By John Hogan
At first take, getting two total knee replacements at once sounds insane. But I decided it would be best for me.
I found no relevant first-hand experience from any brave souls who actually went through bilateral total knee replacement (B-TKR), especially as it pertains to serious road cyclists. The goal of this article, then, is to share the highlights of my experience and to include advice that will make your recovery faster should you elect to have B-TKR.
First, some background on me. I have been an avid road biker for 37 years. I am a 73-year-old and did not want to waste two years recovering from two separate knee surgeries. I really dreaded getting this done, and before making the decision I tried steroid injections (great for a while), Synvisc injections (almost useless), and lost weight to reduce the load on my knees. But knee pain began to dominate my life. Walking down steps and down modest grades became very painful. I had to do something, and that something was B-TKR.
Disadvantages of B-TKR
In my opinion, B-TKR has two major disadvantages when compared with a single TKR:
1. Clotting risk is higher since two knees are being replaced during one procedure.
You can minimize the clotting risk by picking the right surgeon. Risk for clotting is highest during the tourniquet phase of the procedure. It is important to keep tourniquet time short. The surgeon I used keeps this time under 8 minutes per knee. I will give some other guidelines for picking a surgeon later in this article.
2. Recovery during the first 2 weeks is more difficult since you do not have a “good” leg for mobility and balance.
My original plan was to go home after release from the hospital and use in-home physical therapy. With a single-knee TKR, you should be able to head home in 2 days or less with no problem. At the end of my three-day hospital stay, I could handle a walker on the flats, but I was in absolutely no shape for stairs (I live in a 2-story house).
In fact, this was the low point of the entire knee replacement experience. The solution was to move directly into a skilled nursing facility with a strong physical therapy unit for a week. “Skilled nursing” sounds horrible, but trust me, if you pick the right facility, it is great. In my case I received physical therapy twice a day for seven days. That made a huge difference: at the end of my seven-day stay I was ready to go home and start out-patient physical therapy.
Important Considerations
1. Pick the best surgeon you can find. Travel if necessary. Make sure the doctor has a stellar reputation and performs bilateral knee replacements routinely. Volume is a very important indicator: the surgeon should average at least 10 replacements a week. The entire surgical team is important, as well as the hospital that manages the surgical facility. If you live in or near the Charlotte, North Carolina, area, I highly recommend Dr. John Masonis of OrthoCarolina. He is absolutely outstanding.
2. Make sure the hospital’s infection rate is super low. Infections in a replacement joint are very difficult to treat and will set you back months in recovery.
3. I am an advocate of the custom-fit replacement joint (Google “Conformis” for more information). Not only do you recover faster, but the surgeon has precise cutting guides for fitting the knee replacement to the bone. This eliminates the most common cause of replacement joint problems/failures – bad surgical fit.
4. Train for your surgery. It is a big event. Go in with strong quads (usually not a problem for a cyclist) and strong upper body. After surgery, you will be doing lots of pushing off chairs and handrails. Push-ups are an ideal upper body exercise.
5. Research skilled nursing facilities in your area. Make sure the facility has a 5-star Medicare (federal) rating. You want an excellent physical therapy unit, spotlessly clean room and, being a cyclist, good food. If you have your B-TKR done in the Charlotte area, I highly recommend Sharon Towers.
6. Once you are discharged from the nursing facility, start out-patient sports rehab. Sports physical therapists are more aggressive and they are a better match for the serious cyclist. Don’t settle for in-home therapy because they lack the equipment and cannot provide the same level of care.
Recovery Milestones
I was most interested in how long it would take to drive and, of course, get back on the bike. After just 2 weeks you start to hit milestones that make real improvements in your daily life.
- After 2 weeks I was able to transition from a walker to a cane. That is a big deal because a cane is more natural to use.
- After 3 weeks I really didn’t need a cane except where there were obstacles such as curbs and uneven surfaces.
- Pedaling with both legs was slow to happen for me. You need at least 105 degrees of bend and one knee was slower to get there. I started off pedaling one leg at a time on a stationary bike (about 2 weeks) and worked up to both legs (about 3.5 weeks).
- After 4 weeks I could drive. The hardest part for me was just getting my legs into the car; the actual driving was no problem.
- My first day out on the bike was 6 weeks, 5 days after surgery. It was just a 5.4-mile ride in the neighborhood at a blazing 15.4 mph average, but in spite of that, it was a great day. No joint pain, but my quads were weak from atrophy.
- Improvements happen quickly once you get back on the bike. After two weeks I slowly increased my distance up to 13 miles and average speed has improved to 17.6 mph. Nothing to brag about, but I am just 8 weeks, 5 days post-surgery. I anticipated more like 12 weeks to reach this point.
