Revision TKR 18 months post TKA-and pinching, clanking etc.

[runlikethewind]

I have pinching type pain behind my knee mostly on the left side. You can actually see the bump of the prothesis there and that is the area it is most painful. The thought is the popliteal tendon rubs across that part of the prosthesis and it causes pain and when more swelling in general, the more pinch I feel. I do have lots of clicking and clanking in the knee as well and my knee cap sticks at times.

I do still get swelling. When it swells and is really tight I have about 90 degrees flexion opposed to 105-110 passive. I still am seeing my PT who really helps with loosening it up when things are tight-IT band, Hamstrings, quad. She feels that there is too much movement - the tibia slides back. The joint is not tight/stable enough. I have started wearing a brace that adds PCL and ACL support. With the brace on I have more stability, less pinch, and actually walk better. I have a bit of extensor lag but my gait is so much better with the brace on. The though process here is that the tibia does not slide back and forth as much so it is more stable with the brace. My quads are still lacking strength and muscle tone but I have a history of RSD in that extremity prior to the TKA.

The DR has done x-rays and say they look good. It is the only time that the knee was x rayed after the TKA surgery. He has done ultrasound to see what he can see and made a strange comment that the tibial plate looked tilted but maybe the way the US made it appear. At my appointment this week he noticed the swelling and my PT had mentioned ruling out allergy so he sent me for ESR and CPR
which would indicate inflammation and those came back low and in normal range indicating no inflammation. Another PT thinks that the prothesis may be too large as she was concerned that you can actually touch that part on the back of my knee and feels that the popliteal tendon will always be irritated because it is always rubbing on that.

My PT would like me to see another Ortho, one who does revisions and complicated cases just to see what idea someone else has.

I am about 5'5'' and 100 pounds so I do not put much stress on that joint. Stairs are still nearly impossible. I still am no where close to as active as I was prior. An injury led to the decision to do the TKA so I was not planning on having a TKA ever until the injury caused issues I did not have before.

AM so sorry for the length of this post. Am just not sure what to do, where I am headed or?

 

[kneeper]

Did your current OS examine the knee? Such as move the leg around etc? If your current OS is dismissing your concerns it wouldn't hurt to seek a second opinion and a revision specialist sounds like good option as they see all kinds of tkr knees that may or may not have issues.

 

[skigirl]

Yes, of course, you should see the revisionist---thanks to your PT for suggesting one for you. Your knee is not functioning well and there is a problem---it is always better to know what the problem is and what your options are to deal with it.

I seriously doubt that the Ultra sound makes something appear tilted!!! Go, find out what is the cause of your problems and what options you have.

 

[Josephine]

I agree. And you need a surgeon who does at least 50 revision knee arthroplasties per year.

 

[runlikethewind]

Yes, my OS has examined my knee. I have had appointments with him on a consistent basis (every two weeks, or four, or six at the most depending on what has been going on/how it is doing). My PT has either been seeing me weekly or following my progress at home. Was with her for 6 months in clinic and then off for 4 months until after the OS did a scope to remove adhesions, and then have been seeing her for the past 6 months. He has actually been really good at keeping an eye on it but I am not sure at this point what he is thinking.

I am in the process of trying to chose a OS who can handle revisions, complicated cases, and Reflex Dystrophy as it will flare and is affected by all that goes on. Doing my research.

I guess I am just in need of a reality check:
Is it normal that it is still swollen at this point (18 months out)?
Is it normal that you can feel and see the metal/prothesis in the back of my knee (left side only)?
Is it normal that it pinches or I get pain daily in that area (where is sticks out)?
Is it normal that I still get a lot of stiffness, pain, and swelling after doing my PT exercises or about one to two hours of doing household chores or out running errands or sitting at a desk for about 2 hours (or in a car)?
Is it normal that it clanks, clinks, or clunks?

I am not sure what "normal" consist of.

Thanks everyone for your input

 

[Josephine]

Is it normal that it is still swollen at this point (18 months out)?

Most certainly, especially since you have a tendency to RSD.

Is it normal that I still get a lot of stiffness, pain, and swelling after doing my PT exercises or about one to two hours of doing household chores or out running errands or sitting at a desk for about 2 hours (or in a car)?

