By Tom Holzel, 

Knee surgeons (and knee  patients) have recommended this site for a detailed view of knee replacement surgery that they themselves can't give (for fear of telling too much or too little).  88% of the 3700 visitors/mos. are referrals from knee patients and other websites.

 
The NY Times states:

"Despite excruciating pain and decreased mobility, many people with knees damaged by arthritis put off joint-replacement sur­gery out of fear and uncertainty. But last week, a federal panel found that replacing a diseased joint with artificial parts quickly relieved pain and improved mobility and quality of life in 90 percent of the patients. The 11-member panel, which the National Institutes of Health convened, also found that the results lasted for years and that women, could benefit most from total knee replacement..." (12/17/03) 

NEWS FLASH: A Minimally Invasive Total Knee Replacement procedure is announced. Use this if you qualify. (See http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=6924.0 for a discussion group on this exciting new operation.)

  
A  140-degree squat after 25 months, but this is still not 100%.  This is as far as I got, and gave up trying to get a true native squat to avoid excessive stress on the knee parts.     

This essay describes the decision-making process and results of a 61-year old man suffering increasing knee pain and immobility, who finally decided to have both knees replaced. It differs from the usual Doctor's Office descriptions of knee surgery in that the experience of a single person is used, avoiding the diluting effect of broad, all-encompassing generalities designed to cover all possibilities. It differs also in that none of this is medical advice. The writer has no medical training whatsoever. This essay describes a major medical procedure as experienced by a layman. Statements written as "facts" are merely my opinion, of which there are plenty. Judge or dismiss their value for yourself.  

Symptoms

At age 55, my left knee was beginning to ache more and more frequently. At first it was from sitting still (at the movies), or from longer runs. But this aching was easily treatable with ibuprofen. However, by age 58, this steadily escalating "discomfort" was enough to have reduced my running from 3-5 times a week to once or twice. I have been a life-long runner, skier, hiker. In the last five years I have become mildly overweight and (because of the knee problems) more sedentary.  

Eventually, moments of acute pain would occur while merely walking that required me to sit down and rub the knee to get it back in order. After consultation with knee specialists, I decided to undergo arthroscopic cleaning of the knee joint. This is usually an outpatient debridement of the knee joint of all the chewed-up meniscus floating inside the joint. (meniscus is a pad that cushions the knee joints.)

Cartilage is the softer lining of the bone that cushions the bearing surfaces of the knee joint. As one ages, the meniscus and cartilage is slowly worn down or shredded by cuts, until the knuckle of the joints rub up against each other as bare bone, causing acute aching. This loss of cartilage can be easily seen (in x-rays) in the reduced spacing within the knee joint between the tibia and femur. And it can be felt by the doctor as he moves the knee and lets his hand feel the grinding.

Photographs of the interior of my knee showed the meniscus to look like so much crab meat salad, along with fragmenting of the bone surface itself. A clean interior looks smooth and shiny, much like the inside (mother of pearl) of a clam shell. Shown on the right are four views of the inside of my knee just prior to arthroscopic surgery.  The "crabmeat salad" are ragged slivers of chewed-up meniscus.  Note the spawling of the femur bone surface top left (arrow).  No amount of cleaning is going to repair that damage. 
 

However the knee doctor [1] at Stanford Medical Center was very straightforward about my prospects: "Sure there'll be some improvement, but you've got 60,000 miles on 30,000-mile knees, and no amount of cleaning is going to put tread back on that worn-down tire." The alternative was total knee replacement, a major surgery that no one wanted to suggest, especially at my young age. Total knee replacement was reputed to last about ten years, at which time the leg bones become weakened by the constant pounding of the knee-joint spikes that attach the artificial knee joint surfaces to the tibia, and thus make a re-do even less strong.
  

Total knee replacement sounds like a horrendous operation with the leg essentially being severed at the knee--and then re-attached. So I never seriously considered it.

The arthroscopic cleaning did seem to work as advertised--but nothing more: it did initially eliminate the sudden onset of sharp pain when walking, and I no longer had to stop and reposition the knee by massaging it to stop the occasional acute walking pain. But it did nothing for the background ache. I still could not sit with my leg in any one position for too long, and running was becoming more and more unpleasant, inflicting a dull ache that was beginning to verge on downright pain. At the end of a hard day, the knee would swell and feel deeply bruised.  One side effect of the operation was my inability to straighten my knee completely and lock it in place (so as to be able to stand on it without using the quad muscle to hold me up). I was told this was due to my failure to exercise--stretch-out-the-hamstring-muscle adequately after surgery. And it is true I could have done that with rehab help. But I am certain I went into surgery able to lock my knee joint, so the subsequent crook was definitely a consequence of the procedure itself.

Two years later my other knee started acting up. I had it arthroscoped with the same results: less pain, no significant improvement in functioning, and now neither knee could be locked straight. I could stand briefly in a slightly crooked position, but standing for any length of time (e.g., at a cocktail party or trade show) was impossible. The knee still ached.  After a year or two, the sharp joint pain came back as well.  Two operations later, was I any better off?  It seems the medical profession is also having second thoughts about the long-term effectiveness of knee arthroscopy.

New Note-25 May 06: According to a Consumer Reports article, June 2006:

After two years of follow-up, [in a trial published in the New England Journal of Medicine,] the bending and walking of people who had the real surgery (arthroscopiic knee joint cleansing) were no better than in those people who had the fake operation. A newer study, published in Arthirtus and Rheumatism in March 2006, suggests arthroscopic procedures might actually contribute to cartilage degeneration.

Although it is disgusting to see doctors try to push procedures on people where they are of questionable value, I probably would have been better off having had knee replacement surgery 3 years earlier than I did--and wish I had been pushed harder to have had it done. The medical profession seems reluctant to do so because the life of a knee replacement has traditionally been only 10 years, and a re-do is more difficult because of the wear and tear of the bone caused by the first replacement. However, today's versions are reputed to last up to 20 years (if running is given up). One wonders if insurance company recalcitrance to fund earlier knee replacements has anything to do with this professional reluctance.

[Note: Many web sites advise that new knees will NOT restore your legs to their pre-injury state. You will not be able to do full squats. (Maximum knee angulation will be about 120-degrees.) But consider how much better shape you'll be in than you are right now. No more pain when walking, for example. No limp. No ache from sitting in one position for an hour or so. However, my doctor says there is no mechanical reason why nearly complete flexibility can't be obtained--if one works at it long and hard enough. (See more on this below under "Day 79.")  However, flexibility and strength are not the same thing.  And while I eventually restored nearly (but not all) all of my knee joint flexibility, I am not anywhere near able to do one-legged squats, as before.]

[Note: There is a cartilage regrowth therapy (that I had never heard of before) which claims to be able to regrow cartilage in those knees NOT suffering from osteoarthritis. This would primarily be for younger people (<30 years old) who have suffered a specific injury to a small point on the cartilage surface. See: http://www.arthroscopy.com/sp08001.htm  ]

Here is a knee forum that answers a lot of questions.

Still afraid of total knee replacement, I found on the web the mention of a less invasive procedure called "Unicondylar" repair (Photo, right). Many injured knee joints are only worn out on one side of the joint or the other. Or there is a cartilage tear at one point only.  In that case, if the rest of the knee is still in good condition, instead of replacing the entire knee bearing surfaces, left and right, top and bottom, an inlay of metal is incised into the top afflicted bearing surface, and a shock-absorbing plastic strip is cemented into place on the bottom joint surface. One doctor has perfected this operation into a one-hour, outpatient procedure [2].  However, while it is clearly the first choice if you have the choice, in retrospect I suspect this procedure is mainly for people with knees in relatively good shape, but with a single point of damage.  Life-long knee abusers like me will have a lot wrong with nearly all of the load-bearing surface, in which the Repicci-style operation won't be enough.  And it does not eliminate behind-the-kneecap pain.

