Creaking at 6 months post TKR.

[robert johnson]

Hi Everybody,

I found this site by googling "creaking noise coming from my TKR". I'm glad I found it. Let me give you a quick synopsis of my situation.

On Feb 28th I had a left TKR with Stryker Triathalon. Right from the first day I got out of bed, something felt wrong. It felt like I had a clunk-clunk on every step I took, but couldn't really be sure of anything. How would I know what it's supposed to be like. I started PT right away and was a model student, with perfect ROM right from the beginning. After the first month, I still had some pain, and still had the clunk-clunk, and was still taking oxy and/or hydrocodone. I tried telling the doctor about it (the clunk-clunk), but couldn't really convince them that there was anything wrong. I saw him again two weeks later, and he heard the clunk for himself. He agreed it shouldn't be like that. Later that night he called me on the phone (yes my doctor called me!). He told me to concentrate on hamstring exercises. He reviewed my operative notes with a colleague and said there was nothing obviously wrong, so concentrate on trying to build up my strength. I said ok.

After 2 months I got off pain pills, finished up with PT, and it was just me and the clunk-clunk. Within a week I was convinced that the clunking was wrong. It drove me mad. I was afraid something was going to break. I even recorded it on my cell phone. I went back to the doctor at 10 weeks post-op, and told him I was pretty sure something was wrong. This couldn't be right. He examined me and agreed there was more play then desirable, and said my tendons may have relaxed some since surgery (yeah like since the minute the nerve block wore off). He asked me a question: Does it just bother you hearing the sound, or what? To which I answered: I'm afraid it's going to break, and once in a while the clunk is extremely painful. He said in that case let's go back in, and we setup another operation for May 28th. The plan was to (a) replace the poly liner with a thicker one, (b) remotely possible revision.

The second operation, all he did was replace the poly liner from 13mm to 16mm. When I was in post op recovery the PA came in and agreed with me that it was the right thing to do. There was too much slop in there. I asked her if I was right in insisting, and she said yes. The doctor later agreed.

Back to another round of 8 weeks of PT. Perfect ROM again. Some clicking and clunking, but not anywhere near as bad. Basically, it was a success...except...

The second time around my knee feels different. It feels like it's taped up, even when it's not. It's very susceptible to swelling and injury. And if I do too much it's like 2 weeks post-op again. At 4 months post-op (2nd op), the doctor told me to lay off the resistive exercises and "try and get this behind me". I took his advice. Also, I was recently told to use neoprene sleeves if I have any problems, which I do at times.

So, I'm doing ok at 6 months post 2nd op, sort of, but I have this incessant "creaking" noise. I don't like it. It sounds like "friction" noises to me. Someone named "Crystal" on another thread called it "Velcro" noises, and I yelled out to my wife, "check this out!" Yes that's it, it's a Velcro noise! My wife agrees!

Can someone please tell me what it is? They told me early on it's scar tissue, but really I have to tell you I'm not so sure I believe that. Has anyone ever "proved" it's scar tissue? Does anyone really know the mechanism of the noise? Is the scar tissue in the area inside the joint? Where is this alleged scar tissue?

I apologize if I'm sounding too demanding. I'm just trying to be as exact as possible in explaining my thinking. I've been through a tough 9 months, and I would really appreciate any help I can get.

Oh yeah, and I don't take anything for pain anymore, other than an occasional tylenol or advil.

Thanks in advance,
robert johnson :jump:

 

[Josephine]

Hi there, Robert, and welcome to BoneSmart. Glad to have you aboard!

Noises in joint replacements is a big issue for some people but research has shown that it happens in people who have got really good placement of implants. There's no real evidence as to what causes these noises in these cases. There is a forum for Noise Issues and although it seems to be more about hips, the discussions do apply to knees as well.

The creaking very often is scar tissue but this isn't anything abnormal. Anywhere tissues are divided, split apart or cut, it will be joined back together by fibrous tissue which either gets shrunk or absorbed or remains thick - these are what scars are. When the joint moves and applies pressure to this scar tissue, it creaks and makes velcro like noises. As long as the joint is moving okay then there's nothing to worry about. It generally abates over time, could take anything up to a year.