Is it normal that you can feel and see the metal/prosthesis in the back of my knee (left side only)?
Is it normal that it pinches or I get pain daily in that area (where is sticks out)?

I very much doubt you can actually feel the prosthesis unless your surgeon has misplaced it! But truly, the implant is so deeply placed it's impossible to feel it with your fingers. Or has your surgeon agreed that he can feel it also?

Is it normal that it clanks, clinks, or clunks?

Perfectly normal. My new knee is like a bag of marbles at the moment and my old knee (6 years and counting!) still knocks when I try to kick the duvet back in place in the night!

 

[runlikethewind]

My surgeon has agreed/confirmed that the bump that you can both see and feel is the implant.

 

[Josephine]

Really? I think I should want a second opinion on that if it were me because it should be so.

 

[runlikethewind]

Opinion from an different OS: said because I am, "skin and bones and small muscled, that the component it more prominent.
Looking at x-ray his opinion was he sees no fractures or indication of loosening and it looks like the right size. His opinion for the snapping on that part of the component was the calf muscle is rubbing on that part of the component that you can see/feel. His opinion was that the swelling is because my body does not like that there is a foreign object. His opinion was it will never be as good as before and never feel like a normal knee.

 

[skigirl]

Something about the above opinion strikes me as a little odd----the CALF muscle is rubbing against the component? Really--and why is that? If the swelling is because of the knee being a "foreign object" is he implying that you are allergic to the nicklel in the knee? Or what? if that was normal, everyone would have swelling.

I would think that being skin and bones would work in your favor--and if you were a runner are you really "small muscled"? Surely your PT is working on improving your muscle tone---but, wait, it was your PT who suggested that the knee did not seem right. Was this OS a friend of the first one? A person who does and understands revisions?

 

[skigirl]

Oh yes, I need to tag Jo to also see that report @Josephine

 

[Josephine]

His opinion for the snapping on that part of the component was the calf muscle is rubbing on that part of the component that you can see/feel. His opinion was that the swelling is because my body does not like that there is a foreign object. His opinion was it will never be as good as before and never feel like a normal knee.

What a load of tosh! Is this man is a knee surgeon?

'the component was the calf muscle is rubbing on that part of the component that you can see/feel': so far as I am aware, no part of component comes anywhere near the calf muscle!

'my body does not like that there is a foreign object': this is also a really bad bit of advice. Most people I know are totally unaware of their implants and they function very well.

'it will never be as good as before and never feel like a normal knee': Another bit of nonsense. I was at a conference of knee surgeons a couple of years ago where one surgeon was purporting this kind of opinion. In the end I had to stand up and refute what he was saying that patients with TKRs would never be able to function well, never be able to do stairs well or forget they had a TKR. So I got up and ran down and then back up a not inconsiderable flight of stairs to a round of applause from the audience. His face was like thunder but he never responded! (he's an enthusiast and, it has to be said, an expert in partial knee replacements, btw).

I don't know why surgeons say these kinds of things when patients go to them with problems. The last thing we should be giving such patients is unwarranted negative input and I very much doubt he had any real evidence to back it up .

 

[runlikethewind]

I agree with both of you.

As far as I know the two OSs are not friends but who knows if they know each other. They are not in same practice.

I have no idea as to why that part of the component is so prominent. I also do not lnow why the CALF muscle (the end of it- gastrocnemius )is rubbing or how. The second OS did say the the
Tendon is inflammed and that is why it is rubbing. I say it is inflammed because it is rubbing. Two other PT did say that as long as it ( whatever IT is) rubs on it it will forever be aggrivated and inflammed and her/his thought was the component was too big because it sticks out( this was stated 7 months ago). I have wondered if it is the Popliteal tendon that is rubbing.

The second OS is blaming the swelling on my past history of RSD. He asked how long it took before it burned out. RSD does not burn out but can go into kind of a remission in which it was until the injury that led to the decision of TKA. This has probably irritaed the RSD but is in no way all related to it. When I use compression bandage it helps with the swelling some. I couldn't wear that compression bandage or indure the touch of physical therapy all these months if RSD is the main issue.
Also rememering that RSD flares because of an issue that is causing the flare, not just because.

