A Knee Replacement Revision
written by Dr. Carl Freeman
I am in the midst of recovering from my 21st knee surgery. Below is what I have learned, what I wished I had known, and what I recommend you do.
Full disclosure: I have worked with the team at X10 Therapy for more than five years as the Director of Research. I study the data that we obtain from our patients, looking for patterns and trends in the recoveries of X10 patients.
My Knee Story Starts in the Fifth Grade
In 1960 I was in the fifth grade when I dislocated my left knee playing football. In middle school and high school, my knees dislocated frequently; the doctor did tendon extensions on both knees in 1967 but extended them too far, adding pressure on my knee caps, and causing them to wear away. In 1968 both knee caps were removed.
Between 1968 and 1983, I had numerous cartilage trims, meniscus repairs etc. In 1983 I slipped on the ice putting the right knee through the quadriceps tendon, pulling ligaments out of the bone and severing an artery. It took two surgeries to put it back together. In 2011 I had two total knee replacements. Between 1983 and 2011, I had manipulations under anesthesia, cartilage trims, and other repairs.
For my knee replacements, I chose the surgeon who did these smaller repairs (a mistake). The surgeon chose to use implants for patients who had knee caps. I didn’t have knee caps and my left leg was unstable; in 2015, I went to a different surgeon for a revision of my left leg. The knee revision was a disaster. The surgeon added space between the bones so that the joint line was an inch and half thick, instead of half an inch. The two components of the new knee were rotated in opposite directions putting my knee about 1 inch out of perpendicular, stretching the ligaments, causing immense pain and instability with every step. I complained from my first visit to my last and was told simply to exercise. I exercised religiously, but the knee was so painful and unstable that I could not stand for more than a minute or two. On July 18th 2018 I had my 21st knee surgery.
This is what I have learned:
- The most important decision is, “Who is doing the surgery”. Patients with exceptional surgeons quickly regain range of motion have about a 1% chance of needing a manipulation under anesthesia (MUA). These surgeons typically do hundreds of knee replacements a year. Less qualified surgeons typically have MUA rates of 4-15%, and do fewer than 100 knee replacements per year.
- The state of your leg is in before surgery is crucial. The average patient has gone down in strength and range of motion for over eight years before getting a knee replacement. It is essential to do pre-habilitation exercises. Prehab could come in the form of outpatient physical therapy or the X10 in your home. Outpatient physical therapy involves going to a clinic for eight weeks; less than half the patients comply. In contrast, X10 Therapy is used in-house for prehab (over 90% compliance) and is more efficient: as little as three weeks of therapy has proven efficacious. This is what I did.
- After surgery you have got to move; the nurses will get you up and walking the day of surgery, but within a day or so, you will be home—then what do you do? You either move the joint or you lose your range of motion and muscle strength. Many patients take weeks to regain their range of motion (it took me four days on the X10) and that the average patient has a 50% quadriceps strength deficit at one month and a 30% strength deficit at one year. I am in process of regaining strength, but the average X10 patient has more quadriceps strength one month post-surgically than they had the day before surgery. I am betting on the X10.
What I wished I had known (Knee Replacement Revision)
More than anything I wish my parents, and later I, had known how to choose surgeons. How do you find the exceptionally good surgeons? You have little choice but to listen to recommendations, but don’t stop there. Meet several surgeons and have a frank talk with them about their manipulation and infections rates, law suits, and complaints.
The other thing that I wished I had known was the X10. It has proven so useful in prehab and rehab and helped me quickly restore my range of motion and build strength (the usually forgotten subject)
I grew up in an era when doctors were gods. I have learned that surgeons understand the surgery, but the vast majority don’t understand rehabilitation. Doctors run on belief systems. Some believe that all patients should go to a skilled nursing facility, others favor home care, still others favor going directly to outpatient physical therapy. There have been no randomized studies that have tested these beliefs. I shocked my present doctor because I declined all of it. I came home to an X10. Four days later I had 0°extension and 130° range of motion. I did this before scar tissue could form to limit my recovery as it had done so often in the past. For me, No MUA.
The X10 Meta-Blog
We call it a “Meta-Blog” because we step back and give you a broad perspective on all aspects of knee health, surgery and recovery. Knee Replacement Revision (by Dr. Carl Freeman)
In this one-of-a-kind blog we gather together great thinkers, doers, writers related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. Whether you have a surgery upcoming, in the rear-view mirror, or just want to take care of your knees to avoid surgery, you should find some value here. Executive Editor: PJ Ewing (firstname.lastname@example.org)