So I would advise you to try not to let it get to you. So long as you have good action in your knee, this is not going to be a problem and it will either go away or you will learn not to notice it so much.

 

[Jamie]

Hi, Robert! Welcome to BoneSmart. Josephine covered everything I might have said. I can tell you that we have had quite a number of folks with noise issues on BoneSmart and the noises do quiet down given some time....not just a few weeks, though. Be prepared that it could take months to improve.

This is a major surgical procedure and things are pretty much disrupted inside your knee. It takes the soft tissues a while to settle down and then strengthen. You'll need to work on the strengthening at a gentle pace and then just try to be patient.

 

[robert johnson]

Hi Josephine-Hi Jamie,

Thank you very much for your answers. That's very helpful, and very convincing. Seems like this is a familiar subject.

I'd like to ask you a couple more questions, if I might.

Is it believed that the mechanism of the noise is the stretching out of the scar tissue? In other words (to illustrate), supposing I had a 5 inch long by 1/4 inch piece of scar tissue in my hands. Something that was sort of in the shape of a small piece of rope (I'm generalizing here, of course), and I pulled it out so that it was stretched to 6 inches or more. Is the idea that the simple act of stretching scar tissue can produce these noises? Or is the issue more of a "pulling off" of whatever the scar tissue is stuck to, sort of like pulling Velcro off of it's attaching surface, implying that the scar tissue is "sticky"?

I realize I may be getting carried away, but I'm very curious how much is known about this whole thing.

My other question is: would I get anywhere if I tried getting answers to these kinds of questions from a Stryker Representative directly? Do you know if anybody has tried that? I'm usually pretty good at that sort of thing after years of a high profile technology career. I'm wondering though, if they might not want to go down the medical path with a patient, even though I'm really asking somewhat of a technical question. I want to rule out that the noise is coming from the poly liner friction with the femoral component.

I think the answers you gave me takes me most of the way towards forgetting about this, and if I could get someone to tell me: there's no way the titanium on poly is making that noise, that would take me the rest of the way.

My last question is, assuming it's scar tissue, do you recommend "working" it more rather than less? Like stationary bicycling "in spite of" the noise on the theory that it would make the scar tissue more pliable? Or do I run the risk of irritating the scar more by over working it, causing more problems?

Thanks again for your help.
robert :catkiss:

 

[Jamie]

Jo will have to say for sure, as she is the medical expert....but I would think you could get a sound from either a stretching or tearing apart of tissues. It just depends on what is going on inside. But all of it is a normal part of the healing process, so I don't think it should cause you any worry.

As for getting information about this from a Stryker rep, I doubt that. I would imagine they tend to be a bit "politically correct" in any discussion with a patient, given the state of litigation in this country. The components don't make noise when in motion...that's the whole point of the design....no friction.

Now, as for the exercise....I would do things like a stationary bike as much as you can comfortably do. It will not serve you well to push too hard and cause swelling. That's what you want to avoid. But any exercise you can do to strengthen your muscles should be a benefit as long as they do not result in pain during the exercise or in the day or so following.

 

[Josephine]

Is it believed that the mechanism of the noise is the stretching out of the scar tissue? In other words (to illustrate), supposing I had a 5 inch long by 1/4 inch piece of scar tissue in my hands. Something that was sort of in the shape of a small piece of rope (I'm generalizing here, of course), and I pulled it out so that it was stretched to 6 inches or more. Is the idea that the simple act of stretching scar tissue can produce these noises? Or is the issue more of a "pulling off" of whatever the scar tissue is stuck to, sort of like pulling Velcro off of it's attaching surface, implying that the scar tissue is "sticky"?

I realize I may be getting carried away, but I'm very curious how much is known about this whole thing.

Well, being curious is allowed! And I can understand why you would be. This is more a simple case of just stretching the scar tissue like elastic is stretched. And it creaks when it is stretched. There's nothing more mysterious to it than that. As long as it isn't actually causing you any pain, there's no problem about it.

My other question is: would I get anywhere if I tried getting answers to these kinds of questions from a Stryker Representative directly?

