BILATERAL TKR

There are actually two types of bilateral TKR.  One is simultaneous bilateral TKR whereby both knees are replaced during the same surgery on the same day.  The other is staged bilateral TKR whereby both knees are replaced at different times either days or months apart.  For those who only need to replace one knee, its called unilateral TKR.  Lets look at the pros and cons of simultaneous and staged bilateral TKR.

SIMULTANEOUS BILATERAL TKR

Simultaneous bilateral TKR appears to be the most logical thing to do as it involves one surgery, one anaesthesia, one hospitalisation  and one recovery.  It also saves a lot of time and costs.  If both of your knees are equally bad, then you are a candidate for simultaneous bilateral TKR.   Of course, this is not a decision to be made by you alone as it also depends on the recommendation of the Orthopaedic Surgeon (OS).  As this procedure requires a longer surgery and is more demanding on the body, patients who have cardiovascular problems, pulmonary disease or are over the age of 80 are usually advised against a simultaneous bilateral TKR.  Studies have shown patients undergoing simultaneous bilateral TKR have a slightly higher risk of cardiac events and needing blood transfusion.  The risk of complications such as infection, blood clots or pulmonary embolism is the same for both simultaneous and staged replacement.

In my case, I did not hesitate at all to do a simultaneous bilateral TKR as both my knees were equally bad.  As I was only 49+ at that time and relatively healthy, my OS did not have any problem with my decision.  We did not even discuss about any other option.  And I am so glad that I did that because now I have two pain free knees with one surgery.

However, many people worry that replacing both knees simultaneously may pose a problem in recovery as they do not have a good leg to work with.  Yes, during my recovery, I did experienced difficulty in getting up from a chair or toilet bowl due to the weak muscles and the stiffness and tightness in both knees.  It was exhausting as I have to rely on my upper body strength to pull myself up.  So if you have a strong upper body, it would be a great help.  However, walking is not a problem at all.  Eventually, it just got easier and easier when my muscles begin to strengthen.  For more elderly patients, I would imagine that they may take a little longer in recovery but it would still be worth it as they only have to deal with one recovery as opposed to two recovery if they have a staged bilateral TKR.

I have come across a lot of people from my TKR forums who have done simultaneous bilateral TKR and they are so glad they did that and would not have done it any other way. 

STAGED BILATERAL TKR

I understand that some OS does not advocate the practise of simultaneous bilateral TKR.  They prefer to do a staged replacement in order to minimise the risk of complications.  For this reason, I have come across people who did their bilateral replacement within days apart but during the same hospitalisation.   Then there are some who did it within one month apart and some within several months apart.  I have great admiration for these people as they have the courage to go through two surgeries within a short time frame.

For those who are in the high risk group in terms of age and medical condition, the staged replacement appears to be safer than simultaneous bilateral TKR.  These are factors that your OS would consider in order to make the necessary recommendation.

The disadvantages of doing a staged bilateral TKR involves having to deal with two separate surgeries, two anaesthesia, two hospitalisations and two recoveries.  And the time and costs spent would be much more than a simultaneous bilateral TKR.  Additionally, there are people who ended up with one good knee because the fear of going back to do the other one is too great.  So these are factors for those who are suitable candidates for simultaneous bilateral TKR to consider when making a decision.  And you need to find an experienced OS who is willing to do a simultaneous replacement.

Overall, the result of both simultaneous and staged bilateral TKR is the same in terms of pain relief and knee function.

TKR SURGERY

Recently, we had an interesting discussion in one of my TKR forum where we discovered that many people are still very ignorant of Total Knee Replacement (TKR).  This ignorance turned out to be quite hilarious because one member tried to relate to her boss that her surgery was coming up and she was scared about it.  But her boss made light of the surgery by saying that it's just a keyhole surgery. How wrong can that be? So it was suggested that she show a video on TKR surgery to the boss to proof how major the surgery is.  Well, it's the same for me.  When I tell people that I had a bilateral TKR surgery, some of them they will go like... is that possible?  how does it work?  what is it made of?  oh, it sounds like you are a bionic woman!

