UKH

I am heading for full knee replacement and am trying to get the best possible information on what it would mean for my climbing to help with decision making. I have read previous UKC threads and some other stuff online, but still feel a bit in the dark about what I can expect.

My situation is that I have arthritis in both knees (confirmed by x-ray). It stated affecting my hillwalking a bit over two years ago and, with ups and downs, is gradually worsening despite strengthening work under the guidance of a good physio. At the moment I can still do some modest hill walking (shortish one or two Munro type days of a few hours) using pain killers. It doesn't really affect my rock climbing as such, except that I have pretty much had to stop doing any mountain cragging.

I am lucky enough to be able to get the replacements done privately (one at a time) and can choose the timing with three months or so notice. My very experienced surgeon who came highly recommended and my physio are confident that replacement has every chance of getting me back to more or less normal hill walking and non-technical mountaineering but both are decidedly discouraging about my prospects for rock climbing due to loss of knee flexion. However, it is clear that plenty of people do, in fact, get back to rock climbing to a lesser or greater extent.

Clearly it is going to be a trade off between walking and climbing. If I did not climb, I think it would be an easy decision to get them done as soon as possible, and, if I only climbed, an easy decision to delay as long as possible.

So what I need to know is how much flexion I am likely to get and the extent to which my climbing is likely to be affected. I am recently retired so it goes without saying that I will have the time and motivation to do the prehab and rehab religiously. I currently think of myself as an E3/7a onsight climber (when uninjured and fit!). I think I would find some drop in standard acceptable if it meant I could get  back to freely enjoying hill-walking, mountain cragging and modest alpine climbing. On the other hand, if climbing became so frustrating or laborious that I ended up more or less giving it up, I would be gutted (I have lived and breathed mountains and climbing my whole life).

So, while I fully appreciate that there will be a fair bit of uncertainly in my own outcome, I would really appreciate hearing about anyone's experience of replacement, particularly how it has affected their rock climbing.

Thanks in advance.

In reply to Robert Durran:

Robert, I am now 67 and had my left knee replaced about 7 years ago and my right hip about 4 years ago. Both were done on the NHS and by the same surgeon. He was very downbeat about my chances of getting back to rock climbing, paragliding or most of the things that make life worth living. In the event he was completely wrong and happy to be so. His pessimism was based mainly on a lack of understanding of the activities rather than a lack of confidence in the surgical outcome.

It did take me a long time and much hard work (2 years +) to regain enough knee flexion and strength to really enjoy my climbing again, but it did come and with very little reduction in grade (broadly similar to yourself, but I do very little sport climbing). It was 100% worth it as I had reached the point of being able to do very little before the surgery. Long hill days and regular climbing were a real pleasure again, though I have had to adapt my technique a bit to compensate for some loss of flexion.

Unfortunately last year I tripped heavily over a boulder in the bracken in the Duddon and am now recovering from recent arthroscopy on the other, good knee, following twelve months of enforced inactivity. There always seems to be something…… .

Overall my feeling is that the total knee replacement does not have to mean the end of regular and satisfying climbing, but be prepared early on for some hard times and spells when it may seem hard to believe that it will be worth it.

The hip, on the other hand, was an absolute doddle. I was climbing again in Pembroke after just three weeks, albeit without full official approval. 

Good luck with it all if/when you go ahead. 
 

John.

In reply to Robert Durran:

Hi Rob, have you exhausted all other treatments. For example I know a range of folk from around Chamonix, guides and accompagnateurs, with more or less zero cartilage in their knees who have  benefitted from injections of lubricant in their knees. Some for more than ten years.

I also know two guides who have had TKRs, and continue to work as guides, both of whom are very satisfied with the results, but both have loss of knee flexion. However, they both climb to a reasonable standard despite this. That said, one now only top ropes/seconds as he doesn't want to risk a fall.

In reply to jon:

My 70 year old sister can still run a 4 hour marathon. Her orthopaedic consultant recently wrote to her GP: "Claire continues to run marathons, I have no idea how" 

In reply to Robert Durran:

OP going private makes it a commercial transaction - remember that...

57 is very young for a TKR.   Have you discussed with you consultant the life expectancy of the  replacement?

You may get a few years on the hill, followed by a couple of decades hobbling and impaired

In reply to Robert Durran:

I have had problems with my right knee getting increasingly painful over the last three years. I visited my GP who sent me for an X-ray. The result was "Slight damage probably cause by age". I had an MRI scan which I had to pay for (£400). Apparently, my problem was my patella was a bit too high so my knee was not rotating properly. Fix was somehow needing to move my patella down slightly. This could be done with an operation by moving down the ligaments and attaching them lower down thus pulling my patella down. This was expensive and meant a long recovery.  The alternative was a steroid injection and lots of physio. 