I want to rule out that the noise is coming from the poly liner friction with the femoral component. I think the answers you gave me takes me most of the way towards forgetting about this, and if I could get someone to tell me: there's no way the titanium on poly is making that noise, that would take me the rest of the way.

I doubt a rep would actually know this kind of thing. It's not really in their 'patch', so to speak. In my conversations with reps, they could tell me about the technical, metallurgical side of things, I told them about the physiological side!

I can promise you that the noise is not coming from the plastic/metal bearing. It's much too highly polished for that to happen.

My last question is, assuming it's scar tissue, do you recommend "working" it more rather than less? Like stationary bicycling "in spite of" the noise on the theory that it would make the scar tissue more pliable? Or do I run the risk of irritating the scar more by over working it, causing more problems?

I don't think it would matter one way or the other, to be honest. Over time the scar tissue will age, soften and be absorbed until it's minimal, just like the scar on your skin. By the time you are about 18-24 months you will find things settling in a lot more. At that point the noise should also diminish. Healing is actually a lot more long term than we often realise.

 

[robert johnson]

And it creaks when it is stretched...
I can promise you that the noise is not coming from the plastic/metal bearing. It's much too highly polished for that to happen...
I don't think it would matter one way or the other, to be honest. Over time the scar tissue will age, soften and be absorbed until it's minimal, just like the scar on your skin. By the time you are about 18-24 months you will find things settling in a lot more...

Ok, this is really great information, and pretty much tells me all I needed to know on the subject of creaking. Thank you very much Jo! My fear of grinding away at the poly surface has been alleviated.

I do have one other question, though. All during my PT, starting back from the first operation, I often discussed with my therapist the sensation I had when walking that there was a slight risk of me overextending my knee if I wasn't careful. It's subtle, but noticeable, and it's always concerned me somewhat. I never really got any answers, other than how now that the knee has been rebuilt it seemed obvious that there would be some period of "re-learning" of all the motions in the knee.

Well about a month after PT ended after the second operation, I was at an office visit with the surgeon and he mentioned to me how his method of removing both cruciate ligaments, and using the new designs of prosthetics has drastically improved ROM compared to just 10 years ago when getting 90 deg. was considered an accomplishment.

I said, "both cruciate ligaments?! I thought only one was removed." :pzld:

He assured me both were. Later that night I Googled it and sure enough there are issues associated with loss of stability in the forward/backward direction when using this method. I actually found a formal study with diagrams, measurements, and the whole ball of wax.

So, it seems to me, that is what I've been noticing. There appears to be a price to pay for this extra ROM. I hope it turns out to not matter in the long run.

Do you have any opinion or insights into this subject of removal of both cruciate ligaments versus the method that retains them? It almost seems to me that I might have chosen the other method had I had any idea about the subject to begin with. I'm not so sure I ever had all that much ROM anyway.

 

[Martha]

Hi Robert-
I have a funny story to tell on crepitus sounds in the knee. I'm an avid bike rider and about 10 months out my knee started changing and making horrible noises. When I would go up a slight incline the knee would make such horrible loud noises that my husband riding next to me could hear it. Gave him the creeps. It continued on for many months but has finally quieted down so I can barely hear it now. Well last week on a bike ride all of the sudden everytime my knee came up it just loudly crunched. I though all no! It's back. I continue along a ways and was very unnerved by it all then I realized what was going on. Duh! I had one of those little purse kleenex packs in my pocket and the plastic cover was crunching when my leg came up. Felt very silly!
Hope you velcro goes away in time.
Martha

 

[Josephine]

Do you have any opinion or insights into this subject of removal of both cruciate ligaments versus the method that retains them? It almost seems to me that I might have chosen the other method had I had any idea about the subject to begin with. I'm not so sure I ever had all that much ROM anyway.

Well, a lot of people get a bit bent out of shape about this but it's quite simple really: if the cruciates are in good condition, then they will be preserved. However, quite a lot of the time, they are not in good condition have been subjected to the ravages of the osteo-arthritis that led them to having a TKR in the first place.