(This site has some good illustrations of what cutting is done and what the replacement parts look like. Click on the little camera icons. http://my.webmd.com/hw/arthritis/aa14776.asp?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348} )

Nevertheless, this,  I decided, the less invasive Repicci replacement would be the operation for me--a compromise between the palliative of arthroscopic cleansing and the gruesomeness of total knee replacement. But, as clever as my self-diagnosis seemed, this compromise measure was not to be.

I had especially chosen a doctor [3] at Mass General Hospital who did both the Unicondylar and total knee replacement procedure. One of the questions he asked me was whether I experienced any knee cap pain. I told him I didn't, but that I would occasionally experience sharp joint pain. He sent me for x-rays and we made a date for surgery. We would meet for a final consultation two days before the operation.

No sooner had I left his office than I experienced a return of the sharp joint pain--and what do you know: it wasn't in "the joint," it was directly behind the knee cap. I had just never isolated the pain more specifically than "the joint" before. But his question, and my sharp pain was a clear indication of what was to come.

At the pre-op meeting, I told the doctor about the knee cap situation, an event that was becoming ever more frequent. "Well, Unicondylar won't do anything for the kneecap pain," he informed me. "And it won't do a thing for your deformity."  (My "deformity"?  He was referring to the significant increase in bow-leggedness that had occurred over the past two years.  It was true, but I never realized that the bad knees and bowleggedness were related.) In addition, I had stopped taking ibuprofen [4] for the first time in many years (because of the impending operation) and had begun to feel the first harbingers of knee cap pain in my "good" knee. "Not only that, Tom," he added, "but to me the knee cap on the good side doesn't feel as if it's very far behind the bad one." He manipulated both knee caps at the same time and I could feel the worn-in grooves of each one sliding over my knee joint. The backs of the knee caps are supposed to be smooth.

Photo right:
Note my bow legs and the narrow gap between the knee joints (especially the left knee),
indicative of little or no meniscus cushioning.

"OK," I agreed, "let's bite the bullet and replace them both. But I sure as hell don't want to go through this procedure more than once. Can we do them both at the same time?"

The doctor explained the pros and cons of doing them at one time, and spacing them out (see more on this subject, below). The single disadvantage of doing them both at once (assuming the patient is hardy and can endure the twice as long procedure--many older people cannot) is that it makes recovery a little more difficult because the patient doesn't have a good leg to help support his walking rehabilitation. Thus, it is less attractive for totally unathletic types. Having made the two-at-once decision, I was met with wonder by many hospital personnel who spotted the twin incisions. "Brave," was their average comment, and it was obvious from this repeated commentary that only a small group of patients choose that route (10%).

In the two weeks before the surgery, I gave two pints of "autologus" blood, to be used, if necessary, for myself.  (I never learned if it was.)  There are so many blood factors beyond O, A, AB and B (and positive & negative Rh factor) having to do with your race, immunities--to say nothing of the guaranteed absence of health risks--that you are much better off using your own blood.  Then, if you don't need it--count your blessing-- and you've just made a lovely donation. 

Anesthesia

My anesthesiologist explained my three options:

1. General anesthesia via an IV. This was what most people chose because you are out the whole time but can be brought conscious at any moment. However, this method releases the most narcotic into your bloodstream and brain. Given my propensity toward anesthesia nausea, he recommended against this option (but the choice was truly mine to make).

2. An epidural, in which the anesthetic is placed by needle alongside the spinal sleeve. The advantage is that the spinal sleeve is not punctured, eliminating that mild risk factor; the disadvantage is that it takes more anesthetic to perfuse through to the spinal cord, and thus more is floating around the body.

3. A spinal. Here the anesthesia is administered directly through the sleeve housing the spinal cord with maximum concentrated benefit and a minimum of anesthesia used. In fact, you would remain completely conscious with only a spinal. The disadvantages are the slightly riskier nature of piercing the spinal sack (infection, etc.) and (as with the epidural) the fact that it is a one-shot procedure. If the operation drags on, additional anesthesia must be administered, but this can only be done as general anesthesia via an injection or IV drip. But with 300,000 operations done a year in the US, TKRs have become pretty routine operations.  So the timing has been well-established.

I certainly did not want to remain conscious! To me, one of the great wonders of modern medicine is to have someone slip an IV into your arm, and two minutes later, wake up in bandages, an entire 3-hour operation having occurred in the interim. (Knee replacement takes about 1-1/2 hours per knee.)  I chose the spinal. In what seemed like less than a minute, the anesthesiologists numbed the injection entry point, gave me a catheter and injected the spinal. I didn't feel a thing.

Of course even with the spinal, I still wanted to be put under. (Some people want to watch!!)  So I still needed a general anesthetic—but the amount is far less than that required to render you unconscious and kill the pain. (You would wake up  from the pain if you were only mildly sedated.)

One factor with which this surgery reacquainted me was the inevitable nausea I experience due to the narcotic pain killers of general anesthesia, and the oral narcotic pain killers given after surgery. I am told that a significant minority of patients experience excessive nausea, being especially sensitive to morphine and its derivatives. "Percocet" a powerful and ubiquitously-prescribed pain killer for many, causes me acute 'want-to-die" nausea. [Note: If you wake up and become nauseous--one in three patients do--ask for an injection of phenergan (promethazine).]

One knee or two?

About 20% of knee replacements are for both knees [5]. Of these "bilateral" replacements about half are undertaken at the same time, that is, both knees are operated on under the same anesthetic event. Otherwise one knee is replaced and than the other in a second procedure. Since the aggravation of the knee replacement is roughly the same for having one or two knees done, why doesn't everyone have them both done at the same time?

The reasons given for not replacing both knees at the same time are:

1. Older, weaker patients may not tolerate the twice-as-long operation safely enough. That makes sense, and my 78-year old mom had hers done a few months apart for that reason.
2. The recovery process requires a somewhat more athletic patient when he does not have one "good" leg to help the other. Some older patients are very feeble. But plenty of determined people do both, so its not just athleticism that counts.
3. The lesson plan for physical therapy does not even mention how to do various exercises if both legs are incapacitated, giving examples of how to walk by saying "Start with the good leg..." However, with any degree of athletic ability, working two bum knees rather than one is not a big deal. One manages, and is soon over the hump. (But if you are weak, it would matter.)

One maneuver surprisingly not addressed by the physical therapy, is how to get down on the floor--and up again. This is not easy. (A lot of the exercises have you lying down. Presumably this is on the floor. A bed is a lousy place to do exercises.)

It turns out to be quite tricky to get up off the floor with two bad knees, and certainly not something a person with limited upper body strength could accomplish at all. Missing from the arsenal of physical therapy gadgets is a 3-step staircase that you place at the foot of the chair you want to hoist yourself into. Using your arms, you can easily lift your butt two or three inches--from slightly bent elbows to straightened elbow joint. (Lifting a greater disance, i.e., with elbows more bent, is much harder.)   With the Butt-Lifter, you would lift your butt 2-inches onto the lower stoop, reposition your hands and hoist yourself up 2-inches to the next step, etc. It takes just a little strength to accomplish a 2-inch lift, but a lot to achieve the 6-inches necessary to get up to foot stool height. Maybe a crude lever-actuated butt elevator could get you up from the first, most difficult 12-inches, so you could then hoist yourself the rest of the way onto a chair.

My advice is, if you possibly can, try to have both knees done at once. The difference between having one knee done or having two knees done is that two will take a little longer to recover from, but then its over. You're cured. To have the unpleasantness to look forward to of having the first knee, done all over again, understandably turns a lot of people off--and they hobble through life with only one good knee when-with a little more fortitude--they could be fully restored to an active life.

If you decide to have both knees done at once, it would be enormously helpful for you to build up strength in your arms and shoulders, so you could lift your butt at least a few inches off the ground.  You could do this before the operation, by practicing twice a day for 3-4 weeks on a hard chair or on your living room rug. Five minutes of practice is all it takes. Once you've got the butt-lift down pat, you will be able to more easily hoist yourself on a chair (in intermediary steps) from off the floor where you've been doing your exercises.

