Knee Infection* Failed TKR revision - fusion/amputation advice

Clevy1991

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Hi there

I am writing on my behalf of my Dad (67 years old) who has had a rough ride starting from July 2022 when he underwent TKR.

The knee was never quite right and after it being confirmed he was suffering from a bad infection at the start of 2023, he underwent a two stage TKR revision involving complex plastic surgery.

There have been a lot of issues with his care and significant delays/lack of communication, but ultimately, he was left with necrotic skin a d has been informed that the wound will now bot heal.

He has now been told by his consultants he has a number of options. Firstly, further complex plastic surgery (taking muscle tissue from his back and transderinf this as a graft to his knee).

As a family we have decided this is not an option we want to follow through with, my Dad's mental health is really shot and he does not want to undergo this high risk traumatic surgery again, with the possibility the skin graft will still not take.

As such we are left with fusion of the knee or above the knee amputation.

He is in no immediate rush to make a decision and is trying to hold off until my wedding day on 16th September but it would be extremely beneficial if someone could reach out who has undergone either a knee fusion or amputation to give some first hand experience regarding their limitations, what they can do on a day to day, and just someone who he can related to.

Any help would be much appreciated!

Charlotte
 
Oh my, your poor father. I think it's way too early to talk about amputation. Is your Dad seeing an infection specialist? Was the second surgery done after receiving a clear-of-infection diagnosis? Was your Dad's revision done by a revision specialist that was working with the infection specialist?

Please give us the exact dates of your dad's surgeries and which knee it is.
 
Even though Dad's surgery was a while ago, I'll leave you our Recovery Articles:

Each person is different as is their recovery. Most find that the Bonesmart approach works best for them, but others find that a more aggressive therapy helps them more. It's your recovery and your choice on how you recover. As you read more on other members' recovery threads, you’ll get a better perspective of what to expect. The following are our basic guidelines and should help get you started.

If you want to use something to assist with healing and scar management, BoneSmart recommends hypochlorous solution. Members in the US can purchase ACTIVE Antimicrobial Hydrogel through BoneSmart at a discount. Similar products should be available in the UK and other countries.

KNEE RECOVERY GUIDELINES

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.

Try out our great new opportunity to improve your gait. It's OneStep. It's free and you will find it to be a huge help to you. Click here: OneStep
 
@Clevy1991, since your dad has already had his replacement I moved your thread out of the Preop Knee Forum to the Knee Recovery Forum.
 
I am so sorry to read this about your Dad. I had to read up on fusion of the knee and it sounds like it could be very painful with a long recovery. I think I would ask the surgeon about the difference between recovery and rehabilitation in the 2-procedures and maybe his PCP because he/she knows his health history. I'm sure your dad is deconditioned and not feeling like himself. Did they remove all the necrotic tissue? If not, are they concerned that it might grow?
 
Please post the surgeons he’s seen and what hospitals you’ve been to for treatments. It also would be helpful to know if he’s been seen by an infection specialist. I’m going to tag @Jaycey, who is in the UK to see if she can help direct you to someone for additional opinions. Don’t be in a hurry to commit to either the fusion or amputation until you seek additional opinions.
 
Hi everyone

Thank you so much for your responses.

By way of a little more background, the original right TKR took place in July 2022.

Due to infection, the knee joint was removed and a spacer was put in on 31 March 2023 by the ortho consultant (to include debridement of necrotic skin and local musculocutaneous gastrocnemius flap, propeller fasciocutaneous flap and SSG from the left thigh by the plastics consultantl.

The second stage of the knee revision was carried out on 26 May 2023 with both plastics and ortho consultant present.

There was the involvement of a consultant of infection, but I am not 100% sure as to whether he 'signed off' so to speak before the second stage of the knee revision took place.

Fom our perspective, the fact the second stage surgery went ahead, we assumed that the skin grafting had suitably taken and the infection was no longer present.


After the second stage surgery in May, the wound had never healed. He had an area of necrotic skin which has now been removed but the issue is that there is not enough tissue bed to carry out another local skin graft, it would need to be a graft taking tissue/muscle from his back (so we have been told) and extremely traumatic, likely a 1 full day or more op, not something my Dad personally feels he can go though.

The frustrating part is that at present, he has movement in his knee, he can drive, walk around without walking aids, although of course not extremely far as he hasn't had any physio, but the knee itself has certainly not 'failed'.

Therefore with the fusion or amputation he is going to be far worse off that he is know mobility wise but obviously leaving an open wound on his leg is not sustainable.

