Revision TKR Knee not properly balanced during TKR

[Mr. Baxter]

Hello all, I apologize for the long post ahead of time. Finally Had TKR on right knee June 2022, had 5 scopes prior for torn meniscus, all this because a malunion tibia fracture that healed on 13-degree varus angle.

Had a lot of problems straightening the knee after surgery during rehab knee and still doesn't straighten now. During PT when knee is bent feels like something is pinching in back of knee not as bad one year out but still feel it when bending the knee past 110 degrees. 4 months after surgery had increased pain on outside of knee was told it was ITB friction and given a shot in knee which helped and actually increased motion and relieved a lot of stiffness.

6 months out i noticed the knee clunking when bend knee walking up stairs and sometimes just walking. The knee also clunks if i am sitting and tighten my quads, Dr said the will go away in time. Now at 14 months still have pain and clunking, unstable.

Went for three second opinions First DR. said knee was not properly balanced and plastic insert too small and mid-flexion instability. Recommended larger insert rebalance the knee IT band release and stated larger insert will make straightening knee worse

Second DR said knee is way too loose during anterior draw test and mid flexion instability, but basically said borderline malpractice issue, but DR wouldn't get involved w revision.

Third DR. said mid flexion instability, but implant was well aligned and well sized the clunking is from the post on the tibia implant hitting the side of femoral component. gave me a brace to help and said he doesn't use Depuy knee system but would check w them see if a larger post was available but not a good option and said knee revision raise joint line. but cautioned that the revision required a longer stems and the tibia stem would be very close to the malunion tibia fracture so if the revision wears out when I am 75 a third revision may be problematic

I am very frustrated and depressed as I was looking forward to being able to walk and hike again, no high impact stuff. I went back to original Doctor, and he said that's the best I could expect. My question anyone have issue with instability?

If the knee is unstable, how do they fix that during revision surgery? if all the components are properly sized and aligned why take them out is there a way to just fix/tighten ligaments.

Any input/thoughts from your experiences are welcomed !

 

[Roy Gardiner]

to BoneSmart

First, the general stuff:

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.

 

[Roy Gardiner]

Looks like you've got on top of it with more than one extra opinion, but have lucked out in that they don't agree with each other!

2nd doc wouldn't get involved with revision - clearly not a specialist then. Revision really is a highly specialised area, perhaps - sorry - you need further opinions and maybe ones from such specialists.

 

[sistersinhim]

Please list the dates of your surgeries and we'll add them to your signature for you. Being able to see these will help us to better advise you.

 

[Pumpkin]

Hi,
I had a revision for flexion instability, and I also have a malunion tibia fracture ( off by 5 degrees).

During PT when knee is bent feels like something is pinching in back of knee

I had a similar pinching feeling when my knee was bent to end range, it is gone since my revision.

If the knee is unstable, how do they fix that during revision surgery?

I have a hinged knee, only movement allowed is flexion/extension. Currently ROM is 130 degrees flexion, -5 degrees extension. Before my revision my flexion was 120 degrees, extension 0 degrees.

My knee is still off by 5 degrees after my revision, and causes the outside of my lower leg to spasm if I do not use a full length 5 degree lateral wedge in my shoe.

Recommend you search for a surgeon specializing in revisions or complex joint reconstruction for a 4th opinion.
You may need to travel.

I consulted with 4 surgeons before selecting the 4th one for a Revision.

 

[ski_bum]

I am very frustrated and depressed as I was looking forward to being able to walk and hike again, no high impact stuff. I went back to original Doctor, and he said that's the best I could expect. My question anyone have issue with instability?

Any input/thoughts from your experiences are welcomed !

I have IT Band issues with both knees. Was told to walk it out!

 

[Jamie]

With knee problems, it's rarely just an "easy fix" like tightening ligaments. Getting the proper balance in any knee can be challenging and it's one of the reasons we urge people to seek out experienced surgeons when getting a knee replaced.

As Pumpkin mentioned, a hinged knee implant can do wonders to stabilize a knee. This may be an option for you to help your situation. But you need the guidance of a very experienced revision surgeon. Unfortunately the only surgeon on my list is a hip guy. I do have a couple of surgeons in Nashville if you're willing to drive there for a consultation. One of the surgeons does telemedicine, so it's possible you could use that for an initial consultation. Here is the information if you're interested:

Nashville, Tennessee
Dr. Jefferson C. Morrison
Dr Michael Christie
Primary and revision hip and knee
Southern Joint Replacement Institute
2400 Patterson, Suite 100
Nashville, TN 37203
Phone: 615-342-0038

When searching for a revision surgeon, look for the terms "joint revision" or "adult reconstruction surgery" in their profile information as a starting point. You really do want someone who has many successful revisions under their belt since you have the added issues associated with the fracture.

 

[Mr. Baxter]

Thanks for the reply, curious about the hinged replacement compares and how the Doctor determines the need for one,. None of the DR mentioned hinged to me. Getting my fourth opinion next week and meeting with third DR for questions i have.

My knee is still off by 5 degrees after my revision, and causes the outside of my lower leg to spasm if I do not use a full length 5 degree lateral wedge in my shoe.

Recommend you search for a surgeon specializing in revisions or complex joint reconstruction for a 4th opinion.
You may need to travel.

I consulted with 4 surgeons before selecting the 4th one for a Revision.