"Pain Management"

Since the middle of the century the U.S. medical profession has been cursed with the Puritan stricture of "no pain, no gain." Which is to say, some pain is inevitable and even good for you. Eliminating pain borders on having fun. Although found no place in the bible, Puritanism (and most Christian religions) has suffering and anti-pleasure woven into its very warp and woof. This attitude is mirrored in the fundamentalist philosophy guiding the U.S anti-drug effort, which can be summed up as the acute fear that someone, somewhere, is having a good time.

[The Boston Globe finally acknowledges this on-going travesty of insufficient patient pain management with two articles on the subject on 4 Nov 03:  "Painkiller phobia inflicts needless suffering," and "Doctors face suits for under-medicating."]

This has changed somewhat, and the patients in my wing of Mass General Hospital were on self-administered morphine drips. You can push the button as frequently as every 10 minutes (or any interval set by the nurse) to get a shot of pain-killer. Essentially the idea is that once you feel a lot of pain, it takes more narcotic to eliminate that pain, than would be used in smaller doses to keep it from occurring in the first place. So by allowing the patient to give himself a small squirt as soon as he feels the first onset of discomfort, he can nip the pain in the bud and use less narcotic than the previously rigidly scheduled intervals (4 hours). Plus, correctly self-administered, he never feels any pain at all--a very civilized procedure, instituted only 50 years behind European hospital practice. People in pain almost never get addicted to morphine (except in novels and the movies).

The operation of the morphine squirter was all explained to me, but it took three days before I learned to negotiate the rocky road of too little morphine and too much discomfort, or no joint discomfort but a constant sense of nausea. Pain vs nausea. To me, the nausea is worse. The majority of patients not allergic to morphine will find the system very effective. But, of course, not 100%. Some patients will still be subject to some pain some of the time-usually in the first post-operative week.

It took me a while to make my nausea complaint clear to the nurses, but they finally took me off morphine and gave me the pill "Ultram." Ultram is a cox-2 inhibitor that binds in the body to certain opiod pain receptors. By doing this, it modifies the pain message--specifically by blocking the re-uptake of the neuro chemicals norepinephrine and seratonin. The net result is effective pain relief.

Ultram is a narcotic-type painkiller without many of the side-effects.  For some one like me who reacts badly to most morphine-based narcotics/painkillers, Ultra is a wonderful exception.  And, it doesn't upset the stomach. (Although it gave me a bile-tasting dragon breath.) Constipation is a side effect of Ultram [6], and I got it, but not severely so. Patients coming off the IV and not nauseated by narcotics might be given Percocet or Darvon. [Tidbit: I got an annoying case of Restless Leg Syndrome during my recovery--which Ultram knocked out long enough to get to sleep.]

The biggest mistake I made was not taking enough pain reliever during rehab--again, influenced either by a macho "I don't need any pain relievers", or an "ethical" (i.e., political) posture against taking too many pills of any kind--all of which goes back to the cold dead hand of the Puritan Ethic.

Taking a minimum of pain pills (and feeling smug about it) resulted in "discomfort" setting in. By "discomfort," I mean exactly what the word suggests (before it became a medical euphemism for sharp pain), that is, a pressure or aching stiffness. But not sharp "dentist pain." This gnawing pressure was significantly relieved by exercise-stretching and activating the muscles. I would be sitting in bed, squirming to get comfortable by shifting my position from one to another, never able to get comfortable. I did not think of this pressure as "pain." As a result, the first few days I exercised too much and my legs became stiff and tired. I actually back-slid on my daily PT test. I called the next day off and did nothing, just to let my muscles relax for once. And I snuck in a few Ultrams--not only to kill the discomfort, but for the relaxation effect which let me nap. Sleep is a wonderful balm.

Even "Ambien," a marvelous, hang-over-free sleeping pill, would not let sleep occur in the presence of the discomfort. Once I figured it out--that Ultram did work on the discomfort (eliminating it completely), I didn't need the Ambien--sleep could come naturally.  (By the way, doctors are not wild about providing sleeping aides to older patients for fear that they will be dizzy--and fall--on their nightly trips to the head.) > <

So the drill for me was to not let discomfort occur at all, because as it arose, I would unconsciously exercise to subdue it, on top of my regular twice-a-day hour-long PT exercises. This pain-reliever exercise would amount to an additional 3-5 hours more of fidgety half-hearted exercise-and always resulted the next day in sore, stiff muscles with less strength than before.

I was lucky not to experience any "pain" (as opposed to discomfort) at all. My stitches never hurt, my muscles never hurt (except when doing physical therapy: then they hurt a lot). Only the gnawing ache of the joint itself occasionally bothered me, and that was largely controllable with pain pills. However, my lack-of-pain experience was not the norm. Others in my rehab wing did experience some non-exercise pain, most of which (but not all ) they were able to control with pain pills. However, there is always a small percentage of people for whom this operation does result in a lot of unpleasant pain that sometimes takes months to relieve. (Nothing is perfect--except Allah.) My single complaint about the whole business: I went in mildly bow-legged (like all good runners) and came out slightly knock-kneed [7].

My Recovery

* Day 0. Operation. 

* Day-1-3.  These three days were spent, somewhat woozy, exercising each leg for 45-minutes at a time, twice a day, in the elliptical mobilizer, a CPM machine. Your operated leg is strapped onto a CPM (continuous passive motion) machine, which slowly rotates in an elliptical motion to cause you to bend the knee back and forth to improve range of motion.  You can't get enough of these, so hog as much time on them as possible.  And increase the thrust and speed so you muscles get a work-out -- don't just sit there just marking time.  All nausea occurred during these four days.

* Day 4. Left Mass General Hospital for the Spaulding Rehabilitation Hospital. A rehab hospital specializes in rehabilitation only and does not perform the medical functions one associates with the term "hospital."  They are there for one reason only:  To get you back on your feet.

*Day 11.  They took out the stitches.  My stitches were actually metal staples that made my leg look like a zipper.  Underneath the skin is another layer of stitches that dissolve -- but they are not as strong as the metal staples.  The doctor removed the staples with a little staple remover gadget.  It sort of pricked a bit, but was not a big deal.

* Day 14. Left Spaulding Rehab Hospital for home. They required me to show I could maneuver my way up and down stairs using a crutch and the handrail before they would let me go. But my insurance (Blue Cross HMO) covered me only for 10 days in the rehab hospital and another two weeks of home therapy. The whole Blue Cross paperwork issue was extremely well-handled and patient-friendly.

Just before you leave the hospital, I was offered gadgets to take home -- crutches, a bathtub chair, a walker, etc.  Only some of them may be covered by your insurance.  If you are athletic, don't bother with the walker or the bathtub seat. > <

* Day 16. A beautiful fall day.  I went outside and hobbled around for 100 yards on the sidewalk using my crutches.

* Day 19. First tenuous walks indoors without crutches.

* Day 22. Walked one-half mile without crutches, including going up and down stairs using the handrails. Muscles ached the next day, but not severely. But the joint didn't! (However, I'm still pretty creaky, and by no means able to walk at normal speed.) In spite of lots of stretching exercises, still can't completely straighten out my hamstring muscles, so I still can't lock my leg when standing up. But I will prevail.

* Day 74. Walk completely normally. Going down stairs still tweaks a bit. Can lock one standing-up knee, but not yet the other. (Still working it--45 minutes a day.) When I sit in one position for an hour or more (e.g., at the computer) getting up is done with very stiff muscles! They adjust in 15-30 seconds, but the doc says not to worry, this will clear up in 1-2 YEARS!

* Day 79. I seemed to have hit a solid barrier in bending my knees: 120-degrees for the left one and 115-degrees for the right one. Pushing harder seems to be stopped solidly. The doctor says no--I should be able to flex as completely as before the operation(!), i.e., there is no mechanical reason normal flexibility can't be achieved. By accident (sore back) I took two ibuprofen, and when I then exercised--lo & behold, the "solid" resistance softened, and I was able to push a bit past the barrier. So now I am softening the barrier with ibuprofen--taken with breakfast--and pushing to achieve greater flexibility.