I am just at the start of my physio, so don't know if this will work.

However, I would recommend you get an MRI scan which will give much more detail than an X-ray. 

In reply to John R:

Thanks. That is very encouraging.

Yes, I'm not expecting it to be easy.

In reply to jon:

Hi Jon, Thanks.  I have had a hyaluronic injection through my physio, unfortunately with no noticeable benefit. Physio says it is time to consider replacement and recommended my surgeon.

Have they dropped much in standard (and from what sort of standard)?

In reply to kaiser:

I am satisfied that I have a top surgeon who will do the best job possible. An advantage of going private is that I can choose the timing and can get them done while still fit and strong, which will be a big advantage for rehab, rather than weak after a long period of inactivity.

The surgeon says that 90% of replacements are still working very well after 15 years. Modern replacements can last 30 years. 

In reply to wilkesley:

I would have happily paid for an MRI if the surgeon thought it necessary, but the x-ray clearly showed very thin medial cartilage and wear of the kneecap which he would resurface.

In reply to Robert Durran:

The most effective seem to be 3 injections, 1 week apart, twice a year...

The one who now only seconds now, yes. I guess from 7b ish down to 6c ish - though this might well be due to generally losing interest a bit, rather than the loss of range of movement. The other seemed to have maintained his standard at a steady 7a. He's the person who showed me the reduction of flexion, however, skiing is his main activity, and didn't seem overly bothered by it.

In reply to jon:

I just had the one - the physio said that if I didn't notice any improvement then it probably wasn't worth having more.

That's encouraging!

In reply to Robert Durran:

I hesitate to add only slightly relevant anecdote but I fell into pace with a guy running a while back who was very happy with his knee replacements and back to regular fell/trail running. 

In reply to Robert Durran:

My brother in law had operations on both his knees a couple of years ago. I don't know if they were full replacements, but he has happily resumed hill walking in the Lakes. He has had minor problems with infections, but these have been resolved.

In reply to Robert Durran:

Hello Robert. I am 75 and had a double total knee replacement operation in September 2018 courtesy of the NHS. My thinking was that a double operation would give me a much shorter overall recovery time albeit at the cost of a more painful and retsrictive initial recovery. The TKR surgery reason was arthritis in both kneees, with one slightly wors ethan the other. As I have already had two hips resurfaced and two shoulders resurfaced aswell, all due to arthritis, I didn't hesitate for a moment in deciding to have an operation. Initial research revealed a New Zealander who resumed Himalayan climbing after his TKR and various other mountaineers and climbers who had resumed climbing. So more research led to a reputable surgeon and the choose-and-book NHS facility enabled me to book an operation with him.

The operation and initial recovery took about 5 days and then, able to climb and descend a flight of stairs with crutches, I was sent home where a most supportive partner helped out with things.This is a very good thing to have. The NHS physio after the initial get you up stairs stint was very poor and I went private to a local physio. They concentrated on increasing the two knees' flexion and getting my legs stronger again.

It took two months before I was back at the wall doing 3s and 4s but climbing!!! It too another three months of daily exercise to get the knee flexion back to a point where I stopped thinking about it; c95% of normal in one knee and c95% in the other. I set up a lomg ruler on the floor in front of a chair and did exercises daily to try and force my feet backwards to a 90% bend or beyond with the knees. The ruler gave me a numerical measure of how far back I could move my foot.

These exercises hurt but not too much. I climb at 90% of the level I did before, meaning 6a+ leading at the climbing wall, and go mountaineering as well, but with a feeling that my leg strength is not back to what it was in terms of plodding uphill for a long time. I have done two alpine hut walks since the op, plus the Snowdon horseshow walk, and all were a huge effort. Age and a DVT episode may confuse matters here.

I am still wary of over-bending the knees when descending steep mountain paths. And I don't go running anymore, wanting to preserve the knee joints' working life for as long as possible and so avoiding impact sports.

If asked I would say forget steroid injections or taking supplements like glucosamine. Have the operations and get your legs as fit as possible beforehand and then be diligent, boringly diligent, about physio and exercises. Good luck.

In reply to Chris_Mellor:

This is the key, I think.

In reply to wilkesley:

Thanks, yes, always good to hear further confirmation that I can expect to get properly out in the hills again with new knees.

In reply to Chris_Mellor:

Thanks for all that detail. My surgeon will only do one knee at a time. He said less risk of complications and easier to rehab one at a time. Obviously more drawn out though.

