Almost exactly ten years after my right hip resurfacing operation, I’m back for a second joint replacement operation – a partial knee replacement (PKR) on my left knee. About one year ago, in April 2022, I was running hill intervals – run up, walk down. For the first time I noticed pain on the inside of my knee when walking down the hill. None while running up, only on the downhill portion.
As with my hip, my first thought was some sort of soft tissue issue – a sprain or tear of some sort. I gave it about a month rest, then tried a gentle run on a flat surface. No go. A fairly sharp pain with every step.
Even though I wasn’t running, I was starting to notice more clues. I was pretty much pain-free in the normal course of walking around and daily activities, but going down stairs, especially if I was carrying something heavy was painful.
I bit the bullet and made an appointment with an orthopedic doctor about mid-June, but I first had to be seen by his PA (Physician’s Assistant) at the local clinic on our island. The first thing the PA did was order X-rays of both knees. As soon as I saw the left knee X-ray, it was crystal clear — there was next to no gap between the femur and tibia on the inside (medial side) of my knee. The rest of the knee joint did not look that bad to me, as there was healthy separation in the patella and outside (lateral) compartment of the knee.
I have learned a lot about knees and osteoarthritis of the knees since viewing the X-rays. The radiology report stated my right knee was at a level 2 and my left knee at level 3 on the Kellgren and Lawrence classification system. This rating system assigns a score ranging from 0 to 4 to quantify the degree of osteoarthritis as follows:
- grade 0 (none): definite absence of x-ray changes of osteoarthritis
- grade 1 (doubtful): doubtful joint space narrowing and possible osteophytic lipping
- grade 2 (minimal): definite osteophytes and possible joint space narrowing
- grade 3 (moderate): moderate multiple osteophytes, definite narrowing of joint space and some sclerosis and possible deformity of bone ends
- grade 4 (severe): large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone ends
I mentioned to the PA I had torn the meniscus of the inside(medial) compartment of this knee in the year 2001, twenty-two years earlier and I had arthroscopic surgery that year. He said that explains why this compartment looks bad now. Both a meniscus tear in itself and having had arthroscopic surgery are each high probability predictors of later-in-life arthritis.
The PA said I could try various interventions like NSAIDs, injections, acupuncture and lifestyle changes for dealing with the pain, but if I wanted a permanent fix, I would need a knee replacement. I left the appointment having received a steroid injection and feeling bummed out. My younger brother had had both his knees replaced six months earlier and he was still having recovery issues.
I went home and started reading about knee replacement surgery. We are constantly cautioned to not turn to the Internet for medical advice, but the truth is there is a lot of information out there and anyone who knows how to spell google is going to do a search. I learned that in addition to the standard “bread and butter” Total Knee Replacement (TKR), there was something called a Partial Knee Replacement (PKR) for those who one, or possibly two, deteriorated compartments. Hmm … might this not be a possibility for me? I also learned that in addition to the standard TKR in which the cruciate ligaments are cut/sacrificed, there exists a technique called Cruciate-Retaining TKR, in which the name is pretty self explanatory. None of these options had been mentioned by the PA, by the way.
I next decided to quit screwing around and I booked a consultation with the doctor who had done my hip resurfacing operation ten years earlier. He confirmed that I was indeed a candidate for a PKR. He also explained that later in life, should I need more work on that same knee, I could either go with one or two uni-compartmental PKRs or a TKR. This sounded encouraging to me and I was all set to schedule an operation with him. But I didn’t. Why not? I had learned even more. I had become aware of a system call Mako Robotic-Arm Assisted PKR.
In short, the Mako Robotic surgery is performed by first performing a CT Scan on the knee, then the scan results are fed into software that produces a 3-D model telling the surgeon exactly where to cut. The system is not an automated cutting robot — it merely outlines and provides hard-stops where the surgeon needs to cut in order to have the prosthetic fit precisely. It also takes into account the patient’s anatomy and can compensate for non-perfectly aligned legs. Mako is not the only such robotic system, but it is the most established. According to the papers I read, the Mako system results in statistically better outcomes than does traditional surgery. Naturally, this approach appealed to the engineer in me over the option of having a surgeon show up with a protractor in hand to eye-ball the angle of the cut.
It was for this reason that I decided to not go with my hip resurfacing surgeon — he did not use Mako, or any other robotic assisting system. I then went on the hunt for a Mako certified surgeon who had a lot of surgeries under his/her belt. I interviewed one surgeon in Seattle and three in the Scottsdale area. I settled on Dr. Steven Kassman, who practices in Scottsdale, AZ. My surgery is scheduled for March 31, 2023 at 7:00 AM, with a check-in time of 5:30 AM. I sure hope Dr. Kassman gets a good night’s sleep on the night of the 30th!