Revision TKR Counting Down to 2nd TKA Revision

[celynda]

Has anyone seen Dr Figgy or Dr E. Debbi at HSS?

I’m seeing Dr Debbi with Dr Figgy following tomorrow as part of a full day of testing and scans.

According to the X-rays, the implant is loose and there’s concern about infection. The initial TKR was June of 2015, Revision in March 2018 and ORIF for peri prosthetic R Femur break 11/20. Over the last six months, the pain has gotten worse and I’ve gone back to using a cane.

If anyone had surgery at HSS, I’d love to know more about the experience. I don’t have a support system at home (West Virginia) and am concerned/curious/nervous about traveling for major surgery. Especially if it means two surgeries.

Thanks.

 

[Jaycey]

@celynda Welcome back to BoneSmart! So sorry you are possibly facing more surgery.

Many of our members have had their treatment at HSS. I can't think of a single instance where a member has had a problem. Some highly skilled doctors there!

I'm sure our members will be along soon with their input.

 

[spaniel]

I happened to see your post in the left side of the forum. I am typically in the hip forum. I graduated across the street from HSS decades ago (Cornell-NYH which is now NYP). HSS has a real backup staff to help with issues like navigation. There are places to stay that they can help arrange for you if needed. I will likely be going there myself (or to NYU Langone) as I had a messed up local surgery in upstate NY. Best of luck to you.

 

[celynda]

@spaniel, thanks for your “peeking.” I will definitely take advantage of any help HSS provides to help patients. I’m staying at the NYP Helmsley Medical Tower for the appointments and am already the one block walk to the hospital. I’m using a cane and have underestimated my stamina (I ventured out for bagels).

Good luck with your travails.

 

[Jockette]

According to the X-rays, the implant is loose and there’s concern about infection.

I’m so sorry. You’ve been through so much already.

I don’t have a support system at home (West Virginia) and am concerned/curious/nervous about traveling for major surgery. Especially if it means two surgeries.

I’m sorry this is the case, I’d be very concerned, too, in such a situation. Hugs and prayers that things will work out well for you. While it’s not the same as in person support, we’ll be here for you. Best wishes and keep us posted.

 

[Layla]

Hello celynda,
I am sorry to read you're in pain, back to using an assistive device and possibly facing another surgery. Prayers there is no infection involved.

I've only heard good things about HSS. Many here have gone through the Hospital for Special Surgery for joint replacement or a revision. You may want to type HSS into the Search at the top right of the page and the many threads where it's been mentioned will pop up.

I hope you find the help and support needed to travel and begin early recovery back home. Please know that we're just a few keystrokes away if you're looking for advice, a little company, or some encouragement. Best Wishes to you.
@celynda

 

[celynda]

While I don’t have a definitive plan for the knee pain, I do have an update from my day at HSS. the first thing Dr Figgy asked was “How long has your knee been crooked?” This was not at all what I expected. In looking back, it started after the revision in 2018. I remember looking at my post-op leg and noticing that at rest, the foot and leg pointed to the right. I never mentioned it to anyone as I could straighten it without much effort and thought maybe I was forgetting what “normal” looked like.

Turns out there is mild varus alignment of the femoral component of the replacement. The plate from the ORIF femur repair (2020) has lifted away from the femur by 1.5 cm. The gap has increased since X-rays taken in August 2022.

Dr Figgy is presenting my case to colleagues this evening (in particular to one trained in both trauma and arthroplasty) and the probable fix is to break the femur and realign it with plates on both sides. Hopefully they can realign the implant without replacing it.

This is a complex, unique challenge and I am really glad the HSS is in my corner. I may hear from them this week or it could be in early January. Dr F did say I would have to decide if the SX and recovery time was worth it. I said my goal was to be able to walk without pain (or a cane) to get the mail, go shopping, and walk the dogs.

Because I also have osteoporosis, they’ll connect me with an Endocrinologist to get the bones as strong as possible before surgery.

I know many of the members have been to HSS and I’d love to hear more on the experiences. I would also love to hear from anyone who’s implant has tilted or otherwise gotten out of alignment.

 

[celynda]

The notes from the initial consultation are in the EMR. The finding is “if the knee is not infected, would be for a corrective osteotomy of the femur to restore neutral alignment while keeping existing implants.”

This image is from the standing (EOS) xray where you can see the bowed femur and tilted implant. I’m waiting to hear from HSS on the conference results and next steps.