I think that for whatever reason that component ( it looks like the lateral posterior femoral portion) sticks out- the tendon or something rubs on it and everything gets inflammed. I can and the OS s and PTs can FEEL it rub/snap over that part.

I am thin and I do not have defined muscles and yes PT has me work on strengthening everything. Right now the focus is on pain relief.

i am pretty much at my wits end with this. It would be great if I could get rid of the snapping/pinching, swelling ( as the day goes on it swells more and my ROM goes from 115 to 90), and my kneecap sticking ( ocassionally sticks upon exstention). The TKA did resovle the probems I was having prior but I now have these issues.

 

[runlikethewind]

UPDATE: went and saw an OS who does revisions (he said about 70 a year) and complicated reconstructive surgeries.
He took x-rays, examined the knee, read the PT's report and suggested a revision to:
1) place new components that are more constrained (less AP movement=less pinching and swelling?)
2)a smaller femoral component (yes that is the component we see and feel so perhaps why things snap/rub?)
3) align the femoral component different than it is now (alignment not good and aligning it differently will create more space and I am guessing between the back of the knee cap and femoral component eliminating the knee cap sticking/catching?)

So he gave me a huge list of negatives: higher infection rate, could fix my problems, could make them worse, could stay the same, could have a stiffer leg etc etc. I asked him if there are any positives and he said he felt there are more upsides than downsides and that I needed to decide If I can live with it how it is (said this is it as it is right now) and my quality of life (all aspects of my life not just knee-not sure what he was getting at but the knee affects many other aspects of my life).

Thought I'd share my answers. I kind of swing one way then the next. Can I live the rest of my life with it (I'm 55 this year)?

 

[DogLoverx3]

Tough decision. I was told pretty much the same thing regarding a revision (that it could end up worse, put it off as long as possible, etc...). I'm about 19 months post RTKR and still on the fence about whether or not to do it. I've been told that the femoral component is too big and overhangs more than it should. I get the pinching as well and was told that because the plate overhangs my bone, the ligaments (or whatever are on the outside of my knee) are constantly rubbing against it. Since metal is harder than bone, it keeps everything a bit 'angry'. My knee does not stick like yours does though, but I have been told by my PT that part of my issue might be because I have 'too much' movement in the joint. Basically my ROM is that of a 'normal' knee and apparently that's pretty rare. I'm glad that you found a good revisionist that has identified the issues and has given you a realistic view of things. Only you can decide if this is something that you can live with.

Btw, I had a scope to remove remove scar tissue which even my surgeon was dubious about it helping (as ROM was never my issue, but pain was/is), but it has. A little. I just wanted to explore every possible 'fix' short of getting a revision. Please keep us posted!

 

[Josephine]

Tough indeed. But do remember that your knee won't stay they way it is right now. The likelihood is that it will just get worse. This chap seems to know his business and for me has said all the right things to convince me of that. If t'were me, I'd go for it.

 

[skigirl]

I am with Jo on this one. The quality of life issue addresses how your life will be with that knee. Will you be able to run up a flight of stairs?? will you be able to hike for 5 miles? Will you be able to walk around and do the things that you want to do? lift up grandchildren, walk the dog, walk across uneven ground to go to an art fair??

If not, then your quality of life is not where it should be. I can do all of the things I asked you about, by the way, and I have two fake knees. I had a revision on my left knee---to remove adhesions and to replace the spacer with a slightly larger one. I did NOT want to have more surgery---after all, we think that a tkr is supposed to solve the problems, no one mentioned a second surgery.

I was sick to death of rehabbing knees and did not want to do it again. But, the pain from the adhesions was impacting my life. I went on a 20 mile bike ride and was in agony at the end of the ride. So, I did it. Was it easy?NO. I had to take it really easy so that I did not flare up the inflammation on the knee--and cause more adhesions to form. It took 3 long months to rehab the knee since I had to be so careful in the beginning.

That was three years ago---am I glad that I did it??? Oh yes, I am. I can ski 100 days, I just went on a 30 mile bike ride and i often hike 10 to 15 miles in Glacier National Park. My quality of life is right where I want it to be.

Was I mad and snotty about having the revision --yes, I was, I was disgusted to say the least. But, the quality of life was not where I wanted it to be and now it is. That is ultimately the decision that you will have to make for yourself. And, Jo is right, I think you have the right doctor this time.

