Bilateral PKR Greetings from the other side

[Jamie]

@TKAA .... Please try not to worry about odd pains popping up this early in your recovery. It's normal. Your knee is going to be especially sensitive to any twisting motions for quite a while. Try to avoid those situations if at all possible. This all has to do with your soft tissues which were manipulated quite a bit during surgery. It takes time for everything to settle down and for muscles, ligaments and tendons to all adjust to your new implant and your leg's corrected alignment.

If you want to step down from opiate pain medication, you can ask your GP or your surgeon about using Tramadol. It does a good job on pain for most people, but it's not as strong as the actual opiates. Many people use Tramadol with Tylenol, then gradually switch out Tramadol doses for Tylenol until they eventually transition to just the Tylenol.

 

[TKAA]

Thank you Jamie. That's exactly what I started doing the last couple of days (tramadol and acetaminophen).

It's been a hard couple of days but I feel like it's important at this stage to get off the oxycodone. It has been tearing up my GI tract and leaving me too doped up to function effectively. The pain is still pretty overwhelming but I hope it'll subside soon.

Have a followup appointment with the surgeon (including x-ray) on Wednesday and will look forward to a positive prognosis and next steps.

It's a great help to have so many of you who have so much experience to guide us newbies. Thank you!

 

[TKAA]

Hi - been a while so I wanted to post an update and ask a question. I'm continuing my pain management rollercoaster. Having gotten off the oxycodone I was finding the tramadol really hard on my GI tract so I've been trying to get by on acetaminophen, naproxen, and ibuprofen in rotation. Nothing really cuts the pain spikes so I'm re-introducing low doses of opioids (e.g., 1/2 tab of 7.5mg hydrocodone) and that seems to help. I'm 6-1/2 weeks post-op so I'd really like to be off completely but the spikes are too much to just power through.

Most recently I've had an increase in pain and decrease in ROM in my left knee. I had a follow-up with my surgeon last week and she thought everything looked good - couldn't offer an explanation for the increased LK pain. I looked at the x-ray from that visit and noticed that the RK looked really clear and open next to the prosthesis but the LK seemed to have something in the way (see photo attached). I asked my OS via message what she thought and she said it could be a bone fragment or loose cement fragment. I asked if my pain persisted if some sort of clean-out debridement would be appropriate (I've had those after my other allograft/autograft procedures) and she said she didn't think so as it would require removal of the polyethylene insert.

So finally, here's my question: if I do have bone/cement fragments floating around in there, what's the treatment? Will these (hopefully) find a place to lodge where they don't cause pain, and what if they don't? (Haven't had a chance to ask the OS that yet but will follow up, but was wondering if anyone here has had experience with debris post-UKA and how it was handled.)

PS - after several days of increased pain/decreased ROM, today that knee feels a lot better (yay!). So I'm hoping things have resolved themselves naturally. But I'm still curious as to what to do about it if that really is debris and it becomes a recurring problem.

 

[_Annie_]

Yikes, I don’t like the looks of that. But maybe somebody smarter than me has a different opinion. I feel for you. Let us know what you find out.

 

[sistersinhim]

I'm glad you're feeling better. Back in '93 when I had my right kneecap removed, my OS wired my patella tendon together. Years later it was discovered that some of the wire had broken off and embedded itself in my tissues. I knew it was loose, but it didn't cause me any problems. When I had my tkr, my OS saw the wire piece but said it'd cause more tissue damage getting it than it would be to just let it stay. So, there it still is and causing no discomfort. If you have loose material, it's possible your knee will be the same as mine and you won't even know it's there.

 

[TKAA]

Thank you @sistersinhim. That's encouraging.