 

[Jamie]

I think you are in excellent hands there at HSS. You do have a rather unique problem and it's just this type of hospital where you need to be treated. These specialists see many, many unusual and challenging cases and that offers you an excellent chance to reach your mobility goals. As you can see, you have a team of doctors weighing in on your situation....that's always good.

Please don't fear the logistics of surgery and some initial recovery away from home. The folks at HSS do this all the time and they have many resources to be sure you're well cared for until it's safe for you to return home to recover fully. Just be sure to ask plenty of questions. Write them down so you don't forget anything.

We're here if you need us, as well. You'll have the complete support of your BoneSmart family.

 

[celynda]

1. Would an Admin please change the title of this thread to: Bowed Femur and Crooked Knee Implant.
2. Please also change the R ORIF in my signature to R Femur ORIF.
Thanks!

 

[celynda]

I’m still waiting to the hear from HSS on the aspiration results and the outcome of the case conference. The test results should be in tomorrow and I don’t expect them to find an infection. I know it’s a holiday so I am trying very hard to not to get spun up about the future. I’m horrible at waiting…

I am prepared to hear that an osteotomy is probably called for. If the knee implant doesn’t re-align, they’ll need to revise it for the 2nd time. Prior experience with TKA, revision, and broken femur has given me some idea of what recovery/rehab might be like and I don’t like what I remember . I know every SX is different so I not sure how to prepare for surgery #4. Or, maybe there is no way to prepare. Can someone put me to sleep and wake me up in 2024 when everything is healed and good.

 

[Jockette]

Can someone put me to sleep and wake me up in 2024 when everything is healed and good.

 

[InkedMarie]

I’m so sorry you’re having these problems. I’m thinking of you and will watch your thread.

Marie

 

[celynda]

Dr Figgie (HSS) ordered a nuclear bone scan which I had today. The findings were:

On the arterial phase of the examination there was no significant asymmetry in the flow. On the blood pool image there was faint uptake along the medial and lateral femoral condyle. On the planar images there were multiple focal sites of increased uptake within the right femoral cortex. Specifically at the tip of the knee replacement femoral prosthesis as well as along the medial and lateral distal diaphysis and the medial femoral condyle. There was some increased uptake along the lateral and medial aspect of the tibial prosthesis without significant uptake at its tip. There is increased uptake within the right patella. Diffuse increased uptake is seen within the left femoral metaphyseal and subchondral region. Upon reviewing the x-ray there was a fracture within the medial femoral condyle and bony hypertrophy with callus formation at the femoral tip. The changes on bone scan may reflect loosening of the tibial component.

IMPRESSION: Possible tibial component loosening

Not 100% sure exactly what this means other than another revision is needed in addition to the femur osteotomy.

Still waiting to hear from HSS regarding next steps.

 

[celynda]

March 5 Update:

Finally heard back from HSS. Going back on March 21 for a second consultation with Dr. Figgie and Dr. Brian Chalmers. Have no idea what to expect. The pain ranges from 6 - 9. Sometimes it hurts more at the top of the implant where the femur break was and other times, it’s right at the knee.

Since I know surgery is in my future and exercise isn’t really an option, I’ve decided to start taking Wegovy to lose as much weight as possible before the surgery. I’m waiting for the medicine to come back in stock at the pharmacy. I know it’s an expensive drug so was expecting a high copay. I am pleasantly surprised that between the contract price and a saving program, the cost to me is zero.

 

[jboles]

I’m happy to hear that you’re possibly going to find some answers to your questions. The not knowing what is wrong, but at the same time knowing that there is definitely something wrong, is awful and stressful. I filled out the online request form for the complex case review with HSS yesterday. It sounds like it’s a long process? You’re in my thoughts and prayers as you embark on the next step in your recovery journey

 

[celynda]

@jboles, I first contacted HSS in September. I wasn’t able to participate in the online case review because my state (WV) doesn’t allow internet consultations. So I sent them all my records and images. It took about six weeks for them to get back with me and ID an OS who wasn’t concerned with my BMI. I made an appointment to go to HSS for their December clinic the week before Christmas.

I’m glad I went as they did X-rays, CT, MRI and bloodwork the same day. The results were available for review by the time I saw the doctor. Because I had already met my out of pocket max, the cost was Zero. The bill was 13k. The best thing IMHO was the EOS which is a standing X-ray that shows the entire leg. It was weird but cool to see the bowed femur and the misaligned knee implant. The $500 fee for the complex case review is not covered by insurance.

It took another seven weeks to hear about next steps. I’m on the way to see the original OS and another OS he wants me to see. Hopefully, tomorrow I’ll come away with plans for a final surgery to fix the femur and probably another revision as the knee implant is loose.

