TKR Accuracy of 3-part bone scan and CT Spect 2.5 years post TKA?

[HopefulRunner]

Please Help!
I'm a 50-yr-old female, a former runner, in good shape. History of 2 ACL reconstructions on the left knee from soccer injuries when I was younger. But have hiked, run, and been athletic for years since then with very few issues. Was out running in Feb 2021 and suddenly stopped in my tracks due to sharp knee pain. MRI showed bone on bone but not bad enough yet for TKR. Rec'd cortisone injection. Within 48-hrs, I stepped off my front porch and my knee popped. Severe pain and couldn't walk. Turns out to be a meniscus root tear (rare) which it devastating to runners and really anyone who is active. Long story short, my knee went downhill fast.

Ended up having it scoped in April and then total TKR in July 2021 here in Ohio. Chose a reputable surgeon for the TKR who does a lot of these procedures. However, I'm now 1-yr post op and the knee is not better. Consistent swelling and pain. This subsides (mostly) if I get a cortisone shot or lots of anti-inflammatory meds. But once I stop the drugs, the pain and swelling immediately is back.

The range of motion is good, I've worked hard to rehab but limited at times due to pain/swelling. Ride the Peloton bike and walk. But have pain EVERY DAY. Some days are worse than others where I can hardly walk or bend my knee and feel like I need a pain pill. Just being on it for an hour or two is problematic. Have tried taking it easy for a few weeks, etc., but NOTHING helps long term.

Got a second opinion in March. Doc says the knee feels tight and that "maybe" the spacer is a bit too thick. But otherwise, the implant is placed properly, etc. MRI and X-rays are all good. Doc who performed my surgery ran tests for infection, all negative. He disagrees the spacer is too thick and says he's never had to replace one in his 30 years, blah blah blah. LOL. He's now consulting with another doc in his practice to review my case.

I am at my wits end. There has to be a logical reason as to why I'm not improving. Seriously, zero improvement in the last 6 months. I don't know where to turn at this point. Have had pain fairly consistently on the medial side near the tibia where the screw was for my ACL surgery. Also some random lower leg pain near lateral side of shin on occasion...kind of throbbing (not while working out). Living the rest of my life with my knee like this is NOT an option. Willing to travel anywhere in the U.S. to see another surgeon but don't know who is good with revisions etc. (can't fathom having another surgery, but something clearly isn't right). Open to suggestions, surgeon recommendations, etc. PLEASE HELP! Thank you!!

 

[ski_bum]

but something clearly isn't right). Open to suggestions, surgeon recommendations, etc. PLEASE HELP! Thank you!!

You have wrote most of my story. Regret having second knee surgery after first knee is no better after 13 months.
Wishing you the best.

 

[Roy Gardiner]

to BoneSmart.

First, general background reading. Then some specific answers.

Knee Recovery: The Guidelines

We are all different, as are the approaches to recovery. The key is, “Find what works for YOU.“ Your doctor(s), physiotherapist(s) and BoneSmart will offer advice and are there to help. The advice may vary, but YOU are the final judge as to the recovery approach you choose.

1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary

2. Control discomfort:

rest​

elevate​

ice​

take your pain meds by prescription schedule (not when pain starts!)​

don't overwork.​

3. Do what you want to do BUT

a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​

b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

the BoneSmart view on exercise​

BoneSmart philosophy for sensible post op therapy​

5. At week 4 and after you should follow this

Activity progression for TKRs​

6. Access these pages on the website

Oral And Intravenous Pain Medications​

Wound Care In Hospital​

The Recovery articles:

The importance of managing pain after a TKR and the pain chart​

Swollen and stiff knee: what causes it?​

Energy drain for TKRs​

Elevation is the key​

Ice to control pain and swelling​

Heel slides and how to do them properly​

Chart representation of TKR recovery​

Healing: how long does it take?​

Post op blues is a reality - be prepared for it​

Sleep deprivation is pretty much inevitable - but what causes it?​

There are also some cautionary articles here

Myth busting: no pain, no gain​

Myth busting: the "window of opportunity" in TKR​

Myth busting: on getting addicted to pain meds​

We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.