[The wife & I moved to Oxfordshire, England to take on a new consulting assignment. ]

*Day 105:  Can walk 3 miles easily. 4 miles make my leg muscles ache. It surprises me that I haven't been able to walk farther more quickly. I'm improving--by pushing it, but slowly.  Down to 2 Ultrams a week. Restless leg syndrome almost completely gone.]

* Month 5.5:  Walking 5-6 miles regularly, after which my muscles are tired, but the knees don't bother. Take Ultram maybe once every two weeks when restless leg occurs, but not nearly as before. When warmed-up, the right leg can be bent nearly all the way; the left leg still has a ways to go. When properly warmed- up, I can squat, sort of (i.e. not fully, but I can get into the squat position). Knees still sort of bother if I sleep without a pillow between them. I feel that they need to be kept straight during sleep or they'll ache the next day. The only "discomfort" is an occasional tweak if the knee is twisted mildly, which would not occur if the knees were normal. Most of the mild discomfort is muscle related, not the knee joint itself. I think the torque of the knees causes some dull ache on the bone where the metal parts are attached--who knows. In no way are my knees back to normal as if they had never been injured. But they are far, far better than when I went in--and I bless the day I decided to have them done. Today, my wife and I had a two-hour walk in the glorious English countryside, followed by a lovely dinner at an English pub--the Boar's Head in Ardington south of Oxford. My legs ached from the effort, but relaxed deliciously as the red wine hit my stomach. No question that red wine gives as much relief as Ultram--and goes down a lot easier.  (Plus it's good for your heart!)

Note that this recovery time may not be not typical. I have a history of rapid recuperation, am a lifelong athlete, and relatively young for this operation, which is usually conducted on patients in their 70's and 80's. But even average patients do recovery in perhaps 50% more time [8].

The biggest problem older patients have is not keeping up their physical therapy. If even young, athletic patients MUST exercise, so all the more must older, less agile patients. A nine-month exercise program is necessary for the agile; A year or more for the older and less athletic. There is no way around formal exercise, and those who don't see it through will be doomed to hobble around in the "Frankenstein walk" characteristic of inadequate muscle control due to lack of strength and lack of flexibility. Of course, if you aren't going to resume an athletic life, you won't need to keep up your therapy beyond where you can do the following things effortlessly:

Success is being able to:

1. Go up and down stairs with no pain or stiffness. Going down is harder than going up.
2. Being able to bend the knee enough to pull on your socks and shoes.
3. Sit still for a hour or so and be able to get up without the sense your knees have rusted fixed. This  may take a year or more to achieve!
4. Get in and out of a car without having to grab your foot to force it to bend enough to clear the door.
5. Be able to stand up from a low chair or the toilet without muscle tweak.
6. Be able to lock your knee joint straight so that standing for long periods is no problem (because your bones are carrying your weight, not the quad muscles).
7. Be able to sit comfortably with your legs crossed.  I can do this to some extent, but even now--4 years later--I still can't really cross them properly. 
8. Be able to lift your leg up and prop it across your knee in the shower to reach your toes (to clean between them.)  I got good at this, and then, ceasing my daily exercises for two months (due to moving back to the States and natural sloth) and found I was having difficulty reaching them smoothly.  Back to work.
9. The only thing I can't do is a full, complete squat, or to stand on one leg and lift the other by the ankle and press it against my rump. It just won't go that far--which is much more than 140-degrees. I haven't pushed this exercise anymore because I don't want to overly stress the metal rod that goes into my tibia--the first part to go when even this modern medical miracle starts to fail. But I have really tried.  The only downside to this (other than injured pride) is that I can't get into the squat shooting position--ideal as a supported rifle stance in their field during winter varminting.

*Month 13. I was really hoping to be able to achieve a full squat on the one year anniversary of the operation, but I have not been successful. [Note: See photo above; after 25 months I finally achieved a supposedly "full" 140-degree squat--but 140-degrees isn't one.  A true full squat lets you balance and hold a rifle in a stable position, which I have given up trying to achieve.  And I still can't get up off the floor the same fluid way as before.] Perhaps it is a reluctance to roll onto my knees that hinders this maneuver.  The current Month 13 status is this:

Each weekday morning I do 20 leg lifts (sitting on the edge of the bed) and 20 leg extensions as warm-ups. Then I lie down on the rug with my heels elevated on a step to stretch the hamstrings and let the knees experience full lock. I even lift my butt a bit to help pull them into full lock. I then do 20 leg pulls (pulling my knee to my chest). I then hook my feet on the step and do 12 sit-ups to tighten the gut. The sit-ups also flex the muscles above the knee.

I spend 5 minutes on a rowing machine (which nicely flexes the knees) after which I sort of squat down and hold a squat position for about a minute. But, of course, it is more of a half-squat. Even though I can pull my right leg all the way back when sitting in a hot bath (and the left one almost as far), I can't do that unaided in air. And it is not only flexibility that counts, you also need strength with that flexibility. So a squat is the way to go because you need strength to hold yourself up. The rowing machine is perfect because it supplies a platform over which I can squat that is low enough to result in some real gains, and not have me fall down. Of course I'm holding on to furniture when I do the squat. But I have to be careful about pushing this squat business too hard, or the implant aches lower down on the tibia. So easy does it.

At this stage I could probably stop doing any more exercises. I can walk down any steps without the slightest tweaking. I can rise from my seat without feeling as if my legs had rusted in place. (This creaking quickly wore off when I got up, but the onset didn't disappear until 9-10 months after the operation.) Happily, I can now bend my knees enough so I no longer have to grab them to flex them enough to get out of a car.

I walk a mile each weekday at lunch, and a mile or so in the evening with the dog. On the week ends (pronounced "week ENDS" in England), I walk the mutt two or three times for two hours at a time -- about 6-miles. At the end of those walks, my leg muscles are tired, but the joints are fine. I ran (loped) 10 yards for the first time, just to see if I could do -- and I can, just fine, but it is jarring because there is no shock-absorbing cartilage. But I do not run at all, or ski, to save my knees. A pity, for I truly loved both sports. (I might try X-C skiing when we get back to the States.) And yes, the knees sometimes cluck when I walk -- but less and less often. They always set off the metal detectors in airports, now that they've been sensitized due to 9/11. (This means a full search.)

I lost 15 lbs fairly easily by going on a modified Atkins diet. The reduced weight is to help take some strain off the knees, and has flattened my slight beer belly. Also, suits that were verging on being too tight, now fit loosely. (But after six months, carbo-lust became intolerable--and I regressed.  See "If Atkins doesn't work.") 

Tips: If you Decide to have Total Knee Replacement Surgery

1.  Let's not kid ourselves. In spite of possible rapid recover, this is still major surgery. And if you are older and weaker, recovery will be longer and more stressful. Also, a very few people do get horrible side-effects, such as bone infections, and bungled implants. My most important tip is to pick a big hospital and a surgeon who specializes in this procedure. I have read elsewhere the advice that you should not have this major operation done in a hospital that doesn't do at least 50 Total Knee Replacements (TKR) a year, and preferably 100. Don't be embarrassed to ask your doctor how many TKRs he's done in the last year. If he's only done a dozen or so, maybe you will want to get a second opinion -- that is, a more experienced doctor. (And if you are embarrassed, have your kid or a younger colleague do it for you.) [Note: You can get a report card on your surgeon from: www.healthgrades.com]

One highly experience surgeon who does nothing but knees, told me that even when teaching other experienced surgeons in his knee replacement procedure over a six-week period, the "trainee" doctor just doesn't have the sureness he feels is desirable. But, what's a new surgeon going to do, except practice on the less fortunate patients. (Just make sure that isn't you.) Two of my hospital roommates were men who were having bungled hip replacements repaired--originally installed in small hospitals (one can visualize the surgeon, flipping to page 12 during the procedure). The minimum size of the incision, the sure-scalpel slickness of minimizing tissue and muscle damage during the procedure, the speed and accuracy achieved in correctly aligning the lower leg with the upper--all these elements are hallmarks of a skilled and practiced surgeon--and done right will shorten recovery, minimize "discomfort," and result in quicker return to a correct stance and gait--exactly as it did with me.