Bottom Line
The first two weeks of bilateral TKR recovery are the most difficult, but it was not as bad as I anticipated. My guess is that after two to three weeks, there is no big difference in recovering from a bilateral total knee replacement versus a single total knee replacement. Also, pain is pain. You can only hurt so much, so why not get it over with in one shot?
That said, is bilateral knee surgery the best choice for everyone?
No, of course not. You need to be in good physical condition with no serious risk factors (diabetes, etc.) and atthe proper weight. Fortunately, most of you reading RBR Newsletter with two bad knees are in good shape and would be good candidates for bilateral knee surgery.
I went into this very prepared except for anticipating the need for a one-week stay in a rehab facility. If you do elect bilateral knee surgery, I hope my sharing some of my experience will help you sail through.
Very insightful. I hope I can put it off until age 73.
Great advice. I’m almost six years post B-TKR (surgery at the age of 58) and it was a life changing experience. If you need it, and your surgeon agrees (most patients don’t qualify for various reasons) I highly recommend it for all of the reasons above. I actually did it just before Christmas knowing that work would be slow so I recuperated and had PT at home. I was back at the gym on March 1 and fully and absolutely functional…and pain free.
I just had one knee done and I will agree the CONFORMIS knee is the latest in technology and my recovery has been nothing short of a miracle, http://www.conformis.com/
I’m 77 and had both knees done almost 3 years ago. I had reached the point where the range of motion in one knee was such that I could no longer get around on a pedal stroke and hadn’t been able to run in about a year. I chose to have them done 5 weeks apart to overlap the recovery periods on the two. Both times I was out of the hospital on a cane in 2 days. I think not doing them simultaneously was a good decision for me — I live alone and don’t know how I would have gotten up after floor exercises with both of them replaced at the same time! Now, 3 years out, I am doing everything that I was a year before surgery, including running 4-6 miles two or three times a week. I have major points of advice: 1) Sooner rather than later — I was experiencing muscle atrophy in my worst leg and would have been ahead of the game pulling the trigger a year earlier. 2) Work like heck on the PT — the range of motion you recover after a month is what you got for the duration! Bite the bullet and get it done!
I enjoyed your article since I had both knees replace only 5 weeks ago here in San Diego. I’m 72, and have been a bike rider for about 12 years. My recovery has gone quite well. I was walking without a walker in 10 days, and driving my truck–the easiest vehicle to get into–in two weeks. Just before the 5 week mark, the outpatient therapist cancelled all my appointments and “graduated me” when I was bending my knees at 135 degrees each. My surgeon cleared me to get back on my bicycle at 4 weeks, and I have ridden several times since. Like you, my distance and speed have been pretty limited–only 10 miles at about 15 mph. I agree that your physical fitness going into the surgery is very important. My internist told me not to wait too long, because your recovery will be much longer if you wait until your knee problems have impacted your leg muscle strength.Finally, I’d like to add that at this stage, I’m still having trouble sleeping because of intermittent leg pains through the night. My surgeon says that’s typical for the first six weeks.
Thanks for sharing. As someone who works in the industry (though not a physician) I found the article touched all the right points.
Thx very much for your story. I’m a 70 year old roadie and Mtber who is doing the double this winter, and I’m scared shitless. Your story and the comments are very reassuring.
I have a question. Did your surgeon cut the quad tendon? I had bilateral TKR surgery about 7 years and despite being in fairly good shape going in the recovery was slow and the quad tendon was cut. I was surprised to read that you were back on the bike so fast. I know there have been improvements in the procedure and not cutting the quad tendon greatly speeds recovery. Thanks.
Thank you it’s very helpful to read your experiences. I’d like to know more about the operative approach your surgeons used – spare the quad, cruciate and other manufacturers readers have had installed
Hey John, thanks for sharing your B-TKR experience,
I had B-TKR this past July 24 and can confirm all the advise you shared is spot on. One consideration I’d second is the importance of finding a sports physical therapist and also someone with strong experience working with B-TKR patients. I owe so much to my PT for getting my range of motion and strength back as quickly he did. Tomorrow with be my three month anniversary and I’m back walking a couple miles a day, dealing with subway stairs and back on my bike riding the mean streets of New York City.
Another important consideration is the importance of keeping swelling down by religiously icing and elevating the knees as long as your doctor and physical therapist recommend. My team suggested renting an icing machine called Game Ready that made icing so easy and effective. It had a wrapping mechanism that surrounded each knee while applying pressure and continually pumping ice cold water around the joints.
Thanks again to John and all others who share their experience.
I am 60 years old. I have had B-TKR just about 2 years ago, in March. It took me some time to gain mobility since I experienced post surgery problems with the blood pressure, Nevertheless I would say it took me about 3 months (including physio) when I became somewhat active, getting back to golfing and visiting gym. I used to ride the bikes in the past, so that part was always easy and natural to me. I started to be more aggressive on bike around 6 months after surgery. However I do only stationary (Peleton style) bike , never go outside, fearing the consequences of the fall. Presently I can get as fast as 20+ mph on the shorter tracks (up to 7-8 miles) but for longer tracks I just keep it around 18+ mph. The longest non-stop stationary “distance” I have ridden was around 35 miles. So that is all positive.