 

[sistersinhim]

I will ask @Jamie to help you look for a revision specialist. Something is certainly not right with you. If it's just a spacer exchange, that would certainly be a blessing.

What was the exact date of your tkr and which knee was it? Have you had any other surgeries on it? We will add that date to your signature. Knowing the date will help us to better advise you. Was your PT gentle or aggressive?

Many knees take more than a year to heal. Yours might be one of them. You might have to back off on your activities for a few months or more to let that knee calm down. I hope you see relief soon.

 

[WFD]

@HopefulRunner , I see you are in Ohio. In Cleveland (admittedly a four hour drive) is the Noyes Knee Institute. They are reputed to be one of the top two knee clinics in the country (Steadman Clinic in Vail, CO being the other one).

They only do knees and deal with some of the most difficult cases. If I were you, that is where I would go. Maybe see if they will do a Zoom call with you?

Good luck.

 

[Roy Gardiner]

However, I'm now 1-yr post op and the knee is absolutely no better. Tons of swelling and pain

I've worked hard to rehab but limited at times due to pain/swelling. Ride the Peloton bike and walk. But have pain EVERY DAY

I agree that you should find the best revision specialist you can, one with no connection to any of the people you are already seeing.

At the risk of victim blaming, I want to ask if you've been overdoing things? You are athletic, and athletes work through pain. If you've been doing this for a year, you may not have allowed your knee just to heal. Have you tried backing right off and doing nothing but the minimum for daily life?

 

[kneeper]

^true. Sometimes people do aggressive PT or jump back in to their normal pre-op exercise regime prematurely and wind up with some soft tissue inflammation/irritation. The implant is fine but they have other issues.

I'm not athletic, but I had a PT with my first knee that pushed me to do some things I wasn't ready for and I wound up with tendonitis. The implant was fine, but I had to back off of activities to let the tendon heal.

 

[HopefulRunner]

I will ask @Jamie to help you look for a revision specialist. Something is certainly not right with you. If it's just a spacer exchange, that would certainly be a blessing.

What was the exact date of your tkr and which knee was it? Have you had any other surgeries on it? We will add that date to your signature. Knowing the date will help us to better advise you. Was your PT gentle or aggressive?

Many knees take more than a year to heal. Yours might be one of them. You might have to back off on your activities for a few months or more to let that knee calm down. I hope you see relief soon.

Hi and thank u. Really appreciate the help. My surgery was 7/19/21.
PT was not aggressive since I was hurting and had a recent prior arthroscopic surgery back in April 2021. I knew going in that my situation was not the norm and that it would take longer. But after a year and really no improvement these past 6-months, I’m at a loss. I’ve tried backing off activities, giving it two weeks rest, stopping strength training, PT etc off and on over the last year to see if anything would help. Yes, giving it a rest helps sometimes but never completely stops the pain. Sometimes it actually feels worse/stiff when I’m not doing anything. There are days that it hurts so bad that I do nothing…especially if I had done heavier resistance on the bike or did a lot of walking. My gut feeling is that something isn’t right. Still holding out a very small glimmer of hope but if I haven’t turned a corner at this point, I don’t know that it’s going to happen. Either way, would not do any sort of surgery again until 18-24 months. I’d probably give it 2-years unless the docs figure out the issue prior to that.

 

[HopefulRunner]

However, I'm now 1-yr post op and the knee is absolutely no better. Tons of swelling and pain

I've worked hard to rehab but limited at times due to pain/swelling. Ride the Peloton bike and walk. But have pain EVERY DAY

I agree that you should find the best revision specialist you can, one with no connection to any of the people you are already seeing.

At the risk of victim blaming, I want to ask if you've been overdoing things? You are athletic, and athletes work through pain. If you've been doing this for a year, you may not have allowed your knee just to heal. Have you tried backing right off and doing nothing but the minimum for daily life?