Generally speaking the surgeon can make a guesstimate on this from MRI scans or a diagnostic arthroscopy but he won't accurately know the truth of it until he opens up the joint and eyeballs it. It's generally considered to be a technical issue which the surgeon will make a choice about at the time of surgery and not something it's possible to let the patient choose.

You can see the details of it in this post.

As it happens, I also had a cruciate sacrificing knee and experience that hyper-extension you speak of. But I know it's there and happens once in a while and mostly it doesn't bother me. It's not a great deal of hyperextension, just a bit of a rocking backwards.

his method of removing both cruciate ligaments, and using the new designs of prosthetics has drastically improved ROM compared to just 10 years ago when getting 90 deg. was considered an accomplishment.

Don't know where he gets that from! We were using cruciate sacrificing/preserving knees back in 1980! And it was a knee designed by two American surgeons called J Insall and AH Burstein (hence the Insall Burstein Knee)!

And the 'getting 90* an accomplishment' takes me back to 1970 when we were using fixed hinge knees!

I'm very pleased I was able to settle your mind on the other issues. Sometimes it's a case of happening upon the right person to get such information!

 

[robert johnson]

It continued on for many months but has finally quieted down so I can barely hear it now.

Hi Martha,
Thanks for the insight and the funny story. Sounds like something I'd do. My wife accuses me of going from one catastrophe to another. It's good to hear from someone whose noises went mostly away in time.

Robert

 

[robert johnson]

As it happens, I also had a cruciate sacrificing knee and experience that hyper-extension you speak of. But I know it's there and happens once in a while and mostly it doesn't bother me. It's not a great deal of hyperextension, just a bit of a rocking backwards.

Yes that's it exactly. It's not that big a deal, but it is something I feel I have to be aware of.

Don't know where he gets that from! We were using cruciate sacrificing/preserving knees back in 1980! And it was a knee designed by two American surgeons called J Insall and AH Burstein (hence the Insall Burstein Knee)!
And the 'getting 90* an accomplishment' takes me back to 1970 when we were using fixed hinge knees!

I could be confusing issues. Most of the times I've talked to him I've been drugged. Also, he's been doing this since 1980 also, so there's no telling what the perspective of the story is. There was also the story I heard about the new shape of the curves in the femoral component that was supposed to drastically improve ROM. But I seem to remember him saying that when his PA came to work for him she was amazed at the ROM patients were getting and that where she worked prior, 90 was considered good. Take it with a grain of salt.

But thanks again. You've given me some really important perspective. I very much appreciate it.
robert

 

[Josephine]

Most of the times I've talked to him I've been drugged

LOL! Been there, done that! :hehe:

 

[skigirl]

Robert,

I will add a few things--I have two stryker triatheletes--and my os also revoved all the cruciate ligaments. I was bummed about my right knee---the pcl was in pretty good shape, but he explained that he felt that both knees should move in the same way.

Then, I read about someone who had torn her PCL and had to have a knee revision--that game me new thoughts on my knees. Also, I have read many studies and there seems to be the conclusion that the cruciate sacrificing knees perform exactly the same as those which retain the PCl. I have come to the conclusion that is it is a non issue--after all the ligaments are gone=---I am not going to waste my time thinking about whether that is good or bad.

Second, this summer--when my knee was 1 year old, I suddenly began to hear the velcro sound when I was biking. I freaked, of course, since I want perfection!! I reread Crystal's posts and finally went to my OS. He listened and agreed that it was some scar tissue that had grown over the metal. The sound happened when it was stretched. he told me that if the noise still bothered me a year from now, he would remove the scar tissue---oh wait, I don't really want another SURGERY!

Anyway, at first, I thought it was a BIG DEAL--but, as the summer progressed, the noise got to be less and less. I occasionally hear it now--sometimes when I plop down on a low chair---but my OS also said that many times, the body adjusts itself. The tissue will get stretched out and stop making the noise, which is pretty much what has happened.

It is weird how we react to each crunch and snap---for me, it just reminds me that I have a fake knee--and sometimes I want to forget that. Then, this horrible NOISE interfers with my life. I was also worried about the spacer and how it was wearing, but my OS reassured me that the components don't make this kind of noise.