Yes, ignorance can be humorous sometimes.  It's okay if you are not suffering from Osteoarthritis (OA).  But if you are suffering from severe OA, it's not a laughing matter.  OA can make our life  debilitating and miserable.  Most of us who have gone through TKR tend to be very observant of others who are struggling in pain when they walk.  We will wonder whether they know that their problem can be fixed.  We want to reach out to tell them. Sometimes we do but sometimes, certain circumstances prevent us from doing so.  Maybe they know but the fear factor is too great. Or maybe they know, but they don't know enough.  Or maybe they know enough but do not have the financial means to get the problem fixed.  Whatever it is, the purpose of this blog is to create awareness and hopefully you, as readers can help to spread the awareness.

In this post, I will try to provide some basic information related to TKR surgery.  These information  are based on my own personal experience as well as some research references from UKM Specialist Centre, St. Vincent Medical Centre Joint Replacement Institute and BoneSmart.  The images and videos shown here were obtained from the Internet.

WHAT IS A TKR?

TKR is a surgical procedure whereby the diseased or damaged joint surfaces of the knee is replaced with artificial material that allows continued motion of the knee.

TKR is one of the most successful of all surgical procedures, and a virtual medical miracle.  Prior to the development of TKR technology, patients with advanced arthritis of the knee suffered from chronic pain and loss of functional independence.  Following TKR, more than 90% of patients have no pain, or only slight pain, and their walking is no longer limited by their knees.  Most patients can live a full and independent life.

Our knee consist of three bones.  Our thigh bone (femur) sits on top of our shin bone (tibia).  When we bend or straighten our knee, the rounded end of our thigh bone rolls and glides across the relatively flat upper surface of our shin bone.   Our knee cap (patella) is the third bone and it is attached to the muscles that allow us to straighten our knee.  There is a cushioning layer of tissue called cartilage between the joints that allows the three bones to move without creating friction or wear on the bone surfaces.  However, when the cartilage is damaged or worn out, our bones rub together causing friction, pain and deterioration of the bone surfaces.

In TKR surgery, the parts of the bones that rub together are resurfaced with metal and plastic implants (prosthesis).  The Orthopaedic Surgeon (OS) will use special precision instruments to remove the damaged surfaces of all three bones and replace them with the prosthesis.

Anatomy of a Normal Knee Joint
 

Knee joint After Total Knee Replacement

WHAT ARE THE CAUSES OF JOINT DETERIORATION?

TKR is usually considered for patients whose joints have been damaged by arthritis, trauma or other rare diseases of the joint.  The most common reason for TKR is severe OA of the knees. 

OA is the most common joint disorder affecting mostly weight bearing joints such as hips, knees, ankle and foot. It is usually caused by wear and tear of the joint due to ageing particularly from age 50 and above. But today, it is affecting much younger people.  The problem starts with the deterioration of the cartilage.  When the cartilage deteriorates, the bones rub together causing pain, swelling and stiffness. Eventually, this will cause bony spurs (osteophytes) to be formed around the joints and subsequently, the ligaments and muscles around the joints become weaker and stiffer.

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints.  While inflammation of the tissue around the joints and inflammatory arthritis are characteristics of RA, the disease can also cause inflammation and injury in other organs in the body.  Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system.  While RA is a chronic illness as it can lasts for years, patients may experience long periods without symptoms.  However, RA is typically a progressive illness that has the potential to cause joint destruction and functional disability.

I know of two people from my TKR forums who had undergone bilateral TKR at the age of 28 and 31 years old.  One has RA and the other has Psoriatic Arthritis which is a form of RA.  These people had such a debilitating and miserable life to the extent that they were unable to work.  They may be young but their knees were that of an 80 year old.  And they had a hard time finding an OS who would do the surgery.  They were told to come back in 10, 20 years time because they were too young to do a TKR.  Fortunately, they managed to find their OS who were willing to do bilateral TKR because they believed that the consideration for better quality of life outweighs the age factor.  

Comparison of Normal and Arthritic Joints