@HopefulRunner , I see you are in Ohio. In Cleveland (admittedly a four hour drive) is the Noyes Knee Institute. They are reputed to be one of the top two knee clinics in the country (Steadman Clinic in Vail, CO being the other one).

They only do knees and deal with some of the most difficult cases. If I were you, that is where I would go. Maybe see if they will do a Zoom call with you?

Good luck.

Thanks for responding. Noyes Knee Institute is here in Cincinnati. Is it possibly a different one in Cleveland? Dr. Noyes is pretty old and not sure he’s even operating anymore. Been around forever but has done a lot of research, has good reputation but fairly certain he doesn’t do joint replacements.

 

[Jockette]

History of 2 ACL reconstructions on the left knee from soccer injuries when I was younger.

Can you give us the year you had these done, we’d like to add that to your signature.

I hope you can find some help!

 

[Roy Gardiner]

Sorry to be negative, but I still think the best guess is that you are overdoing things.

I’ve tried backing off activities, giving it two weeks rest, stopping strength training, PT etc off and on over the last year to see if anything would help. Yes, giving it a rest helps sometimes but never completely stops the pain.

So backing off does work to an extent, that's good

Sometimes it actually feels worse/stiff when I’m not doing anything.

Again, to be expected if you do absolutely nothing. Gentle stretches - uncomfortable but not painful - would help with that. See below about using the bike.

There are days that it hurts so bad that I do nothing…especially if I had done heavier resistance on the bike or did a lot of walking.

Your knee is telling you. You work hard, the next day it hurts. It's telling you not to do it.

My opinion (please note I am in no way a qualified physiotherapist I've just been around BoneSmart for a long time) is that you are trying to train before healing is complete and are thus preventing healing from progressing, and are stuck in a vicious circle.

Training hurts, and makes you stronger. I works on muscles, it does NOT work on soft tissue. Tennis elbow, for example, cannot be cured by training; training makes it worse.

You can of course train upper body (e.g. weights) but you must now listen to your knee. If your pain is worse the day after doing something, don't do it again.

Don't walk too far.

Don't do resistance training on the bike, but use it as a ROM exercise

• Set the bike to zero resistance
• Set the saddle low enough so that a single rotation is a challenge; difficult but not painful. When a rotation becomes easy right from the start, lower the saddle a max of 1cm.
• Gently turn the pedals, through discomfort but without pain.
• Continue until the knee is 'warmed up' and the rotation is now easy, or for 2 minutes, whichever is the shorter time.
• Repeat several/many times a day, but don't go mad. Diminishing returns will apply; my guess is that half a dozen reps would be enough
• Do not pedal fast or for more than 2 minutes, this is a stretching exercise, not training.
• And if you get any pain or swelling in the 24 hours after doing this, cut it down until you don't

Here is a bit more chat and some pix and how 'healing' and 'training' are different

 

[WFD]

You’re right, Noyes is in Cincinnati. I had the two cities mixed up in my head.

 

[Tower6brkrs]

has pool therapy helped at all? But if its not a ROM issue, maybe it wouldn't. scar tissue? Your an athlete and have definitely gone through big surgeries/ recoveries (ACL/TKR) . Curious if you have seen an OS that routinely treats professional athletes/ team surgeon etc? Some would argue thats a dumb comment & makes no difference in quality of care whatsoever, but there is a reason athletes often go to the same orthopedic groups. sorry your in pain, just throwing out Ideas.

 

[BTKRmarch11]

I have a similar situation, except I am 2 years and 5 months post a Bilateral TKA. I have the same condition in both knees. My co diction is categorized as Instability. Some of it due to poor surgery performed, like less than most ideal bone cuts and placement of the prosthetics and thickness size of the spacer. The other part due to ligaments not functioning adequately, such as PCL and LCL. My MCL is good.
I will be having the first revision surgery on August 5th, 2022, the right knee. The left knee for later.
To control my pain and function, I wear hinged braces on both knees. I have bought several braces over the past two and half years. The DonJoy A 22 and Defiance are very good. They allow me to function and have less pain. If I take anti inflammatory medication, I have less pain, but I can’t take so much medication everyday.
You’re condition could be due to Instability. Prior surgeries of the knee have some contributing effect as well. The type of prosthetic in my knees is Cruciate Retaining type. In the revision surgery, they will replace it with Posterior Stabilized type with added spacer constraint. At least that is the plan.