Oh, yes, I ran into a rep while I was biking this summer. Mostly, he wanted to tell me how wonderful his "Smith and Nephew knee was. He talked alot about his wonderous knee and then he went into raptures about how wonderful my OS was--and that I was so lucky to have had HIM do the surgery. If I asked a question, he told me that my doc was the best and therefore could not have done anything wrong. you get the drift---I think you will have better luck talking to your OS. Kelly

 

[robert johnson]

--after all the ligaments are gone=---I am not going to waste my time thinking about whether that is good or bad.

Hi Kelly,

Yes, that really is the bottom line, isn't it? I thought that right after posting. It's more of an academic thing now. I was interested in relating the slight loss of stability in the forward/backward direction to the lack of cruciate ligaments, and I think Jo confirmed my suspicions.

I freaked, of course, since I want perfection!!

You and me, both. I spent most of my career in quality control (in high tech, no less) telling people what was wrong with things, so I'm having somewhat of a problem separating that out from me the patient. I don't want to go into too much detail, but I don't believe I should have had to have had two operations to get to the point I'm at now. That second operation was very hard on me.

But it really is good to hear these stories and to get this level of answers. Exact answers from people who've been through it, and around it for many years. It's great, and encouraging to hear that the noises will probably go away, or lessen. I was very concerned that it was a friction noise, and friction is never a good thing.
robert

 

[skigirl]

Robert, I agree with you that you should not have had to go through the second operation. Unfortunately, the size of the spacer is a subjective thing--the doc trys out several sizes, trying to find the one that gives you the most rom but also the most stability. My first knee felt a little "loose" to me. I talked to Dr. O-my OS and he did manipulate myleg and told me that it should be about 3 degrees of play in the knee and I have about 5 degrees. He told me that if he had gone with the larger spacer, I would have had more trouble with rom.

At first, I was a little bummed--after all, I wanted perfection--but, now, a year later, I cannot even feel the "looseness" at all. The doc pointed out that I was very strong pre op and that my muscles and ligaments are weak after surgery but that they would get stronger.---he was right, the knee is now very stable and strong.

I was impressed that both your doc and your pa admitted that the spacer was not thick enough--they were completely honest with you and although it is unfortunate that you had to have the second surgery--it was obvious that you did need to make that change. If we reject the image of the doctor as a god--we have to accept him as a human--and humans make errors. Yours was open and honest with you, let you know what the problem was and then solved the problem for you. All in all, I think you have a good doc there. I think that this recovery will go a little faster for you because you will have a stable knee.

I am sorry that you had to go through that---but glad for you that you have such a good doc. Kelly

 

[robert johnson]

I was impressed that both your doc and your pa admitted that the spacer was not thick enough--

Kelly, yes that's true...up to a point, but there's a little more to the story.

they were completely honest with you and although it is unfortunate that you had to have the second surgery--it was obvious that you did need to make that change. If we reject the image of the doctor as a god--we have to accept him as a human--and humans make errors. Yours was open and honest with you, let you know what the problem was and then solved the problem for you.

Kelly, you're interpreting this in the best light possible, and I don't blame you. I can see how you might view it that way. But that's not quite how I see it.

The way I experienced it was that it took me close to two months to break through the defenses of "oh that's normal" and "oh that's scar tissue" and "you have to expect a certain amount of noise" and so on, before I finally broke through and got the Doctor (I never succeeded with the PA) to realize my situation wasn't the "normal stuff" you expect after a TKR.

So the honest truth, and the bottom line is that if it wasn't for my pestering, they'd never have done it.

As to whether or not this solved the problem, I'd say the jury is still out. Although I do agree that the clunking is better after the second operation. But remember, it came at a cost. My knee feels different now, and bothers me in ways it never did between the first and second operations.

My honest opinion is that it is incumbent upon the doctor to get it right the first time, because there are uncertainties with any operation, and revisions are known to be less successful than original TKR's. I read papers out of medical journals on the subject, and there is much agreement on that subject.

I think something went wrong during the first operation, and the result was too thin a liner. I believe it has to do with the fact that I was under general anesthesia, and I had a very strong nerve block in my leg also. Much stronger than the second surgery, where I barely felt numb coming out of it. The first time it was numb for 2 days post op.