He was treated at Hull Royal Infirmary if that helps, if anyone has any idea if there is someone likely to provide additional options I would be interested to hear.

Thanks again for your input, it's greatly appreciated :)

Charlotte
 
I should also say, at present there is no indication that there is an active infection, however, we have been told the wound will now not heal on its own with the necrotic skin removed.

Thanks
 
I think I agree with @Jamie that I would be wanting a second opinion.
Does your Dad have any underlying condition like diabetes that makes wound healing difficult? How well do the surgeons think the alternatives would heal?
There is a right to a second opinion on the NHS and I would be exploring this or looking at another opinion privately.
 
Please post the surgeons he’s seen and what hospitals you’ve been to for treatments. It also would be helpful to know if he’s been seen by an infection specialist. I’m going to tag @Jaycey, who is in the UK to see if she can help direct you to someone for additional opinions. Don’t be in a hurry to commit to either the fusion or amputation until you seek additional opinions.
Thank you! It would be really useful to hear from @Jaycey as I note from her profile she is also from Yorkshire, which is where we are based! Is there a way I can send her a message (I am née to this sorry!) Thanks! Charlotte
 
@Clevy1991 A couple of questions for you before I recommend anyone. Are you willing to travel? And do you have the capacity to pay for a private consultation and then get on the NHS wait list?
 
@Clevy1991 A couple of questions for you before I recommend anyone. Are you willing to travel? And do you have the capacity to pay for a private consultation and then get on the NHS wait list?
Hi Jaycey, thanks for your message. We consider traveling for a second opinion if necessary even just to cover all bases and get a different point of view, obviously the closer to the Hull the better and yes we could pay privately. Thanks again!
 
Professor Nicholas London at the Yorkshire Knee Clinic has some good numbers on the National Joint Registry. What I suggest is to see the consultant privately and then get on their NHS wait list (assuming you can't afford private treatment). This clinic is Leeds based. But you do need to see someone who has no connection to your current surgeon.
 
Hi, your dad is functioning much better than I thought by your first post. Maybe there is another way to get a piece of tissue to close the wound. In any event you now have a plan for another opinion and that's the way to go and give you and your dad hope. Keeping you in my thoughts.
 
There is a new innovation of using fish skin, (tilapia), to replace human skin on opened wounds. I have a friend whose mom had it sewn into an open wound on her leg and she is doing great! The fish skin covers the wound while new skin grows into it. It's very interesting! Veterinarians have been using it on dogs for a while now.
 
Fusion and AK amputation are not good options. Get a second opinion from a top plastics person and maybe they can transfer some of his gatroc muscle to cover most of it as my wife had done. She had the skin graft and a large constrained joint put in that got reinfected a year later. She was given the choice of amputation or living with the draining infection. Since she can still walk it was far better for her state of mind to live with the necessity of daily dressing changes. Fusion was never considered because her legs are quite long and it would make wheelchair life that much more difficult. If they have a way of closing it that may be better since amputation can always be done. The majority of skin grafts do not fail
 
Fusion and AK amputation are not good options. Get a second opinion from a top plastics person and maybe they can transfer some of his gatroc muscle to cover most of it as my wife had done. She had the skin graft and a large constrained joint put in that got reinfected a year later. She was given the choice of amputation or living with the draining infection. Since she can still walk it was far better for her state of mind to live with the necessity of daily dressing changes. Fusion was never considered because her legs are quite long and it would make wheelchair life that much more difficult. If they have a way of closing it that may be better since amputation can always be done. The majority of skin grafts do not fail
This is really interesting @bockoman thank you. It's really interesting to hear from someone who chose to opt for living with wound and having bandage changes. That is currently what my Dad is doing, with a negative pressure machine to drain the wound which means he can go longer without having a dressing change. Please could I ask how long your wife has been living with the wound and daily dressings? Did her skin graft not work or only partially work? Thank you
 
@bockoman also, what type of dressings does your wife have? Is there something in particular that assists in preventing infection? Thanks again, really appreciated
 
Your poor dad, he's been through the wringer with his knee. I think I would definitely seek a second opinion, especially as you said the actual joint and movement are ok.
Fusion by what I understand, will mean the leg will be fixed staright and AKA brings it's own problems. So neither seems like a good option.
As other have said a private consultation gets you seen quicker, if you can afford one and then get transfered to the NHS.
I hope he gets sorted soon. xx
 

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