 

[karenl]

I am at my wits end. There has to be a logical reason as to why I'm not improving.

Hello, I am six months. Still pain and life not back to normsl. I just started rehab again, my quad muscle super tight so hence the pain. Please the cortisone shots eat all and any bone and just makes thing worse. I use ache away oil with cbd made by a herbalist here in Maine. That does help. It is a long road for sure.

 

[Axx72]

As an athlete, I feel your pain. Taking time away from what we love to do is difficult at best. I, for one, am a permanent member of the ODIC.(over-do-it-club). Working through it, staying positive and listening to our bodies is all we really have. I am sorry u are having such a rough recovery. Either way, don’t give up. You will get there!

 

[Peter Mac]

@HopefulRunner , I see you are in Ohio. In Cleveland (admittedly a four hour drive) is the Noyes Knee Institute. They are reputed to be one of the top two knee clinics in the country (Steadman Clinic in Vail, CO being the other one).

Granted, it was 18 years ago, but my experience at the Steadman clinic was god-awful.
I could write dozens of pages about what happened, but I'd rather focus on positive energy and move forward. I'm not sure if I'm allowed to discuss my Dr. Steadman story on these forums anyway.

I did see you only mentioned Steadman as a side note and you did recommend Noyes Knee. However, choosing the Steadman clinic was one of the biggest mistakes of my life.

 

[LaJudes]

I too had stiffness pain and heat in my 2018 TKR , was treated for the past year for infection to no avail , finally had the 2 stage revision surgery and now at 7 weeks out from the second surgery , l am so amazed ! No pain , knee bends easily , no stiffness , l can just get up and go ! And I had no PT . It’s all due to the “ hinged “ knee replacement that l was given ! Didn’t know l was getting that till surgery was done . Apparently they use it for knee replacement on people who have had infection or have unstable knees . Anyway it’s so different than my original TKR in2018 , which never did settle down and just kept getting worse .

 

[ChillTime]

@HopefulRunner, how are you doing? We have somewhat similar experiences in that we are both athletes (although I am older and stopped running some time ago) and have had a TKR with continual pain. My pain at 7 months (28 weeks completed) has lessened a little, but not much. I do not have swelling. I am very limited with my activities. I see my doctor next week for evaluation. Please let me know if you have made any progress or what your current plans are. Take care!

 

[HopefulRunner]

I have a similar situation, except I am 2 years and 5 months post a Bilateral TKA. I have the same condition in both knees. My co diction is categorized as Instability. Some of it due to poor surgery performed, like less than most ideal bone cuts and placement of the prosthetics and thickness size of the spacer. The other part due to ligaments not functioning adequately, such as PCL and LCL. My MCL is good.
I will be having the first revision surgery on August 5th, 2022, the right knee. The left knee for later.
To control my pain and function, I wear hinged braces on both knees. I have bought several braces over the past two and half years. The DonJoy A 22 and Defiance are very good. They allow me to function and have less pain. If I take anti inflammatory medication, I have less pain, but I can’t take so much medication everyday.
You’re condition could be due to Instability. Prior surgeries of the knee have some contributing effect as well. The type of prosthetic in my knees is Cruciate Retaining type. In the revision surgery, they will replace it with Posterior Stabilized type with added spacer constraint. At least that is the plan.

Thanks for the message and best of luck to you on the revisions. Hope it went well. On the contrary, my knee is actually very stable, so that's a plus. The implant is sound...it's where it's supposed to be and looks good (have had multiple docs look at it), which is part of the mystery as to why I'm having continued pain and swelling 13 months post-op.