Last fall, my father-in-law joined the more than 650,000 total knee replacement patients of 2013. He is a long-time golfer and had been struggling to play due to his moderate to severe knee pain for several years. Finally, the pain was too much to handle and he decided it was time for a knee replacement.
The most common reason golfers have knee replacement surgery is due to osteoarthritis. This is a mechanical condition where the “cushion” of the knee, called cartilage, wears out and the bone rubs against the bone with movement. Osteoarthritis can be very painful and highly agitated by the action of the golf swing.
Despite major advance and modern technology, Jim was one of the growing number of patients that would describe his experience as “traumatic” and “highly disappointing.” Enduring months of severe pain, a revision surgery and still being unable to return to golf after eight months, Jim is now struggling with the decision of whether or not to have his other knee replaced. Is it worth it?
Studies have shown that between 14 and 39 percent of people who have had a knee replacement are “dissatisfied” with their implant or reported “results below their expectations.” (Noble, P et al., Bourne, R et al., Scott, C et al.)
With the demand for total knee replacements expected to rise by 673 percent by the year 2030, it is highly likely that you or someone you know will soon be considering your surgical options.
Will you be able to return to an active lifestyle that includes pain free golf or will you be one of the 54,000 U.S. patients needing additional surgery for revisions?
Fortunately for us, science and technology continue to advance and we can now benefit from a major breakthrough in knee replacements. I recently had the pleasure to interview Dr. Gregory Martin. Dr. Martin is a board certified orthopaedic surgeon who specializes in hip and knee arthritis and other painful disorders and is one of a growing number of surgeons who traded in the traditional total knee protocol in favor of a fully customizable procedure through Conformis Customized Knee Replacements.
Q&A with Martin
In the past, a “custom fit knee replacement” meant that the instruments for fitting the knee were custom for the patient but that the actual knee was an off-the-shelf implant that comes in only a few different sizes. How is Conformis different?
“It’s no different than the fit of a suit coming in a variety of sizes versus the precise fit of a custom suit. Only with a suit, being off in fit by a small amount may not matter, but with an implant, precision fit is critical. People come in all different shapes and sizes and Conformis believes so should their knee implants. Conformis is different because they make customized, individually made implants along with instrumentation specifically made for the patient that helps the surgeon put the implant in correct.
Also, the knee has three parts to it and sometimes they are not all damaged. With Conformis, because a CT SCAN is taken as part of the process, if the patient is found to have damage in only one part or two parts of the knee, then a customized partial knee can be made. Partial knees have had a resurgence in popularity because of the ease of recovery and improved satisfaction.
How can custom fit components make a difference in the outcomes for patients?
Although total knee replacement helps most people, studies show as many as 1 in 5 patients remain not satisfied with their outcome after surgery. Persistent pain after surgery is a major factor in these patients. We now know that implant size plays a significant role in causing persistent pain.
Studies have shown that if an implant is too big by just 3 millimeters, it can double the risk of persistent pain after knee surgery. By making the implants fit precisely, the hope is that we will see higher satisfaction rates, which is what I am seeing in my early data.
What differences can patients expect to experience during rehabilitation?
I have seen my customized knee patients recover in about half the usual time. What I am used to seeing at three months, I now see at six weeks. The patients have less swelling, improved range of motion and function sooner. Why? Because bleeding around the knee and swelling after total knee surgery makes rehabilitation painful and difficult.
With the customized knees, the instrumentation and surgical technique is less traumatic, less bone is removed, and all of the bone that is cut is covered with implant because the fit is precise. So what we see is significantly less bleeding and swelling. Blood transfusions that are fairly common with non-customized total knees (around 10 to 20 percent in most studies) are quite rare with customized total knees (1 percent or less).
Can patients expect a difference in time in regards to returning to normal daily activities? Returning to more active activities?
Return to daily activities varies from patient to patient, but as a whole, I would say that my customized knee patients generally recover much sooner. I typically can get the customized knee patients out of the hospital either the afternoon of surgery or after one night, versus two to four nights for my non-customized knee patients. I see a lot more people doing activities that they enjoy at six weeks after surgery than I ever saw before.
One patient, who I recently saw at his six-week follow up, comes to mind. He had a non-customized knee I did a few years ago and he did well but took him at least three months to get back to a normal life. When I did his other knee with the Customized implant and saw him back at his six week follow up, he had just got back from a cruise and was dancing with his wife and happier than ever.
For partial knee patients, I have seen many golfing at four to six weeks and total knees at six to eight weeks. This level of activity would be unusual this early for my non-customized knee patients.
What are the advantages of choosing a Conformis custom knee replacement over an off-the-shelf replacement, specifically for golfers wanting to return to sport?
Although recovering quickly is important and we should always look for ways to get people better sooner, what really is more critical is the long-term outcome. Although many patients after total knee replacement are out of pain, they may not be able to do the things that they want to do like golf or other activities. They say the knee doesn’t feel right, it doesn’t feel like their knee.
The thought behind Conformis customized total knees is that by making the implant sized and shaped like the individuals own knee before it was damaged, the knee will feel more natural and allow people to resume more activities that they love to do.
Can you briefly talk about the technological advances that had to occur to allow for a process such as what Conformis is using to advance knee replacements?
Conformis was founded with the idea that modern technology and imaging techniques can be utilized to make better implants. A CT scan is taken to get precise pictures of the knee. The data in that scan is sent to the company and computer automated design (CAD) technology is used to map the knee and create an implant.
The instrumentation, which is all single use and disposable, is created on 3D printers (as opposed to traditional knee instruments which are re-used and must constantly go through re-sterilization). With Conformis, the entire kit is shipped to the hospital in a sterile box with the implant and the instruments. It is 21st Century technology at its best.
