiar with. He's familiar with the Stryker prosthetics. He likes the materials. He likes the way that it pivots.

He likes the flexibility of it, especially for somebody like me that already is varus, and needs to have that compensation appropriate for me. So, when they go in to do the surgery, they have a kit and that kit allows them to fit and try different prosthetic pieces until they find the perfect alignment that's gonna allow me to have the most optimal outcome. Once they identify that, then they pull the permanent prosthetic out, and they put that permanent prosthetic into the body. Some of them are cemented, some of them are non-cemented. I happen to prefer the non-cemented because I like to think of the porous body or the post being absorbed into my body, and the bones growing into it so it has life, it lasts longer.

It's not gonna be subject to if I do too much activity and I break the bone around the cement, or those kind of things, that I think in my personal studies that that's a better option. So again, there are many different prosthesis. Each surgeon has their favorite. One of the things to be careful of is trying to tell your surgeon that you want a different prosthetic, or a different robot, or a different surgical approach. Surgeons are best at the surgery that they do the most, so I could tell you that I seen one surgeon who is a phenomenal surgeon who does a more archaic procedure, but he himself is a phenomenal surgeon and has great outcomes.

Asking him to use a robot doesn't make any sense. He's gonna do a great job for whoever goes to see him. If he was to try to learn a robot, he'd be a novice again. It would be like all new. The younger generation coming out, however, that's doing surgery are all being trained on the robots.

They're all being trained with these new technical things, and they again are becoming better, faster, and more proficient, and the outcomes are also improving fast. The last part of this is being able to choose your surgeon, and I mentioned that I have gone all over the country looking for my surgeon, and of course you gain an affection typically for the surgeon that puts in new joints for you, and you wanna make sure that you have a great surgeon. It's not always about their personality. I happen to have a great surgeon who has a great personality, but it's much more important that they are a great surgeon. Once you've decided that you need to have a knee replaced, and once you've made that decision, you're ready to do it, and you're on the search, and you're looking for what kind of surgeon, you can take into a lot of different factors, and that's what I have listed here.

One, they performed hundreds, if not thousands of the procedure that you're having. You don't want somebody experimenting on you. All surgeons have to experiment on somebody in the beginning. You don't want that surgeon. You want the surgeon that has done thousands of these procedures.

They perform surgery in a well respected surgical center or hospital. I'm always a little leery, no matter how good the surgeon is, if they do it in a surgery center that is famous for infections, particularly in total joints, that's a disaster. So you want somebody that has a Sigma Six non infection rate of total joints. You really wanna stay away from facilities, and sometimes surgeons can't, great surgeons can't get access to great hospitals, but I'm a big advocate that the most likely problem that is gonna be life threatening to us getting a total joint replacement is infection, and a hospital or a surgical center that doesn't control infection, and you can ask them for their infection rates. You can ask them of what's going on there.

That's a big concern. You don't wanna go home with a bacterial infection or osteomyelitis from the surgeon's error, from the hospital's error. Number three, I'm a big fan of working with surgeons who are not big opiate users, so they're non-op opioid protocol pre and postop. I'm gonna talk about pharma in one of the next lectures, but the idea of staying away from high opiate use and dealing with the pain a little bit, I'm gonna talk about the pain as well, so I like surgeons who wanna use other things to control pain besides opiates. Even if we use opiates during the surgery, right after the surgery, maybe for a couple days, but not using them long term.

It's very easy with a total knee replacement to become addicted to opiates. I can't emphasize that enough to you of how many of my patients, long term, are suffering more from the opiate addiction than they are from the knee replacement, where if they were just told not to use opiates, to use something else for a couple days, they would not have that horrible addiction in their life. And then one of the key things, and I'm biased to this, is that our surgeons believe in therapy. Do they believe in rehabilitation? There are some surgeons out there who think their surgery is so good to the world that there's no need for rehabilitation.

I can tell you going through a total joint replacement that even the knowledge I had as a physical therapist of 30 years was not enough to prepare me for what I needed to know, and so I've made a big emphasis. That's why I'm doing this lecture is how can I prepare you? How can I help you prepare yourself to become ready for a total knee replacement, or a total hip replacement? And how do you make the right decisions? By picking a doctor who believes in therapy, that a therapist can guide you through the first couple weeks, if not the first year of recovering from a total knee replacement is crucial, so make sure that your doctor believes in rehabilitation.

And probably one of the last ones is, and this is optional, but I like the physician that treats you like a human. Just having a little bit of bedside manner goes a long way. I'll share a brief story with you about Dr. Juan Suarez. Juan I had heard about, local in Miami. He was the director of a hospital's orthopedic program, and then at the hospital near me, but I'd gone to Chicago, I'd gone to New York, I'd gone to California, I'd gone to Vale, Colorado, interviewing surgeons, looking at what they're doing, their protocol.

I made the decision that I definitely wanted to have this particular surgery on my hip with a Matta procedure on a HANA table, so I only looked at surgeons who were doing those procedures, who had been trained. Juan happened to be one of them. As I sat down with Dr. Suarez, instead of talking down to me, he sat next to me. We were looking at the imaging, and he asked me what I thought and what I was feeling, and if I felt that I was ready to take that step. And I know that he was taking into consideration the fact that I'm a well-respected physical therapist, but it was also treating me just as a human as the patient, and I felt so comfortable there.

And I just looked at him and I said, "You're my doctor. You're my doctor, you're my surgeon." And he has continued to be my surgeon, and he's the one I'm gonna trust to do the knee replacement as well. He actually has more expertise in the robotic and the knee replacement, and has incredible results. I see a lot of his patients. So choosing your surgeon is a really important step once you've made the decision that you are going to get the knee replacement.

This concludes the preparation part of the surgery. So looking for all of these things, and making the ultimate decision. I've made my decision as you will make your decision, yay or nay. So for me, I've made the following decision, right? This is what fits for me.

This is not what I'm suggesting for you, but I do suggest you go through the same process, and go methodically, and come up with what you want and what you expect, and who you're gonna work with. So, number one, I knew that I wanna work with the robotic assistant total knee replacement procedure. I wanna make sure I do that because I know that the research shows that it's more precise, and I wanna find a surgeon that does that, one particularly close to where I live or where I work. Number two, I decided to go with Dr. Suarez, as I mentioned previously in Miami, using the Mako Stryker system. That's what he's most familiar with, that's what he likes to use.

He's helped develop aspects of it, so I know he is well involved. He's done thousands of surgeries using this system, and he's continually improving his technique. He's continually looking for better solutions. As I mentioned, he's gonna be sensitive to the angle of my knee previous to surgery. I've chosen that in the Stryker hardware, that's the titanium and plastic version of it.

So there's a, I won't go into too much detail on it, but I know which prosthesis I want to use, and it's the one that I've talked about with Dr. Suarez that I think is gonna give me the most range of motion based on what I'm choosing to participate in. There are others that maybe the material could be lasting a little bit longer, but it doesn't have maybe enough absorption or mobility in it like I need for the kind of activities that I participate in as a Pilates teacher, as a hiker, as a gardener, et cetera. And then lastly, just to make sure that the robotic is adjusting for my varus angle. So those are the things that I decided were essential for me to move forward, and then I'm looking at the plan of having a six month window where I can move forward with that surgery, so I'm sure that I'll be back on Pilates anytime with a post-surgery report of what happened with that. I really wish you the very best of luck as well as you go through this decision making process, and certainly would be available for questions through Pilates Anytime regarding making this very important decision that we all make if we're dealing with degenerative knee changes, and the need for a total knee replacement.