Core decompression or knee replacement?

Lookingfothelp

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I am a 43-year-old female who was accidentally injected with 30 mg of epinephrine into my knee cavity during a meniscus surgery. I now have AVN in my femur, tibia, and patella. I was on crutches for seven weeks with no change in my lesions. It has been suggested to me by one doctor that I do a core decompression in hopes to create new bone growth. This doctor said she could not tell me the chances of it working since my situation is so unique. Another doctor said that due to the questionable likelihood that a core decompression would work and the fact that I have retorn my meniscus and have cartilage damage that I should do a knee replacement instead. I am struggling with whose advice to follow. Meanwhile the pain is getting worse. On the one hand, I cringe at the idea of multiple surgeries if I were to do a cord decompression and it didn’t work. On the other hand I am aware of the repercussions of doing a knee replacement at a my age. It sounds like the revisions are even worse than the initial knee replacement, need to be done more often, and have a lower success rate each time. Any input from the group would be greatly appreciated. Thanks in advance.
 
I’m a “fix it” gal so, if it was me, I’d be going for the TKR. I’d rather get a new knee and deal with revisions instead of the decompression especially since your surgeon can’t say if it’d work.

Keep us posted.
 
@Lookingfothelp

I asked Jamie, BoneSmart's Senior Administrator and her response was that she thinks you have far too much going on in your knee - with AVN in 3 areas and cartilage and meniscus damage as well - to be considering a Core Decompression. A Total Knee Replacment (TKR ) has more chance of success.

Not only that, recovery from a Core Decompression can be very painful.

This article is interesting:
https://clinmedjournals.org/articles/jrdt/journal-of-rheumatic-diseases-and-treatment-jrdt-3-053.pdf
Near the start, it says this:
For patients who present with diffuse osteonecrosis, we have found little efficacy in treatments short of TKR.

It concludes thus:
Osteonecrosis of the hip and knee present challenging cases for the orthopaedic surgeon. While many non-arthroplasty interventions have been described in the literature we have found little role for them in clinical practice. Core decompression may be used in small, pre-collapse areas of osteonecrosis especially if the involved bone has minimal involvement of the weight bearing surface. Arthroplasty has proven to be an excellent option for patients with osteonecrosis and debilitating pain and function. While special attention must be paid to these patients as they generally present younger than patients with degenerative arthritis and the native bone stock may be severely compromised, we have found that one can achieve excellent results with arthroplasty in the setting of osteonecrosis.

("Arthroplasty" means surgery to replace the knee.)

Nowadays, a TKR, done by a good surgeon, has a projected survival rate of 20+ years, so there's no need to fear multiple revisions. And, even if you do need a revision years down the track, the vast majority of revisions go well, and cure any problems encountered with the primary TKR.

I had a Revision TKR back in 2011. It went very well and my recovery was no harder than my recovery from the primary replacement.
It's nearly 8 years old now and it's working just fine. I have no pain at all, unless I twist it by accident, and I can do anything I like with it. It feels so natural that I usually forget I have an artificial knee.

In your place, I would choose to have the TKR, not the Core Decompression.
 
It has been suggested to me by one doctor that I do a core decompression in hopes to create new bone growth.
AVN means the blood supply to that bone area is limited or non-existent. Since you have AVN in 3 major areas I am really not sure why any surgeon would suggest CD. Extra recovery that can be very long and painful versus a TKR recovery.

In any case, technology is on your side! Implants have much better longevity these days. We have plenty of members your age and younger going through TKR.
 
Thank you all for your thoughts. I felt very strongly about avoiding the possibility of doing multiple surgeries and set on getting a knee replacement for some time. Then I started thinking more long term and researching revisions and started having second thoughts, wondering if I should give the core decompression a shot. Seeing as most women in my family live to be 100 it started to sink in that I could be looking at 5 knee replacements in my lifetime. I’ve read that the revision surgeries are no small feat, that eventually you run out of bone for them to remove and attach to, that the success rate gets lower each time, that they don’t last as long as the original, etc. All of this is concerning. I’m glad to know that there are more and more people my age having knee replacements though and hope that by the time I need my first revision (say in 20 years) that the technology will be even better than it is currently.
I’m also wondering when the right time is to bite the bullet and get the surgery. Do I continue to wait in hopes that maybe the new bone growth gets ahead of the dying bone and the AVN fades away (is this even possible?) or do I do it now before my pain gets any worse and I mess up other parts of my body with all my limping, lack of exercise, etc?
 
wait in hopes that maybe the new bone growth gets ahead of the dying bone and the AVN fades away (is this even possible?)
I am afraid there will not be any more bone growth and no, AVN will never fade away. Unfortunately AVN will continue to get worse.
do I do it now before my pain gets any worse and I mess up other parts of my body with all my limping, lack of exercise, etc?
I can confirm that continuing to limp around will impact other parts of your body making recovery more complex.

I really would not worry about revisions down the line. If needed you need a revision - say 30 years from now - technology will have moved on that much more. And there are plenty of people who have very successful revisions.

The right time to have your surgery is when you are ready. It's not an easy decision. But if you read some of the recovery threads in the knee area you will see plenty of members whose only regret is that they waiting too long.
 
Seeing as most women in my family live to be 100 it started to sink in that I could be looking at 5 knee replacements in my lifetime. I’ve read that the revision surgeries are no small feat, that eventually you run out of bone for them to remove and attach to, that the success rate gets lower each time, that they don’t last as long as the original, etc.
I don't know why revision get such a bad press. I suspect that much of that is left over from when knee replacements didn't last as long as they do now. Done by a skilled surgeon, the vast majority of revisions are .an improvement over a problem primary replacement.

When knee replacements were only expected to last about 10 years, multiple revisions were a concern. However, now, revisions and techniques have improved and the projected life span of a TKR is at least 20 years, with many already older than that, and the life span is now expected to rise to over 30 years. So it's most unlikely that you would need 5 revisions in your life span.

Yes, revision surgeries can sometimes be more difficult than doing the original replacement,but the wise thing to do is to look for a surgeon who has made a specialty of doing revisions and dealing with problem knees. Unlike a surgeon who mostly does primary knee replacements, this type of surgeon will have had additional experience in doing revisions and fixing problem knees, because he/she does it every working day. With a skilled surgeon like that, there is every chance that you would have just as good an outcome with a revision as with a primary TKR.

The spectre of multiple revisions used to be why people in their forties were denied a knee replacement and were forced to suffer with crippling arthritis for many years. Now that's considered a very old-fashioned approach and many people in their forties are receiving knee replacements and they're able to return to an active life.

I first learned that I needed a knee replacement when I was 50. My surgeon told me I was "too young" and I had to wait until I was 60.
I waited for 9 long, painful years, during which time I became progressively more disabled and my life shrunk until I was almost housebound. Even with a stick, I couldn't walk 100 yards.

My first knee replacement (a Partial - PKR) gave me back the active life I had missed for all those years. Life had value again and I travelled the world with it.

My revision TKR is almost 8 years old now and I expect it to last longer than I will.
 
Thank you both for your insight. I am so grateful that this group exists!
Celle, I’m so sorry to hear that you had to wait so long to get your replacement. That must have been very frustrating.
 

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