He told me that the joint was "tight" when he did it, and that he would never leave it loose, so that means to me that yes it seemed tight, but it really wasn't.

When I say "something went wrong", I don't necessarily believe a blatant mistake was made. I think it's more subtle than that, and that whatever went wrong is not clearly understood. I don't know if you've ever gone to topix.com but there are thousands of stories like mine.

There is more to this than meets the eye. I don't think I would do it again, unless I was incapable of walking from one room to another. I wasn't that bad before this one, and that's a mistake I made.
robert

 

[robert johnson]

Kelly, one other important point. The doctor tried to tell me that the reason why it got loose like that was because my tendons relaxed, as if it was a function of my anatomy in some way in that I have extra flexible tendons.

I find that thinking totally untenable, because if that was true, and there exists this unknown factor of tendons that might relax, with no way of knowing that ahead of time, I doubt very much this industry would have progressed to the point it did. I don't believe there would be confident people like Jo around if that was true. I think people would admit that there are "factors" that make the odds of an unsuccessful operation a little higher than it should be. Honest people would be admitting that.

So, you can see why I'm a little concerned.

 

[Josephine]

Oh, I hope I never gave you that impression, Robert, that unknown factors like ligament tensioning exist - because it's true! You might reason that it was due to your being less relaxed in one anaesthetic than another, but that's not true! When we do these procedures, it's essential that the patient is not just relaxed but paralysed.

If a general anaesthetic is given, then a paralysing agent is given too, hence the need for assisted ventilation via an endotracheal tube (or similar device). If a spinal is given, then that is part of it too - the body from the waist down is not only numb but paralysed too. You see, it's almost impossible to do these procedures if there is any active tension in the muscles or ligaments because we wouldn't be able to retract them enough to get into the joint. I've seen occasions where the muscle relaxant began to wear off and we had to stop operating until more was given. It's one reason why the surgeons prefer spinals because that doesn't happen.

So yes, it is entirely possible that whilst he gets a good fit of implants during surgery, when you wake up and start to recover, things can change somewhat. Ligaments can prove to be too tight or too slack. It's a common issue and a reason why they spend a great deal of time testing different spacers and working the knee, trying to decide which will be best, trying to envision the outcomes of each whilst making allowances for these changes one way or the other - all based upon the pre-op condition of the knee, etc., etc.

In an ideal world it certainly is incumbent upon them to get it right first time but as Kelly reminded us, they are only human and conditions aren't always ideal. This is where the practice comes in and where a surgeon who has done many hundreds of these per year get to be practised in making good judgements each and every time. Even so, the most skilled will still be caught out now and again.

Like I always say - doing violin practice a few hours each week doesn't get you a spot playing at Carnegie Hall!

 

[robert johnson]

It's one reason why the surgeons prefer spinals because that doesn't happen.

I was the last operation scheduled that day, and they told me to be there at 8am for a 10am operation. The anesthesiologist came in to visit me in pre-op and asked me all the questions.

I noticed on his sheets that they had "spinal" checked. I asked him why they were assuming a spinal, as I would prefer a general. I told him I had a spinal once and didn't like the recovery. He said, no problem, they can do a general, and then told me what you just told me. I said are you sure you don't want me to do a spinal and he said it was ok to do a general. They still do the leg block anyway.

At 10am the nurse came in and told my wife and I there was a problem with the surgery before me (a hip replacement) so I probably wasn't going to go in until about noon. Around noon they wheeled me in. I was the last operation of the day.

So what's my point? I understand that nobody is perfect. I worked for almost 20 years in a software engineering team. I once said if we were making planes instead of semiconductor equipment, all the planes would have crashed. But when I look back on this, objectively speaking, I think they left themselves open to making a mistake. All things being equal, there are things that could have been done differently. I can see it clearly now. Much more clearly now that you have told me what you told me.

Not to mention the fact that, nobody ever told me that it might not come out right the first time.

This strikes me as a clear case of where something goes wrong, but nothing is really learned from it, and there's no accountability ("my tendon relaxed!"). It's being sluffed of as a case of "my tendons relaxed." Well of course my tendons relaxed. That's inevitable. But they should relax into the correct configuration.