In short -- use your local community hospital for the small stuff -- stitches for a bad cut, shots, setting simple fractures, etc. As soon as the surgery gets complicated -- bite the bullet and go to the big city. Any joint is complicated and warrants great care in selecting experienced practitioners.

There is also a very small, but significant risk in this operation. "Significant" means a certain percentage of operations will have major negative side effects. The risks are from not tolerating the anesthesia (this is less of a risk if you've already gone under a few times); from blood clots caused by the operation, and from infection and from sloppy surgery.

Recognize that when you Google "total knee Replacement" you will find some blogs where a whole list of people moan about how terrible their result was, how much pain they suffred, and how they're worse off than before, etc., etc.  But thes people are a self-selected group who have had bad results.  They are not typical, but rather a collection in one place of the 5% who lost out.

Here is the Czech orthopedic clinic "Orthes" succinct warning on the risk of infection taken from: http://www.orthes.cz/erisks.htm:

Infection can occur following any type of surgery. In order to minimize the potential for infection to occur at the time of surgery, antibiotics are given before surgery and for 1 to 2 days following the operation. Infection following total knee replacement is of special concern because of the prosthetic components. The prosthetic components have no blood supply and this makes them susceptible to infection. If the prosthetic components become infected, additional surgery is almost always required in order to treat the infection. Sometimes the infection can be treated without removing the total knee replacement components. In some cases, however, they may need to be removed in order to eradicate the infection. Intravenous antibiotics are generally administered for about 6 weeks in order to treat the infection. Once the infection is treated, new components can generally be implanted. If there is concern that the infection cannot be eliminated, then a knee fusion (arthrodesis) may be recommended.

The risk of infection persists for as long as the total knee replacement is in place [Ed note: In other words--for the rest of your life.]. The most common way that a total knee replacement becomes infected is by spread of bacterial infection from another location in the body. Bacterial infections may be spread from the mouth because of a dental infection; from a urinary tract infection; as a result of pneumonia; from a skin infection; or even an in-grown toenail. It is very important that any bacterial infection be treated promptly in order to minimize the chance of spread to the total knee replacement. It is also recommended that antibiotics be taken before any dental procedure, although the need for special precaution during routine dental check-ups is controversial. If possible, any anticipated major dental work should be completed before total knee replacement surgery or deferred for at least four months after surgery. You should inform your dentist that you have a total knee replacement. Similarly, antibiotics should be given if you are going to have any type of invasive procedure such as an endoscopy or bronchoscopy. Viral infections, such as a cold or flu, do not infect total knee replacements.

Remember this little kicker, as well: Once the protective outer "skin" of the bone of your femur and tibia has been cut off to mount the artificial bearing surfaces, the inside of those bones are now vulnerable to infectious microbes swimming around in your blood stream. This means you have to pay attention -- for the next two years -- to any source of infection you get or might get. My doctor recommends taking 2 grams of penicillin (in the form of amoxycillin) before any dental work other then teeth cleaning. At a blood drive, the Red Cross nurse suggested I not give blood because of the invasive nature of the drawing needle. [But once having lived in the UK for more than six months, you are no longer eligible to give blood in the U.S. due to mad cow disease.]

Some small percentage (5%?) of patients will have unhappy results: longer, more painful and sometimes only partial recovery.

But, not to panic!  The net-net is you do everything in your power upfront to assure good results: pick an experienced surgeon of high reputation, working in a big hospital or specialty clinic that does a lot of these types of operations. Then, you having done everything possible that you could do to minimize the risks -- put them out of your mind -- and roll the dice[9].             

In fact the NY Times had a very encouraging report on TKR, excerpted here : (12-17-03)

Despite excruciating pain and decreased mobility, many people with knees damaged by arthritis put off joint-replacement sur­gery out of fear and uncertainty. But last week, a federal panel found that replacing a diseased joint with artificial parts quickly relieved pain and improved mobility and quality of life in 90 percent of the patients. The 11-member panel, which the National Institutes of Health convened, also found that the results lasted for years and that women, who could benefit most from total replacement, and minority patients did not have the surgery as often as white men. [My emphasis]

After two and a half days of presentations, the committee had solid evidence to  support the safety and effectiveness of total knee replacement…

The surgery is so effective, the panel said, that many more people from all classifications should consider it. Just 1 percent of the artificial joints fail each year. By 20 years out, studies show, 20 percent will require replacement. "Many studies show that total knee replacement may be an underutilized procedure," Dr. Marc Hochberg, a panelist from the University of Maryland School of Medicine, said. "There are no data suggest­ing it is being over utilized."

About 300,000 Americans have replace­ments each year. The number has been increasing, and doctors expect it to increase further as the population ages. That is why the panel was asked to examine the pros and cons of replacement. Surgeons usually re­place knees when patients have difficulty walking or performing normal activities or when pain wakes them at night.

Until recently, replacement was carried out mostly in patients from 60 to 75. But the panel found that as materials and tech­niques have improved, replacement is ex­panding its range to those 50 and younger, as well as patients up to 90.

 "It used to be felt that young people would stress the joint by being too active," said Dr. Edward H. Yelin, a panelist from the Uni­versity of California at San Francisco.

 With longer-lasting materials, younger patients can receive implants and safely go back to most, though not all, activities.

The panelists cautioned against waiting, because that could jeopardize success.

In an operation lasting an hour and a half, performed under general or epidural anes­thesia, surgeons scrape bone surfaces that are craggy because of lost protective carti­lage. The surfaces are covered with artifi­cial materials that help the joint glide smoothly.

The complications can include trouble with healing the wound, infection, clots in the legs and lungs, pneumonia, heart attack, kneecap fracture, joint instability and nerve and vascular injury, Dr. Finnegan noted.

Patients usually stay in the hospital four or five days and require four to six weeks of rehabilitation, when they usually need crutches, a walker or a cane.

The pain after surgery is intense, but manageable, Dr. Joshua Jacobs, a surgeon and professor at the Rush Medical College in Chicago, said. "It's extremely rare in my practice for a patient to not have forgotten about that perioperative pain," he said. [Ed note: Not my experience.]

Some people may hesitate because of the cost, $10,400 to $32,000, depending on insur­ance coverage. Medicare pays for 70 per­cent of procedures, leaving beneficiaries large co-payments. The panel found that people with supplemental Medigap insur­ance were more likely to have knee replace­ment than those without it.

The report on the conference is online.

2.  Visualize Small Victories. The first couple of days after the Big Dig, you will be feeling woozy and uncomfortable. And you will be lying the entire time on your back. Imagine the thrill to finally be able (about the 3rd or 4th day) to maneuver yourself onto your side for a good nights sleep. Wow--the sense of accomplishment when you finally make that happen. Complete recovery can not be far behind... And think ahead. In one or two months you will be practically your old self again--much better than your old self--and you will look back and see only a brief blur of the recovery period. Certainly a terrific investment in yourself and your improved quality of life. Hobbling all by myself to the bathroom and finally being able to pee like a man (i.e. standing up) was for me another small thrill.

3.  Coping. There will be a few moments--hours perhaps--in the first few days where you are lying there as miserable as you can get. Throbbing pain, cold sweats-with me it was the acute, wish-I-were-dead nausea of too much of the wrong (for me) pain killer. I find that in those rare instances, one thing to do is visualize that you are a prisoner of war. Many suffered and yet made it back in one piece. Except that in their situation, things only got worse. In your case you will only get better-a lot better-and rapidly. Think ahead to that time, which will be in a few hours, or at most, tomorrow. Takes some of the misery out of it for me.

4.  The Pee Bottle. Right after the operation you will have a catheter in you -- a tube slid painless up your urethra (penis) that drains urine into a plastic bag hanging next to your bed. You'll feel the normal pee-back pressure when the bag fills, so just call the nurse and she'll change the bag.