Now, negative parts. I tend to have knee swellings after biking, particularly one knee is more prone to it than other. Depending on the amount of effort caused by simulated inclines (can be up to 35%) I feel clicking in one of my knees as well. I have not attempted running since my surgery. It can be all mental but simply I just do not trust myself.
All in all, yes I am painless, and yes I can do many different activities that I stopped doing before surgery but I do not feel I am anywhere close to 100% of my “younger years” condition. So questions for my fellow TKR “survivors”. Do you experience any side effects when you engaged in physical activities? Are those swellings and clicking sensations normal?
It took me (59) four months before getting back on the bike, and once I did I still had swelling. No pain,but definitely swelling if I rode longer than 20 miles. I don’t have any clicking sounds but the joint tends to swell and get warm. My PT tells me, “Be a tortoise, not a hare” when it comes to post op training. Hard for me to do, but I think it’s smart. Not everyone recoups at the same rate.
Thanx for the information. My doctor refused to do both knees at once, and i am grateful for that. With a leg to stand on, so to speak, i was home the day after surgery. PT came to the house twice a week for 3 weeks, then I went to a facility twice a week for 5 weeks. I was diligent in every exercise they gave me; off the walker and hiking poles after just a week. But the quad took a while to get back to full strength. I waited until i could bike strongly on the stationary bike for an hour before attempting a “real” ride, which was at 7 weeks. 10 miles at 10 mph. I usually do 20-25 @ 13-14 mph, so it wasn’t a bad start. Walking, for me, is alot harder, but i can do 2-3 miles at about 20 minutes a mile. But the swelling and stiffness comes back worse than on the bike. Doc says that could take a year to resolve itself.
Seven months ago I had the robotic B-TKR with a great surgeon, it was life changing. Twelve weeks in I had to have manipulation because of keloids, but I knew there was a chance because my mother had the same issue. Afterwards, the bending progressed much better. I also had had my hip replaced 8 months earlier because of an earlier bike fall. Today I am going to try to ride my road bike again, but falling has been my greatest fear. I am even thing about getting a different style bike, any advice?
Many years ago had back problems, bought a Recumbent road as offen as my back pains reoccurred. Then started working stomach muscles for the last 20 years. No more back pain and now working on scar tissue both knees replaced this last year.
Thank you so much for your response. I felt that I was giving in by not using my road bike, but honestly I have a fear of falling now. I am going this weekend to look for a new bike.
I fell when I tried to get back on my road bike. I sold it immediately. I now have a trek fx3 and absolutely love it.
It took me (59) four months before getting back on the bike, and once I did I still had swelling. No pain,but definitely swelling if I rode longer than 20 miles. I don’t have any clicking sounds but the joint tends to swell and get warm. My PT tells me, “Be a tortoise, not a hare” when it comes to post op training. Hard for me to do, but I think it’s smart. Not everyone recoups at the same rate.
Might try a small hub motor 500/250 watt/58 volt on front wheel. On front wheel to allow rear wheel gears in tact. Battery size depends on lenth of rides.
Thanks a bunch, both knees replaced 7 months between opperations. I’m a fit 71 year old did 8 day 580 mile ride at 58 and again at 60 and road mosts days for 40 years. Looking forward to doing 100 miles again. Currently doing up to 20 miles. I’m planning on wearing my body out rather than rusting out. Durring this time of covid-19 there’s not much else to do.
I ride a Recumbent, this style puts the heavy part of you to body closer to the ground if you do fall.
I am 65 and just told I need TKR. I thank you for all the hints and hacks. Summer in Florida is miserable for biking so I may schedule during summer. . Building up the quads sounds very important. Wonder if I could work with sports PT before surgery?
Post opp for right knee one year and 1 year 10 months for the left knee. My biggest thing to work through was the scar tissue on the front of knees where the large cuts are made. as of today feeling very good, I do now ride a long recumbent that I have installed a hub motor to front wheel. this gives me additional confidence when the occasional close call happens. A couple of months before my second surgery I took spill onto the pavement and the shorter fall helped a bit I feel. My hub motor helps pushing off.
Post opp for right knee one year and 1 year 10 months for the left knee. My biggest thing to work through was the scar tissue on the front of knees where the large cuts are made. as of today feeling very good, I do now ride a long recumbent that I have installed a hub motor to front wheel. this gives me additional confidence when the occasional close call happens. A couple of months before my second surgery I took spill onto the pavement and the shorter fall helped a bit I feel. My hub motor helps pushing off.
I’ll be 72 in August