 

[Jamie]

@Pumpkin can address your questions. I've tagged her for you.

 

[Pumpkin]

curious about the hinged replacement compares and how the Doctor determines the need for one,. None of the DR mentioned hinged to me.

The decision to give me a hinged implant was made during surgery. They did a trial with a posterior stabilized spacer, my knee was still unstable. They the trialed a hinged implant, which was stable, determining that the hinged implant would be best for my knee.

The hinged implant provides the most stability, compared to a TKR.

 

[Newbai]

Agreed with the stability of Hinge TKR. I have a hinge TKR and it’s stable. With a hinge TKR, they remove all the ligaments, as they are not needed.
Maybe after hearing the opinion of the 4th consultation Dr., ask his/her opinion on hinged TKR. All the best.

 

[Jockette]

Finally Had TKR on right knee June 2022, had 5 scopes prior for torn meniscus,

Please give us the date of your TKR. Was it actually in 2021? Ballpark dates of the other surgeries would be nice, too. We’ll create a signature for you. Having this information in a signature helps us advise you more appropriately.

 

[Mr. Baxter]

Thanks for the replies !
Update I saw with 4 th doctor about knee instability. DR. was very helpful took his time and explained everything in detail answered all my question. He confirmed instability said the flexion and extension gaps were not balanced which is leading to pain stiffness clunking and IT band pain trying to compensate for instability. Same diagnosis as last doctor.
Stated that only need to revise the femoral component with bone cut and larger femoral component rebalance the knee. I asked how many revisions he does, he stated he is fellowship trained in complex revisions/adult reconstruction surgery and about 10 percent of his practice is complex revision surgery, and he is confident that he can fix the issue. I asked how many surgeries he does on surgery day he said 3 and only one revision. I found out later the surgeon who did my TKR does six a day. So, at this point will move forward with revision once i decide on 3rd or 4 th doctor.

 

[Mr. Baxter]

Finally Had TKR on right knee June 2022, had 5 scopes prior for torn meniscus,

Please give us the date of your TKR. Was it actually in 2021? Ballpark dates of the other surgeries would be nice, too. We’ll create a signature for you. Having this information in a signature helps us advise you more appropriately.

my bad with typo TKR was June 2021, 5 scopes 1986, 1991, 1993, 2008, 2018. last in 2018 was for piece of femur broke off and lodged in knee joint

 

[Jamie]

@Mr. Baxter .... it sounds like you have a great surgeon lined up. You were wise to get multiple opinions and keep talking to experts until you believe you have the answer to your problem. Good luck with your surgery and be sure to let us know how things go.

 

[agsmom]

I had a revision in late June due to the original implant being placed improperly. I had a lot of instability and moderate/severe valgus knee. My recovery is going well. My surgeon is fellowship trained and experienced in revisions. I’m glad you shopped around for docs; you want someone who knows what they’re doing for revisions. Wish I had done that for my initial TKR. Good luck!

 

[Mr. Baxter]

I compared other doctors for the initial TKR, one I chose was highly recommended. I found out after he does 6-7 knee replacements during the day. I am no Doctor but seems a lot during my fourth opinion the Doctor said there is a lot of rumblings with healthcare in the area about the amount he does in one day. I honestly think he was in too much of a hurry and when the flexion/extension gaps were not balanced he didn't correct it.

 

[Mr. Baxter]

Agreed with the stability of Hinge TKR. I have a hinge TKR and it’s stable. With a hinge TKR, they remove all the ligaments, as they are not needed.
Maybe after hearing the opinion of the 4th consultation Dr., ask his/her opinion on hinged TKR. All the best.

I asked about hinged knee with 4 th opinion doctor said the hinged knee is not to the point of hinged replacement. Meeting 3 rd opinion next week discuss/have few questions tentative plan is do revision first week of Oct. will have enough leave time to be out for three months but most likely will semi retire in Jan. anyway. Have to decide either 3rd or 4th opinion for surgery

 

[Mr. Baxter]

Hello All,
I had my revision surgery yesterday I was pretty stressed out hoping this would fix it. I will say a complete opposite of the first surgery with the new Doctor, even the pretesting was much better and thorough. Pretesting was well organized the first surgery they just did bloodwork. This time was blood work, EKG, MRS staph test and antibiotics gel for my nose 5 days prior and lots of written information.

I chose nerve blocks and light sedation again. Revision went well he replaced the femoral component and spacer, tibia was good no hinge needed. I was in recover for a short period wasn't as out of it/groggy this time compared to last.

I was surprised when I was moved to a private room. PT nurse showed got out bed no problem minimal use of walker down the hall to PT room did 4 steps up and down unaided and back down hall to my room. I felt good and decision was made no overnight and sent home. Noticed much more bend able to get in front seat of car better than last time.

Up this morning 0600 and pain/stiffness has increased can bend about 90-100 degrees. I extremely happy the pain at this time is times10 less than before and very tolerable. I have CPM and ice machine start PT today at 3. My cousin who is here to help said this is a complete opposite of the last time. So, is my current Doctor that good or was my previous that bad? LOL just kidding, I know am just starting the recovery process and am sure there will be setbacks along the way.

 

[Roy Gardiner]

I have CPM and ice machine start PT today at 3

Please, take it very easily. No pain - more gain! Please keep the guidelines in mind. Good luck, superb bend already.