Catheters are only kept in long enough for you to pee without doing anything -- usually 2-4 days. Once the catheter is out, you can pee in a bed pan (women), pee bottle (men) or by going to the john. Fortunately, you'll not have eaten much at all in the first few days, so moving your bowls is put off. But getting out of bed is so complicated and at first is not permitted unaided, that most men will prefer to empty their bladders by means of the handy one-liter plastic urinal (pee bottle). However, there is an unexpected catch. All your life, your parents, and then you yourself admonished you not to pee in bed. Now, after 60 years of this unrelenting discipline, do you really think you are going to be able to let loose as soon as all the parts are aligned? Think again! For many, the first time we succeed in releasing that recalcitrant urinary sphincter is after coaxing it for 10 frustrating minutes. "It's OK. You can go now. Nothing will spill. Just let loose. Piece of cake." Etc., etc. All your entreaties will fall on deaf ears as we try to unlock a lifetime of Pavlovian training. This can get so embarrassing (the nurse is waiting for you to "do it") that you seize up entirely. My advice--practice a few times at home. (No joke!)

5.  A Fan. Since hospitals are heated so as not to chill any 98-year old women sleeping on top of her bed, the temperature in the recovery wards is always suffocatingly high. Many patients had brought with them small (Not too small--12-inch diameter) box fans that they kept running on their night table. I quickly got one too. What a blessing!

6.  Hospital Couture. Most men seemed to wear polo shirts and either drawers and khaki short pants (instead of the immodest "Johnny"). Another idea is to wear bathing trunks which serve as underpants and shorts in the same garment. Also, bathing trunks are easy to wash out.

7.  Crutches vs Walker. When my mother-in-law went home with her replaced hip, they would not give her a walker, insisting she learn to use crutches. In her case they did that to prevent her from becoming permanently attached to the walker, and never taking the risks associated with learning to walk again. If you are highly motivated, and actually use the crutches (say by walking outdoors with them every day) then using a walker at home has the advantage--for a few days--that you can get around more quickly, and without the constant concentration of walking, that the crutches require. I chose the hand-held "Loftstrand" crutches (which are known under many other names) over the conventional armpit-support crutches. The Loftstrand crutches allow more accurate pointing of the crutch leg, but require some arm strength. Conventional armpit crutches are less comfortable, but allow the user to employ shoulder strength-which is always higher than arm strength. However, once you do switch to crutches, the walker will seem like an anachronism. Try to avoid relying on the walker at all, or off it as soon as possible.

8.  Hateful Exercises. After the operation your main leg muscles and ligaments will have lost all their responsiveness, strength and flexibility. You wake up looking at a useless stump attached to your body called "your leg." At first it will do little that you tell it to. Physical therapy consists of bringing these body parts back up to operating speed. Stretching muscles beyond where they want to go (which is nowhere) is painful. But prevail--there is a silver lining. At first each stretch is equally painful. In fact subsequent stretches may become more painful as you go on, say stretch numbers 4, 5 & 6; however, after this initial warm-up, the muscles do relax slightly--you can feel them soften--and the angle of flex increases a bit. Success! Even my accursed hamstring stretching began to work better after the first half-dozen or so tries and the remainder became a bit easier.

9.  The order of your exercises. It is well known that all physical therapists must first demonstrate an innate passion for sadism--otherwise they are counseled to take up less demanding pursuits. Mine gleefully started me off with the most difficult (for me) one--the hamstring stretch. The more I complained, the harder he pressed. When the Department Head walked by as I was being tortured, I greeted him with "Ow, ow, ow, ow, ow." Without missing a beat he replied: "Only outright crying and tears work around here." (See below for the daily exercises I still do, now 1-1/2 years later.)

When I got home and figured out which end was up, I promptly re-ordered all the exercises so that each one containing a difficult element would be preceded by an exercise that contained less of the same difficult movement. This meant each exercise was a warm-up for the next one. For example, I did the heel slide before doing the quad set. By the time I got to the hamstring stretch, it was...fun!

10.  Warming-up. I once watched Wendel Motley dash fully dressed in street clothes into the Madison Square Garden locker room, late for our indoor 440-yard run. He just barely made it to the starting line in time--and promptly set a new world's record for the indoor 440 (I was second.). Like me, Wendel has muscles that don't really need warming up. I have almost never had a muscle cramp. NEVERTHELESS, I discovered that warming-up for my post operative knee exercises had a strong and beneficial effect, and made the exercise both easier, more productive and less painful. This will be all the more beneficial to those with less flexible muscles. Warming-up is essential to good results. (And this can include massage or a hot bath.)

[Here is an article by Emily Sohn saying what many athletes have known for years: Stretching is not good for you! --US News & World Report, 6/21/04]

Can't touch your toes? Don't sweat it. For decades, flexibility has been considered a key element of fit­ness. From the professional football field to the local health club, trainers have ad­vocated stretching as part of a regular workout. But new research is showing that stretching does not prevent injuries or make you any less sore the next day. On top of that, it doesn't appear to im­prove performance.

Stretching might, in fact, cause more problems than it solves, say a growing number of researchers. This is especial­ly true for women, who tend to suffer from knee, ankle, and other soft-tissue injuries far more often than men do. Extra flexi­bility might be to blame. "It is so hard to believe that stretching could somehow be the enemy," says exercise physiologist Stacy Ingraham of the University of Min­nesota-Twin Cities. "But there has never been any science that actually put stretch­ing into the athletic world."

Indeed, a recent review underscores how little support there is for the value of pulling, reaching, and twisting. Re­searchers from the Centers for Disease Control and Prevention found only six studies designed to isolate the effects of stretching, and none showed a link be­tween stretching more and getting hurt less, says lead researcher Stephen Thacker. In fact, says Ingraham, more-pliable muscles might cause more injuries than they prevent, especially if you stretch be­fore you exercise. Baseball players are notorious for stretching before games, Ingraham says, yet they tear muscles and ligaments all the time. "One study showed that marathon runners who stretched had a higher rate of injuries than those that didn't," says fitness ex­pert Jay Blahnik, author of Full-Body Flexibility.

But why? One explanation is that stretching muscle fibers makes them less stable and less able to resist the jarring impact of running or jumping. Stretch­ing may hinder performance because a stretched muscle can't produce the same kind of force as an unstretched one. And as muscle fibers lengthen, it takes longer for the brain's messages to tell the mus­cles to move.

Rather than stretching, Blahnik and other experts encourage people to warm up by jogging slowly, lightly swinging a golf club, or doing whatever else they need to do to achieve the range of motion required for their activity. Strengthening and conditioning exercises are also help­ful, Ingraham says, because fatigue and muscle weakness cause most injuries. The only reason stretching feels so good, she says, is that it results in tiny tears in the muscle fibers. The body then releas­es hormones that mask the pain.

11.  Massage. Not mentioned once in my rehab sessions was the excellent discomfort relief obtained by simply massaging the afflicted muscles! It would probably be wise to hold off on this until the staples are out and the incision completely healed-some ten days in my case--but massaging my quads and all the muscles above the knee cap reduced ache significantly. I also rubbed the numb area around the outside half of the knee cap and felt those dead portions begin to tingle a bit.

12.  Although this second technique is for later, when your incision is completely healed, get into the bathtub (If you are a bilateral, this can be quite a trick), and sitting up with the hot water covering your outstretched legs, flex/stretch those muscles. WOW--will you be pleased to witness an additional inch or so of movement beyond anything done in the dry. It was in the tub that I first got my accursedly stubborn hamstrings to flatten out, by pushing down on the knee of my straightened leg. A great flex & strength-builder is to squat down in a hot tub, Jacuzzi, heated swimming pool, etc., at a depth where your bum is just going under water as you reach the limit of your flex-ability. The deeper you squat down, the more your body is partially floated by the water, (i.e., taking the weight off your legs) which allows you to squat further without fear of losing control. And the hot water really helps the muscles to relax.