How many degrees flexion have you got back? I did a 6b at the wall recently (a lower grade than I usually warm up on) and noted how much my knees were flexing. I reckoned that there were hardly any moves where it was less than 100 degrees. It seems to me that if I only got 100 degrees, my climbing would be massively compromised. I know that some people get significantly more, but what I am struggling to ascertain is the likelihood of getting to 120+. I think my surgeon is probably understandably playing down expectations. 

I would hope that age would be on my side in getting full strength back (both surgeon and physio are very encouraging on this). Obviously I will do the rehab religiously!

In reply to Robert Durran:

I've had TKR on both knees. Left was 7 years ago and it took me 6 months to get back to my (very physical) job. Right was last year and this time it took a year to get back to work. Both have flexion of 115deg + . Climbing is I think more affected by the general creakiness associated with being 66. I'm also completely pain free.  I was religious about my rehab exercises. 

Unfortunately, I’ve had a terrible experience with a tkr. A nightmare of pain - mainly due to nerve damage. Three years down the line now and still in pain - but about half the pain of a year ago. I wouldn’t have thought I could have stood that level of pain on a daily basis - until I had to.

Was climbing at a high standard before knee finally gave out. Knee strong and relatively flexible (gained a little more flex only a couple of months ago) but climbing is now impossible and I cannot run. Can do crawl kick but not breaststroke kick. Can walk again reasonably well which is a blessing. Wouldn’t like to chance it again.

If I had to, I’d find the best surgeon in the country for doing it and pay whatever I had to. I’m not out of the woods yet but I wouldn’t like to go through that dark tunnel of pain again.
 

Sorry to give you the other side of things but you need to weigh things up carefully because a lot go wrong in some way or the other as far as I can see with the benefit of three years of paying close attention to other people’s outcomes.

Anyway, I sincerely hope you find a good surgeon and have a positive experience and can climb again. I’d have loved to have been able to do that!

In reply to martinturnchapel:

Thanks. Did it take as long to get back to climbing as it did to work? 115+ sounds not bad - was that in line with your surgeon's expectations?

In reply to Marcus:

I'm really sorry to hear you have had such a bad experience and I hope things improve for you. I'm aware things can go wrong. It sounds like the risk of nerve damage is 1% or less, so you have been unlucky.

I have certainly found a top surgeon and am prepared to pay.

Have you seen a lot of poor outcomes in other people?

In reply to Robert Durran:

In both cases I was climbing before I got back to work - I regarded climbing as strengthening in preparation for work. Both knees had very different stories regarding flexion. The first one the surgeon said the thing that would take the longest to get back to was cycling and that I should expect it to take 18 months to 2 years. He was spot on as it was 18 months before I had enough bend (though I was climbing within 6 months). Second knee, when I went for my six week review I already had 110 degrees and was cycling in six months.

In reply to Robert Durran: Most people aren’t really active, so a good outcome for them is far from being a good outcome for a climber, so difficult to tell. In the last 3 years only one two people I have met had no real problems. I think only a small proportion actually would be able to run and climb but are happy doing the shopping and going to the pub - so it seems a good outcome. Heartening to see all the good outcomes posted here - just in case. 

In reply to Robert Durran:

NHS  btw

In reply to martinturnchapel:

I find that surprising. I was actually wondering whether I should accept I might have to cycle as part of rehab (I hate cycling!) since it is non-percussive and I would have thought needs less flexion than climbing properly.

In reply to Marcus:

I had a discussion with my physio a couple of days ago and he confident I had every chance of being fully active on the hills again. He pointed out that a lot of people do enough rehab to get about 90 degrees of flexion and then stop because that is perfectly adequate for day to day activity and basic walking. It is getting the extra flexion needed to climb to a decent standard which is going to be harder work.

In reply to Robert Durran: And stepping up on that bent knee! Scary. And using your knee is out - for everyone I know who has had a tkr anyway. Having said all of this, I’m sure I could still climb selected, fairly easy climbs, say up to about 6b or E1 (if I still did trad) but I wouldn’t want to risk it. I have been climbing for over 50 years now (with gaps) so it’s not too bad. I have belayed my son and that was enough. But it’s taken 3 years to get to this point. As far as the “unlucky” 1% is concerned, it’s like having a Covid jab or some other medication or just taking a risk. You never think it’s going to happen to you - until it does! Very useful for you to check out the Bonesmart community- really good information on their Site. And it’s not always what your surgeon or physio tells you. It’s a must visit for someone in your situation. Hope it helps.