In recovery the PA told me she's seen about 6 cases of this (too loose) over the years she's worked there. So, maybe that means they get it right far more often than they don't. I think that's a reasonable assumption. This is an extremely active office. But when you're the one whose isn't right, it really doesn't matter all that much what the statistics are.

 

[Josephine]

I noticed on his sheets that they had "spinal" checked. I asked him why they were assuming a spinal, as I would prefer a general. I told him I had a spinal once and didn't like the recovery. He said, no problem, they can do a general, and then told me what you just told me. I said are you sure you don't want me to do a spinal and he said it was ok to do a general. They still do the leg block anyway.

This is often the case. They can switch from one to the other before the operation and it really is okay. This isn't an exact science. There are occasions where, for a number of reasons they can't do the spinal and have to revert to doing a general anyway. Plus the femoral block is done just for the patient's sake, for better post-op pain relief.

At 10am the nurse came in and told my wife and I there was a problem with the surgery before me (a hip replacement) so I probably wasn't going to go in until about noon. Around noon they wheeled me in. I was the last operation of the day.

Not an uncommon occurrence either.

So what's my point? I understand that nobody is perfect. I worked for almost 20 years in a software engineering team. I once said if we were making planes instead of semiconductor equipment, all the planes would have crashed. But when I look back on this, objectively speaking, I think they left themselves open to making a mistake. All things being equal, there are things that could have been done differently. I can see it clearly now. Much more clearly now that you have told me what you told me.

I'm not quite sure what you mean by this. Are you implying there was some medical negligence on their part? How come the 'left themselves open' to making a mistake? It's a judgement call which they are making whilst you are asleep and paralysed. The decision is based upon the depth of his previous experience and skill. I'm sure he did the best be could.

Not to mention the fact that, nobody ever told me that it might not come out right the first time.

Well they should have! In the UK (and elsewhere I am sure) there is a list of possible complications which the doctors are required, by law, to inform the patient of. These include:
- infection
- thrombo-phlebitis
- haematoma
- nerve damage from surgery, tourniquet and spinal
- paralysis from spinal
- stroke or heart attack
- death!
and
- continuing pain
- noises like squeaks or clunks
- loosening of implants
- having an unstable joint
- not being able to get good range of movement

These are all the known complications of knee replacement surgery and it is imperative that patients are informed of them before they sign a consent form. This is known as 'informed consent' and these days is a necessary requirement.

This strikes me as a clear case of where something goes wrong, but nothing is really learned from it, and there's no accountability ("my tendon relaxed!"). It's being sluffed of as a case of "my tendons relaxed." Well of course my tendons relaxed. That's inevitable. But they should relax into the correct configuration.

It would be nice if they relaxed into the correct configuration but it doesn't quite work like that. Human tissue isn't like inert materials like metal (of course, I know you know that! Bear with me!) That's what I meant when I was talking about his skill and expertise - the best anyone can expect him to do is make a judgement on how it will go, a guess if you like. That doesn't always work out as expected much less as desired.

In recovery the PA told me she's seen about 6 cases of this (too loose) over the years she's worked there. So, maybe that means they get it right far more often than they don't. I think that's a reasonable assumption.

Well, that's true but I think it was an unwise thing for her to say as I very much doubt it was a statement backed by statistical evidence. She was using a number just grabbed out of the air

when you're the one whose isn't right, it really doesn't matter all that much what the statistics are.

Well that is the bottom line, Robert. I can fully understand and empathise with your frustration and anger. It sounds good when we professionals say "it's only a 0.5% risk of *** happening" but that equates to 5 people out of every thousand and those 5 people aren't fairy dust - they're people!

I hope you've derived some more information from what I've said. Honestly, I am not trying to fluff you off - I just really want you to understand that the surgeon didn't make a mistake of medical negligence (so far as I know) but just guessed something would go one way and it went another. In other words, he had to make a decision at the time and he guessed wrong. No-one can really blame him for that. And I hate to finish it this way as it sounds like I'm belittling your situation and feelings and I'm not, but in truth, he had as much bad luck in this as you did.