13.  The most important exercise duty: JUST DO IT!  Remember why you are in rehab at all--it is to exercise your leg muscles. Be sure you are fully loaded up with your pain-killer of choice! Forget the Puritan idea of working your muscles "naturally." The exercise you do is mostly the mechanical stretching of some shriveled muscle tissue. The more doped-up you are, the farther you can stretch the muscles before pain is reached, and the longer (i.e., one full minute for each stretch) you can hold the stretched position. And being on full painkiller medication will not let you damage the muscle, or the knee implant. It is as strong as it will ever be. So get the maximum benefit out of your work-out and be fully-loaded with painkiller. With me, Ultram took 30 minutes to kick-in. Learn how long your painkiller takes. Add 15 minutes--and then go for it.

14.  Poor little you. It is a riot to hear the variety of excuses given to the physical therapist about why only you can't do some particular required exercise. From one old geezer who used the tired "Weak heart" spiel, to "I know my body," to the one I found myself using (to no avail) of "previous injury."

15.  Too much exercise. Stakhanovites such as me tend to overdo everything. If 500 mg of Vitamin C good, 1000 mg must be better. If two hours of exercise is good, four hours is better. This is wrong. As a college quarter-miler, I found that more exercise than optimum didn't make me faster, it made me slower. It didn't result in more strength, it resulted in soreness, less ability to exercise and a net reduction in reaching peak performance. Likewise, if you are a Type A, you must have the hands-off patience to find the optimum exercise routine that gives your body a good, solid workout without causing stiffness to accumulate into the next routine. Listen to your body. It is the boss, not your iron will. My practice has always been to exercise hard and then nap. Yes nap, as in a short sleep. Even during track meets I would sleep for 10-15 minutes after the first (trials) quarter-mile. Then be much refreshed for the finals, and still have energy left for the last leg of the ensuing 4 X 440yd run.

16.  Muscle Memory. Walking correctly after surgery requires that the lower brain (the unconscious motor activator) learns what is now required of it. This is done by physical repetition. No amount of cogitation or book learning can teach your autonomous nervous system how to do something. Walking can only be "learned" by doing it, and letting the brain figure out what is required to achieve maximum efficiency and elegance. So if you want to relearn to walk quickly, walk a lot. You don't need to think about; you just need to do it.

17.  Balance. After making up my own exercise of stepping up and down off a foot stool with one leg to simulate stair-climbing, I let go of my hand rail. Whoa-nelly--did my legs go jittery to find equilibrium. Apparently, your knee bearing surface has stress sensors in it that communicate to your brain what the lower leg is doing. These are gone now, and your body will have to learn to sense this information from leg muscles. And so I learned to do as many standing exercises without holding on to anything. And quickly gained an extra measure of stability and confidence. However, I was extremely sure-footed going in. I could always run across a rocky stream knowing that I could always quickly be able to find some rock on which to place the next footfall. I can't seem to do this anymore, and I fell down a couple of times trying (Got all wet). So, while it's not noticeable in normal everyday behavior -- it might make some athletic tasks more difficult, e.g., ice skating.

Side Effects

Quite amazing was the lack of any description of side effects for knee replacement surgery. It is clear from the many descriptions of the procedure that they are all honest--and they are all sales documents; that is, everything they say is true. It's what they leave out that is discussed here.

1.  Biliousness.  At first I blamed the Ultram for a sense of biliousness that always hovered in the background. But when I stopped taking that pain-killer, this sub-clinical nausea persisted. This was a sense of not feeling good--almost like a minor hangover. Initially it would make itself known at 11 AM and result in my taking a 45-minute nap. (I slept at least ten hours a day.) Spirits restored, it generally was held at bay until the evening. Even 8 weeks after the operation, it was still an annoying part of my life, but diminishing.

2.  Lack of appetite. This was not a disadvantage, but one thing the biliousness did was greatly restrict the amount of food I ate. Going out for evening dinner was always as flop, as I could not get up an appetite for food or drink. (So we switched and went out for lunches instead.) I lost 25-lbs (down from 225 to 200) and 2-3 inches around my waist. Almost all of that weight loss came from a recently acquired beer belly, and the effect was quite positive. It will undoubtedly pass. [Day 74--starting to get my appetite back--and the weight!] [Day 165: beer belly almost all back, weight back to 210. Food tastes great.]

This lack of appetite is the same as when I spent 67 days on Mt. Everest in 1986. I would get hungry, but shortly after having eaten a bit, my appetite would disappear. Finishing a normal plate of food was never easy, and I did it only to keep up my strength. At the end of the expedition, I had lost 35 lbs of muscle mass (from 195 to 160 lbs)! It didn't take long to get that all that back, either.

3.  Dead zone. There is an area of skin around the outer side of the incision around the knee cap about the size of a pack of cigarettes that became anesthetized. The doc said this was unavoidable but would reduce in size as time went on, but not entirely. [Day 165-it seems the area has reduced, and underneath the dead area seems to have come back to life. But kneeling is still psychologically frightful.]

4.  Reduced flex. This is mentioned extensively in the literature. Normal knees are said to flex about 140-degrees. This lets you squat and get up off the floor quickly and easily. The maximum flex for an artificial knee is repeatedly said to be about 120-degrees, and could be less for the lazy. (That's still more than I had going in to the operation, so I'm not complaining.) It means you always have to sort of roll on to your feet when getting up off the floor. However, the doc says there is no mechanical reason while one can't get back full motion. It's just the stiff, shortened (from lack of stretching) muscles, ligaments, etc., that hold you back. We'll see... [Well, I saw. I can flex to about 140 degrees but that is not a full flex for me, and while I can squat--sort of--it is not a proper, fully relaxed and stable squat. I can't shoot from the squat position, a real handicap in wet and snowy weather.]

5.  Restless leg. Long after I no longer needed routinely to take a pain killer during the day, or even ibuprofen to facilitate physical therapy, I still needed to take something to reduce the "restless leg" syndrome that turned-up when I went to bed. This fidgeting might start with my crossing and uncrossing my legs while sitting, and then, in bed, not being able to find any suitable position for my legs when lying down. The legs didn't feel any different; they didn't itch or ache--but they would not lie still. Every change of position felt better than the last, although there was nothing noticeably wrong with the last position! I tried to wean myself from Ultram (which works great against Restless Leg) by taking Tylenol, aspirin, ibuprofen, but although they helped, they didn't really do the job. So now, seventy-four days later, I still need to take Ultram at night about every other night to stop this infernal fidgeting in order to fall asleep. (By Day 105 I was down to 2 Ultrams a week for restless leg; by Month 5.5, down to one. Can't recall when Restless Leg completely disappeared.) I suspect that restless leg is a subclinical tightness of the muscles which you don't overtly sense, but which is relieved by movement. (Feel the desire to take frequent walks? How much of that is restless leg in disguise?) 

6.  The shocker. The bill (paid for by Blue Cross) for a bilateral knee replacement arthrosplasty (In other words, having both knees replaced) was thirty-seven thousand, five hundred dollars ($37,500) for the surgery and four days stay at Mass General Hospital. The anesthesia bill was twenty-two hundred dollars ($2200). Not included was a 10-day stay at the Spaulding Rehabilitation Hospital. Let's say that cost $1,000/day. That means my new knees cost twenty-five thousand dollars ($25,000) dollars each! (Worth every penny!!) In England, a fraternity brother had his knees done for $8000 each about five years ago. His scars are about 1/2-inch wide, and are -- frankly --ugly. Mine are thin an not too noticeable. And he skis!! (But gently).

Good luck

Afterword

Okay--so where am I now, 1-1/2 years after the operation? Occasionally, I will feel a sharp tweak in my knee if I twist it oddly. And I still prefer to sleep with a pillow between my knees--although I can sleep nearly as well without it.  I can kneel -- and my doctor said -- go ahead -- kneel as much as you want as long as it doesn't bother you. But the thought of it keeps my kneeling down to a minimum. I still do not get up off the floor in the same fluid manner I could before the operation--which requires one to kneel and then get up.  But I'm still working on that--although hardly urgently.