Is there anyway to know, prior to surgery, if a person is a better candidate for a custom knee (anyway to know if an off-the-shelf knee would be difficult to fit perfectly)?
We know that people come in all different shapes and sizes on the outside, and their knees look just as different on the inside. Other implant companies have realized this over the years and have created gender specific implants and have increased the number of sizes available with their non-customized knees. However, this may help fit more patients, but will never fit all patients.
Only true customized technology can achieve a perfect fit. After talking with my patients and giving them choices of implants, invariably they wish to have a customized knee. But there are some patients where a customized knee is not appropriate at this time (eg. cases with severe deformities, damage to major knee ligaments, or loss of bony landmarks which would make recreating the knee difficult).
Is there any difference in cost to the consumer when compared to traditional total knee replacement procedure?
Typically in the United States, implant costs are negotiated and covered by the hospitals or insurance companies. Generally, with the exception of any related co-pays for the CT scan required, there are no additional costs to the patient receiving a customized knee implant.
If someone was interested in having a customized knee replacement with the Conformis knee, how should they proceed?
Visit www.myconformisknee.com to learn more about the technology, hear patient’s real experiences and utilize the “find a doctor” feature to find a surgeon using the technology
If patients are interested in your service, what is the best way to contact you or your office?
My practice is in Palm Beach County, Fla., and my information can be found at www.floridajointreplacement.com
In conclusion, the overall success rate of total knee replacements are good. But in my years of physical therapy, I have experienced both the good and the bad. If you are considering a total knee replacement, we have found that the success of the surgery is largely dependent on two factors: the quality of the product and the skill of the surgeon.
As a result, the advice that I always give to golfers considering knee replacement is this:
- Visit www.myconformisknee.com to find surgeons in your area using this technology.
- Get surgeon referrals from two to three local physical therapists who treat patients recovering from total knee replacements. Physical therapists have extensive experience treating the patients of local surgeons and will know which ones have the best results.
If you have any questions or comments, please respond below and we will be happy to respond.
 Knee Replacement Statistics: http://www.healthline.com/health/total-knee-replacement-surgery/statistics-infographic
 Arthritis Related Statistics CDC: http://www.cdc.gov/arthritis/data_statistics/arthritis_related_stats.htm
The Gear Dive: Discussing the drivers of 2020 with Bryan LaRoche
In this episode of The Gear Dive, Johnny chats with his good buddy Bryan LaRoche. They chat on life and do a deep dive into the drivers of 2020.
Want more GolfWRX Radio? Check out our other shows (and the full archives for this show) below.
The Wedge Guy: The 5 indisputable rules of bunker play
I received a particularly interesting question this week from Art S., who said he has read all the tips about how to hit different sand shots, from different sand conditions, but it would be helpful to know why. Specifically, here’s what Art had to say:
“I recently found myself in a few sand traps in multiple lies and multiple degrees of wetness. I tried remembering all of the “rules” of how to stand, how much to open my club, how much weight to shift forward or back, etc. based on the Golf Channel but was hoping that you might be able to do a blog on the ‘why’ of sand play so that we can understand it rather than memorizing what to do. Is there any way you can discuss what the club is doing and why you open the club, open your stance, what you’re aiming for when you open up, and any other tips?”
Well, Art, you asked a very good question, so let’s try to cover the basics of sand play–the “geometry and physics” at work in the bunkers–and see if we can make all of this more clear for you.
First of all, I think bunkers are among the toughest of places to find your ball. We see the tour players hit these spectacular bunker shots every week, but realize that they are playing courses where the bunkers are maintained to PGA Tour standards, so they are pretty much the same every hole and every week. This helps the players to produce the “product” the tour is trying to deliver–excitement. Of course, those guys also practice bunker play every day.
All of us, on the other hand, play courses where the bunkers are different from one another. This one is a little firmer, that one a little softer. So, let me see if I can shed a little light on the “whys and wherefores” of bunker play.
The sand wedge has a sole with a downward/backward angle built into it – we call that bounce. It’s sole (no pun intended) function is to provide a measure of “rejection” force or lift when the club makes contact with the sand. The more bounce that is built into the sole of the wedge, the more this rejection force is applied. And when we open the face of the wedge, we increase the effective bounce so that this force is increased as well.
The most basic thing you have to assess when you step into a bunker is the firmness of the sand. It stands to reason that the firmer the texture, the more it will reject the digging effect of the wedge. That “rejection quotient” also determines the most desirable swing path for the shot at hand. Firmer sand will reject the club more, so you can hit the shot with a slightly more descending clubhead path. Conversely, softer or fluffier sand will provide less rejection force, so you need to hit the shot with a shallower clubhead path so that you don’t dig a trench.
So, with these basic principles at work, it makes sense to remember these “Five Indisputable Rules of Bunker Play”
- Firmer sand will provide more rejection force – open the club less and play the ball back a little to steepen the bottom of the clubhead path.
- Softer sand will provide less rejection force – open the club more and play the ball slighter further forward in your stance to create a flatter clubhead path through the impact zone.
- The ball will come out on a path roughly halfway between the alignment of your body and the direction the face is pointing – the more you open the face, the further left your body should be aligned.
- On downslope or upslope lies, try to set your body at right angles to the lie, so that your swing path can be as close to parallel with the ground as possible, so this geometry can still work. Remember that downhill slopes reduce the loft of the club and uphill slopes increase the loft.
- Most recreational golfers are going to hit better shots from the rough than the bunkers, so play away from them when possible (unless bunker play is your strength).
So, there you go, Art. I hope this gives you the basics you were seeking.
As always, I invite all of you to send in your questions to be considered for a future article. It can be about anything related to golf equipment or playing the game–just send it in. You can’t win if you don’t ask!
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