I’ll update my post after the appointment.

Hopefully the case review doesn’t take as long. Good luck.

 

[celynda]

23 March Update…

Saw Dr Figgie and new surgeon, Dr. Brian Chalmers, on Tuesday. So glad to finally have a plan. I need another revision.. Dr Chalmers is going to remove the hardware (implant, plate and screws) and use a new implant with a longer femoral step to stabilize the femur. Breaking/resetting the femur shouldn’t be needed. It is a complex revision and Dr Chalmers tilde me he’s requesting four hours of OR time which is double the time for a TKA. He also said he couldn’t guarantee a pain free outcome due to scar tissue and trauma history. I also don’t think he’s familiar with the BoneSmart philosophy on rehab. No worries, though, I know what to do.

After 3-4 days in the hospital, I’ll spend a week or two in rehab in NYC before traveling home to West Virginia. If anyone has any recommendations or other suggestions for rehab in the NYC area, I’d love to know about it. I’ll be working with a case manager to sort out all the details.

I should have a surgery date within a week. I’ll have to go back to HSS for pre-op blood work, X-rays, medical clearance from Internal Medicine and meet with pain management. All of this has to be within 30 days of surgery but at least a week or two before surgery.

Let the countdown begin…

 

[Jaycey]

@celynda All a bit daunting but at least you are moving forward. Sounds like you have an excellent surgeon - a real comfort I'm sure.

Please keep us updated!

 

[celynda]

1 April Update…
Surgery date is 24 May by Dr Brian Chalmers at HSS. I return on May for extensive pre-op appointments: medical clearance, discharge planning, pain management, blood work, x-rays, another aspiration (There is a small effusion in the knee)., endocrinology (osteoporosis, management) and nutrition. The last one is interesting as I started Wegovy .25 on 11 March. Took the 4th weekly injection yesterday. So far, I’ve lost 12+ pounds.

While we didn’t discuss the specific implant, according to the EMR, he’s going to use a Stryker Modular Rotating Hinge MRH. He also told me he’s requesting four hours of OR time.

I expect to be in the hospital 3 - 4 days and then off to rehab for 1 - 2 weeks. I am planning to use a facility in NYC. Then home to West Virginia. How I am going home is TBD. The flight is 1.5 hours from LGA to Roanoke followed by a 90 minute drive.

Logistics are starting to overwhelm as I have four small dogs at home and I really don’t want to board them for 3 - 4 weeks.

From the office notes (my comments are in italics):

• The knee has significant laxity to varus valgus stresses and easily more than a centimeter of laxity and anterior to posterior in flexion and mid flexion.
• We discussed technical details of this including removal of at least part of if not the full plate. We discussed removal of both components and placement of a hinged device. There was no discussion about type of device. Should I care?
• She has a well fixed tibial component with a tibial cone and we will plan to leave the cone if it is well fixed and remove any remaining cement in place a new hinge MRH tibial baseplate.
• We would plan to utilize a cone in the distal femur and cement and a shorter stem.
• I think we can correct some of the varus but not all of the varus without
  doing an osteotomy which Ithink would be significantly more complicated with much higher risk of complications if we were to attempt that. Her primary plan would be to remove the femoral component, remove the distal screws and cut the plate and work in the distal segment. We will have a distal femoral replacement on backup if the distal bone stock is not adequate to support a condylar type of the implant. We discussed the complexity of the surgery at length.
• We discussed that she is at significantly elevated risk of complications given the complexity of the surgery, multiple prior surgeries, peri prosthetic fracture, varus deformity of the femur, adipose tissue around the knee and weight, and multiple incisions about the knee creating a skin bridge.
• We discussed that the biggest risk of surgery would be wound healing problems and
  periprosthetic joint infection, medical and anesthetic complications around the time of surgery, loosening or wearing out of the components over time, continued pain and dissatisfaction with the knee, stiffness requiring manipulation or reoperation or dissatisfaction with the knee, and VTE. Don’t know what VTE is.
• We discussed the surgery would take likely several hours and she would be in the
  hospital for several days after the surgery. We discussed we may limit her weightbearing or range of motion after the surgery to facilitate cone ingrowth and wound healing. I asked if the rehab/recovery for this surgery is comparable to a typical TKA revision. He said it was. Which is confusing since encouraging weight bearing and ROM is standard post-op care.
• We discussed the lengthy recovery and that recovery may take up to a year or 2 to regain strength and stamina in the leg.

I’d love to hear from anyone who has experience with a hinged implant and the recovery.

Thanks.