 

[runlikethewind]

@DogLoverx3 Your knee issues sound almost exactly like mine. I do believe that the femoral component being too big is reason why tendons etc rub and snap causing constant irritation and/or tendonitis. The pinching because the soft tissue gets impinged in the components and it is worse when swollen or I should say the more swelling the more impingement and there is too much AP=forward/backward movement. (A PCL brace helps this so I am kinda confident that the more constrained component would help this issue. Why they did not use one to begin with, I do not know since I do not have the PCL). If anything the brace proved too much AP movement for me.
With all the rubbing/snapping/impingement going on the knee is forever "angry". I too, had a scope to remove scar tissue and it did help in the area that it was removed. BTW=am a dog lover too (well animal lover )

@Josephine I totally agree with you. My thoughts have been that with all the irritation/rubbing etc it is NOT going to get better but worse.
So being that all 3 things he plans on changing is in regards to Mechanics, I see it as more of a "needs" to be done, than should it be done.
More of a necessity?

@skigirl you are spot on. In trying to justify to myself on having the revision, I made a list of can not do's. "Will you be able to run up a flight of stairs?? will you be able to hike for 5 miles? Will you be able to walk around and do the things that you want to do? lift up grandchildren, walk the dog, walk across uneven ground to go to an art fair??" Can not walk up flight of stairs without handrail (my house is two story), No to the 5 mile hike, no to walking around and doing things I want to do-can't walk my dog-(even the biggest, slowest, easiest one), uneven ground is hard, my driveway has a slight slope and that causes pain, and walking in the sand at the beach is almost impossible. So, not able to do things I need or want to do, either at all or comfortably. If I am going to be happy sitting on the couch the rest of my life then it would be fine.

My thoughts are that he has 3 things he would do and all affect the mechanics of the knee-and each one address a problem that has a huge impact on my function and if those 3 things get fixed I should have a good outcome. Am I on the right path?


Thank you all for your input. Happy to at least have gotten answers from this Doc. Even undesirable answers are better than no answers.

 

[runlikethewind]

13 days post op REVISION. I did it and now we will see how things turn out. He put in a more constrained component, different size for both components, and aligned the femoral component properly. Can no longer feel the component on the back of my knee. It feels like a normal knee now, no huge bump poking out. Just need to see how it works as things get moving. He has made the comment that now that everything is in the right place it should work much better. I must say that this surgery has been a completely different experience in many ways. He had to do some fancy incision closure but used staples and I am actually really afraid of the removal (never had them before), the incision is not down the middle of the knee as he needed to follow the past (and past and past) incision, so on the inner part and my RSD history makes me a bit more sensitive there. Any ideas on how to get thru that part, without completely making a fool out of myself, please let me know. Pain control has been different as I had low BP issues. I ended up receiving a unit of blood because I had lost so much after the surgery thru the drain. When they gave me pain meds my bp would drop so I was limited on what they would give me.

 

[Celle]

Welcome to the recovery side again!

I hope that the revision does the trick for you.

It's quite a while since your first surgery, so I'm going to give you the recovery reading list:
First are the BoneSmart mantras ....
- rest, elevate, ice and take your pain meds by the clock
- if it hurts, don't do it and don't allow anyone - especially a physiotherapist (PT) - to do it to you
- if your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again
- if you won't die if it's not done, don't do it
- never stand when you can sit, never sit when you can lie down, never stay awake when you can go to sleep!
- be active as much as you need to be but not more than is necessary, meaning so much that you end up being in pain, exhausted or desperate to sit down or lie down!

Next is a FAQ (Frequently Asked Questions) thread.

And here are some very crucial articles
The importance of managing pain after a TKR and the pain chart
Myth busting: no pain, no gain
Swollen and stiff knee: what causes it?
Activity progression for TKRs

Healing: how long does it take?
Chart representation of TKR recovery
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling

Home physio (PT) and activity progress: suggestions
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds
Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

And then some wise words from members who have shared their experiences ...
Where are you in recovery?? (TKR)
Five “P’s” of knee recovery
TKR: work “smarter” and not “harder”
Recovering a knee - from one who knows!
It's never too late to get more ROM!
It's worth the wait for ROM

I'm looking forward to hearing how you're getting on.