In reply to Robert Durran:

this  https://peerwell.co/blog/range-of-motion-after-knee-replacement/  Summarizes rather well - I’d always thought 6 months was the key point - after this, it won’t improve. 

This article is rather more aggressive and aims for 3 months, possible to leave some room for aggressive physio  if enough flexion isn’t reached  

knees and shoulders are the toughies- dismally designed joints.

I’d agree that one at a time is more sensible. Having a “good” knee as a baseline will encourage more effort in the operated knee - the goal is symmetry bilaterally for normal activities to avoid other vaguely related skeletal problems caused by asymmetry. And climbing, of course!  

(ex orthopedic researcher and possessor of hip prosthesis)

In reply to pneame: If you look on Bonesmart which is a community comprised of tkr (and hip replacement) people, you’ll find that their experience is that range if movement comes at different times, and it can be regressive to force it early on. I found this myself and, in fact, I had a big increase after 2 years and another smaller increase at about 3 years. I really tried to force bend early on and it was super painful and not successful. The physios and doctors seem to have this wrong because they all advocate forcing a good range of movement early which I and huge numbers of people who have actually had tkrs think is not a good idea. Don’t believe me, check out the thousands of reports on Bonesmart.

In reply to pneame:

Thanks.

In reply to Robert Durran:

Yes I was surprised just how much flexion cycling involves - I tried at three monthly intervals with the saddle very high and it was too painful. However the second knee had 115 deg within 6 weeks and I'm sure that, had my bike not seized up, I'd have been cycling again.

In reply to Marcus:

It isn't "forcing" a good range of movement. It is working towards a good range of movement progressively. Forcing will certainly result in a poor outcome, as tissues do not get a chance to heal correctly. All these joint replacement surgeries are violent surgery involving a lot of collateral damage. It is critical the the physiotherapy match the patient's healing process. 

In reply to Robert Durran:

I note that hyaluronan injections have been mentioned in the thread and, separately 57 being relatively young for TKR . I've recently been in discussion with a local physio who is a strong advocate for MBST (MRI therapy). There is a lot of support for this in the orthopaedic community in Germany. Seems to provide good clinical outcomes in delaying surgery, better than hyaluronan injections. The physio I've been talking to has used both on himself, injections had to be repeated, but MBST only one course in 2 years, got him back to skiing. I've been reading some of the literature on potential mechanisms of action, very limited, but some in vitro work suggests damping inflammatory response and stimulation of an environment conducive to some cartilage regeneration, which really surprised me. 

In reply to Robert Durran:

I'm afraid my experience wasn't good. Both my  knees were worn out after 40 years of fell running, walking, climbing & skiing. About 6 years ago I had a TKR of left knee, and whilst it did mean I was no longer in pain every day the result has seriously curtailed my outdoor pursuits.

I did all the exercises I was given but it was only at the 6 week follow-up appointment that the Surgeon ask how my physio was going, and I told him I hadn't been offered/given any. He sent me straight off to physio but by then it was too late, my 'bend' was barely 90 degrees.

18 months after the first op the surgeon opened it up again, cut away a lot of tough scar tissue and shaved a little off my new patella to try to make a bit more room inside the joint. With physio arranged from day 1 this time I have managed to improve flexibility to about 110 degrees, but I can't run and can only comfortably walk the hills for a couple of hours or so. I took up cycling instead and initially struggled to ride my bike with limited bend to the knee, so I now use what's called a 'swing crank' which means when the pedal is at its highest I don't need to bend my knee anything like I do on my 'good' right knee. It's a clever little device and I don't really notice its there, as the pedalling just feels 'normal'.

In view of my poor outcome on the left knee I'm holding off getting the right one done, I daren't risk having both wrecked.

If I remember correctly, the surgeon said chances of a satisfactory outcome were something like 9 out of 10 which I was happy with. However that means 10% of people don't get a satisfactory outcome, which is actually quite a lot of operations over a year where patients are left possibly worse off than before. My advice would be delay the op as long as you possibly can. 

Good luck if you decide to go ahead with the op, I'm sure you'll be one of the 90%.

In reply to Colin Scotchford:

Thanks. That sounds worth looking in to.

In reply to BobtheBagger:

That sounds like you were badly advised. I wonder how much that affected the outcome.

110 doesn't sound too bad. What is stopping you walking? Pain? Having to take up cycling would be an appalling prospect for me - I hate it!

Thanks. Sorry it hasn't worked out for you.

In reply to Robert Durran:

Nothing useful to add I'm afraid - but I just want to wish you well.