This gentleman, born in 1946, has had 20 years of progressively-worsening knee pain, where he was struggling to walk a mile but could really only manage 50-60 yards before needing to take a break. He also had a lot of night pain.
He has always been very active, especially enjoying off-shore sailing - in fact 6 years ago he sailed the Atlantic. He is also a competitive archer, and he wanted to be able to retrieve his own arrows but walking had become an issue for this task.
When I examined him, I found that he had a reasonable range of motion with a stable knee. His X-rays showed that the patello-femoral and lateral compartments were in good shape, but his problem was a bad medial osteoarthritis. This, of course, is not that uncommon. You can see on this weight-bearing X-ray how the joint space is narrowed medially (inner aspect of the knee).
After reviewing the MRI scans and confirming that the patello-femoral and lateral compartments were good, I decided that a partial knee replacement was the way to go despite his being in his 70s with that level of activity. He subsequently underwent bilateral simultaneous partial knee replacements under my care.
Within three weeks he was already on the train going up to his art lessons in Newbury travelling up from the High Wycombe area and was walking without crutches. In fact he wants to start driving and has no pain and very little swelling. Both knees have an excellent range of motion. He described his experience as ‘amazing’, and he couldn’t believe that he was this good at such an early stage.
This is fantastic result on a >70 year old simultaneous bilateral unicompartmental knee replacement patient.
This just shows that with minimally invasive surgery, appropriate handling of the soft tissues, a large quantity of local anaesthetic infiltration and the GameReady device - which we use as a cryotherapy device post operatively - patients can get back on their feet very quickly.
This patient very kindly agreed to answer a few questions for the benefit of readers -
1. why did you and your surgeon both decide to do the two knees at the same time?
"My research of knee replacements suggested that success is influenced by the physiotherapy needed to restore the movements and muscle operation following a quite invasive procedure. It did not seem to be very constructive to "learn" how to walk, balance etc after one knee, where all the muscle sets would develop asymetrically, only to be followed 3-6 months later with a complete "relearning" when the second knee was replaced. I did not realise that simultaneous operations were "unusual"; and that most physio exercises are described by reference to the "good" limb, and the recovering one; in practice this really has not been a problem, and although recovery of the two knees has developed differently, they have been comparable. (the differences were probably associated with "injury" incurred in over enthusiastic exercise at about week 4).
I have read papers from the USA, which compares simultaneous bilaterals, with separate operations, the overall impression that I tòok was that there was a statistical increase in risk of infection and blood clots, (which like many statistics could be challenged), but that there is a reduction of perhaps 40% in overall cost, but above all the patient experience was in all cases greatly improved. My wish for simultaneous operations arose before meeting Professor Wilson, and following his initial investigations I was very reassured by his proposal."
2. what it very challenging to get about in the very early days?
"In short very much less than expected. On standing for the first time the day after the operation, I was pleased to note that I was immediately standing on the balls of my feet, rather than on the heels, which had characterised my gait for several years. Pain relief was important to allow me to move easily, but I quickly dispensed with the Zimmer frame in favour of crutches; sitting and standing from the WC was a struggle, which was not particularly helped by the raised seat adapter. Although stairs are featured as a prominent physio milestone, I did not find these any more difficult than normal walking. Here the physio instructions ( lead UP with the "good" leg, and DOWN with the damaged one ) did not apply, and I was particular in ensuring that Left and Right were exercised and taxed similarly, and I still do. I used the two crutches for 3 weeks following the operation and then a single for another 4 weeks, thereafter I used one when I got a bit tired. I still have one in the car, and one at home by the stairs, in case I feel the need, but have not used it at all since about week 10. My physiotherapist encouraged me not to give up with it too soon, as I do need to avoid the rolling gait that I had developed over the last few years, and the reduced weight will help keep my developing new gait straighter."
3. to what extent do you feel the GameReady helped?
"Greatly; but in addition the spinal anaesthetic was an important contributor to the initial recovery. It was interesting being "awake" throughout, whilst recognising that I was somewhat sedated, and would probably liked to have been allowed to watch in more detail. During the hour that I was kept in recovery, I was able to start the leg lifting and flexing exercises that had been recommended, it was a little disconcerting when later I found I was unable to lift my left leg at all; this recovered quite quickly following post-discharge physiotherapy. As I did not have to "recover" from a general anaesthetic, the GameReady's were immediately effective in reducing swelling. I understand that this can be severely debilitating in the early days, in my case it hardly arose as an issue. I had continuous use of two systems during my 4 days in hospital, and these seemed to work well. The nursing staff were kept busy refilling the Ice, which might have seemed a bit tedious. When I was convalescing at my daughters for the following 5 weeks, I only had a single system which was switched between the two legs. I had requested the GameReady twin connector and two leg wraps, but GameReady Rentals do not offer this, claiming that people found them difficult to manage. I do believe that for operations such as mine, a single system with the twin connector and dual wraps would be better. At home I found that the Ice could be loaded with a single block frozen in a 250gm margarine tub; this was far easier to load and reload than using loose Ice-cubes, and appeared to work quite effectively.The system was used virtually continuously for 3 weeks, and then twice daily until week 5."
4. if you had to do this again, would do again choose simultaneous ops?
"Absolutely, I believe that my original assessment/investigation has proved totally correct, and despite a number of people expressing surprise and admiration at my "bravery" I do not feel that there was anything to be brave about; with my knees being in the state they were there is no reason not to have a simultaneous operation."
5. how long is it now since the op and how is your progress ?
"I am now at week 14. Progress is I believe is very good. It is difficult to know what to expect and for this reason I have had physiotherapy for 30 mins each week; perhaps less for the actual exercises, and more to provide a reference point for any difficulty or to advise on my next challenge. I do admit to not following all the exercises that I have been given, and do feel guilty about this, but my physio remains very impressed with my progress and is supportive in recognising the amount of "regular" activities that I have resumed. This week I spent two days (2x 6 hours) in the bilges/engine room of a canal boat, doing a major refit as a volunteer, of a disabled tour boat; this involved climbing in and out in steps of 3-4 feet, with much bending, some lifting and the occasional kneeling. It was tiring and I might have overdone it a little; but its only a few aches and a bit of DOMS. Last week I completed the plaster repairs to my lounge ceiling, ladders are actually easier now than they were in September. Clearly I have still to redevelop many of my leg and thigh muscles, standing for long periods such as at last Saturday's party are quite exhausting, and I don't really "run" up and down stairs yet; but unlike in September when everything was always getting a bit harder, it is now regularly getting a bit easier.The scars are still visible, but daily massaging with Bio-Oil is working wonders; they are still a bit tender if I knock them against a chair for example, but overall I am really happy."