So you could say that my everyday life is completely normal--except that I have completely given up running and skiing -- my two favorite sports. "Oh, dear, how can you give up the joy of your life," you ask. Well it's simple, really. I've been there; I've done that. I was a world-class quarter-miler in collage, setting the high school record, the Dartmouth collage record, the Berlin (Germany) university record and getting second place in the IC4As in New York, and second in the 4 X 400m in the German Nationals in Düsseldorf.  What more could I possible expect from running? I ran for years after school, but quickly realized that I would never again achieve the supreme light-footed fleetness achieved at 21 years of age. So the joy of running for me had long ago turned into the joy of exercise and the joy of being outdoors with the wind in my face. There's a lot of alternate ways I can get wind in my face outdoors without fighting shin splints and twisted ankles. (Mountain hiking, for example.)

As for skiing, in the early sixties I set my sights on one simple goal--to be able, some day, to wedel over the Tuckerman Ravine headwall (55^o). I did that in April of 1993, after nearly thirty years (on and off) of trying. It was a brilliant day, snow conditions were excellent. Toni Matt, the first skier to schuss the headwall in 1938, had been back to visit the bowl the day before -- a good omen. And I had one run in which I skied over the top like a god. What more could anyone possibly want from skiing? An endless winter? (I am not a ski cruiser who glides down intermediate slopes enjoying the passing scenery. To me skiing is fall-line combat with the mountain.)

So I always look askance at ageing athletes--many who only started their punishing fitness quest long after their bodies were already on the downward slope--or who never quite got out of college athletics what they wanted -- and have doomed themselves Sisyphus-like to just keep trying. Note that if you were a top-notch athlete before your surgery, you will not, repeat–not–be able to resume your previous high-level performance if that relies heavily on your knees. Torque (skiing) and pounding (running) will cut joint life in half. I also don't believe you ever get 100% of your muscle tone back. So grow-up and be thankful that your active life has been restored to 80%.) 

However, after a while, the above morning exercises just aren't enough exercise. Now, just about 2 years after, I joined a health club becuse the home exercises just weren't enough.  I wasn't getting stronger, and I still aim for a near complete recovery.  So at the gym I:

A.  Do 20 minutes on the elliptical runner--a cross between a stair climber and a treadmill--which simulates running without the impact of each footfall.  (The next generation of ellipticals are rumored to offer variable stride length which will get rid of the one problem, that of making a real runner feel like he's always stuck in second gear.)  One really great way to restore balance is to exercise on the elliptical runner without holding on. Swing your arms just as if you were running.  Balance is awkward at first, but in a couple of days, you'll feel quite normal. And all the leg muscles that contribute to balance will get a good workout.

B.  Do 8 minutes of rowing. Good for the upper body, arms and the lower back.  Because of the knee-bending involved, after rowing, I do a manual squat to stretch the knees.  I've made a little progress in getting my flex back to normal--but I'm still not there yet.

C. Do various machine exercises, particularly a recumbent squat--lifting about 135 lbs with my quad muscles. This strengthens the quads well beyond what you can accomplish with simple stretchy exercises.  Having done these for about a month, I now notice a little less flexibility, and a lot more assurance in getting up from a seated position. (I don't grunt any more as I get up.)

I will shortly be taking up tennis again -- doubles as I won't be able to explosively leap for the ball. And now, back in Boston, I hope to be able to cross-country ski again. So exercise and wind in my face seem once again a good possibility.

Daily Morning exercises. (If you can't go to the gym.)

1.  Sit on corner of bed and do 20 alternating knee lifts.

2.  Still sitting on bed, do 20 alternating straight knees. Flex quad muscle when leg is straight.

3. Lying on your back on the floor, do the "TH combo leg lift and bend": Lift one leg about a foot off the floor, and then bring the knee to your chest. Return to the straight-leg (still elevated) position and then lower knee. Repeat with other leg, 20 times. This is a great all-purpose exercise that works a lot of muscles.

4. Lying on your back, hook feet under bed or dresser, bend the knees and do 15 crunches. This is not -- strictly speaking -- a knee exercise, its' more for the back. And it loosens the waist and groin area which makes your body more flexible.

5. Sitting up, knees bent with soles of feet touching each other, press knees down with your hand to loosen groin muscles. Lean your body forward to stretch the back. Make your fingers crawl forward to pull those taut back muscles loose.

6. Do something aerobic. Walk the dog, use the elliptical runner, or row. Rowing not only strengthens your upper body–particularly your lower back–but it also nicely flexes the knees to keep them limber.

_____________________________________________________________________________________________________________________

Four years later (May 2005).  Knees are going great.  Here are the specifics:

1. There is rarely any sense that I have artificial knees except in two instances:

A) I hate to kneel on them (even though there is no "discomfort"), which makes getting up off the floor still somewhat awkward.

B) I still sleep with a pillow between my legs, even though I can easily do without. On my side, the knees feel "knobby" one on top of the other.

2.  The zone of dead skin above the knee has disappeared completely and now feels normal.

3.  I still can't squat like a native. I have really given up trying because my knees would ache with the effort, suggesting I was putting a great strain on the implant. Not a longevity-inducing practice.

4.  Going through airport security guarantees a complete pat-down every time.  When the magnetometer goes off and the office suggests I go back through again, I just say "Metal knees," and he shunts me over to the pat-down area.

5.  The knees almost never "cluck" anymore.

6.  I do seem to have a mild reoccurrence of "restless leg." Nothing to take any pills for, but such that I find I want to have my legs out straight for a few minutes, and then folded in (bent) for a few minutes--back and forth. At home I need to walk the dog every 4 hours or so. (This type of restlessness may be something I had before the operation.) 

Seven Years Later. (February 2008) Still going great. I almost never think of my knees at all. What can't I do? (Other than running and downhill skiing?)
The only impediment is stepping down a great distance--say two feet or so--off a ledge or rock. This is a headache when hiking over rough ground and I have to scramble around like the old fart that I am, rather than just bound down as before. A small price to pay for the huge freedom of mobility I received compared to before the operation.

*********************************************************

Endnotes:

1. Dr. Robert Mohr.

2. Dr. John Repicci. http://www.repicci.com/contact.html

3. Dr. John M. Siliski at:  http://www.allaboutmydoc.com/surgeonweb/surgeonId.9761/clinicId.9561/theme.theme7/country.US/language.en/page.surgeonhome  
  
4. Which promptly cured several years of heart-burn!! Coming home, out went the 2-3 bottles of ibuprofen, out went the Tums, out went the Zantec 75, out went the glucosamine. Extra tip: to greatly reduce the incidence or severity of heartburn or acid reflux, place a brick under the legs at the head of your bed. Use the smallest dimension of the brick -- about 2-1/2 inches thick. This slight elevation will help to keep stomach acid from flowing out of your stomach and up into the esophagus. This little trick worked really well for me.

5. Estimate by Dr. Ricardo Knight, Spaulding Rehab Hospital. But this number might be low--that is, more patients should have both done, but don't--due to patients not wanting to even consider having both knees done at once. Be bold.

6. The constipation only occurred when taking 3 Ultrams a day, was partially neutralized by taking one CVS brand "Stool softener plus stimulant laxative" (which is 100 mg of docusate sodium and 30 mg of casathranol) with each tablet of Ultram. But I was never "regular" (until I cut back to one Ultram a day). Increasing the dose of stool softener resulted in diarrhea. Also, 3 Ultrams made me fart more than usual

7. My doctor winced at my knock-knee complaint. "Tom, we line up the ankle-joint, the knee-joint and hip joint to be on a straight line in order to equalize the weight on both sides of the knee joint. Yours is within one-degree, so you're actually straight-legged for the first time in your life."

8. I feel like the miracle weight-loss ads on TV. "Miriam lost 60 lbs in 30 days," the ad bellows. In small type below is the barely legible note: "Results not typical."

9. This is philosophical, not medical, advice.

**********************************************************

For another, more official view of this subject, see:
http://www.vh.org/Patients/IHB/Ortho/KneeReplace/KneeReplacement.html#1
Also: http://www.scoi.com/tkr.htm

And: http://my.webmd.com/content/article/17/1676_50418.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348

For trenchant Business assistance, be sure to visit: www.velocityassociates.net