 

[kneeper]

Hi - been a while so I wanted to post an update and ask a question. I'm continuing my pain management rollercoaster. Having gotten off the oxycodone I was finding the tramadol really hard on my GI tract so I've been trying to get by on acetaminophen, naproxen, and ibuprofen in rotation. Nothing really cuts the pain spikes so I'm re-introducing low doses of opioids (e.g., 1/2 tab of 7.5mg hydrocodone) and that seems to help. I'm 6-1/2 weeks post-op so I'd really like to be off completely but the spikes are too much to just power through.

Watch out for the naproxen and ibuprofen, which are both NSAIDs and can be hard on the stomach. Taking more than one NSAID can cause real GI problems (and it can be silent problems). Have you consulted with your doctor on this plan?

 

[TKAA]

Hi - been a while so I wanted to post an update and ask a question. I'm continuing my pain management rollercoaster. Having gotten off the oxycodone I was finding the tramadol really hard on my GI tract so I've been trying to get by on acetaminophen, naproxen, and ibuprofen in rotation. Nothing really cuts the pain spikes so I'm re-introducing low doses of opioids (e.g., 1/2 tab of 7.5mg hydrocodone) and that seems to help. I'm 6-1/2 weeks post-op so I'd really like to be off completely but the spikes are too much to just power through.

Watch out for the naproxen and ibuprofen, which are both NSAIDs and can be hard on the stomach. Taking more than one NSAID can cause real GI problems (and it can be silent problems). Have you consulted with your doctor on this plan?

Thanks @kneeper. It's actually my doctor's recommendation. I really am at a loss as to what else to do as I can't tolerate the current pain level without some sort of analgesic and I'm trying to minimize use of narcotics except to handle spikes. Do you have a suggestion?

I'm more reliant on Tylenol than either naproxen or ibuprofen - is that a preferred course of action?

 

[kneeper]

Tylenol is usually a safer option. Using Tylenol in alternation with an NSAID like ibuprofen is not unusual. I just want to make sure you're not doubling up on your NSAIDs.

 

[TKAA]

Update (8 weeks post-surgery) - I saw the surgeon who partnered with my primary OS for my surgery, regarding my ongoing LK pain and suspected bone fragments/loose cement.

He confirmed that it looks like there are loose bodies but doesn't think they are the source of my pain. He suggested waiting 3-4 months to see if the pain remains and only then consider going in to remove them (and reiterated that he wasn't convinced that would resolve my pain).

Rather, he unexpectedly asserted that I was a borderline candidate for this surgery because of my prior allograft and autograft procedures. He said my bone stock was compromised and he's not surprised that I'm having a challenging recovery. He invited me to book an appointment for a year from now and we could discuss revision to a TKR at that time if necessary.

Obviously not what I was hoping to hear, and not very actionable. I'm still processing this news but I guess my only course of action is to focus on my recovery and do whatever I can to get the best outcome given the circumstances.

I asked repeatedly pre-surgery about whether the prior procedures would interfere with the PKR and my primary OS said we won't know until we're in there and if they do we'll do a TKR instead. So I suppose I knew there was a chance they'd opt for PKR knowing that was my hope and it just didn't turn out as well as we would have liked.

Question - does anyone know of a reputable radiology second opinion service? If it wasn't too expensive I'd consider sending the images out just to see what a trained radiologist's assessment was. Obviously I'm still not convinced my issues aren't related to loose fragments/cement pieces (or maybe I'm just fantasizing that cleaning them out would make a difference).

Thoughts?

 

[Rick951]

@TKAA Sorry you are having so many challenges! Sorry, I have nothing to offer!! In general it is hard to get a 2nd opinion less than a year out.
Wish you the best of luck!!
Rick

 

[Jamie]

The second opinion you need is not from a radiologist. That person would only tell you that, yes, you do have loose bodies in that knee. A radiologist will not diagnose whether or not that might be the cause of your pain. You need a revision surgeon's opinion. Unfortunately, you'll probably not be able to get that until you are at least 9 months out from your PKR. You certainly could try, though. And I would definitely do that because after your experience with your primary surgeon and the assistant you just talked with, I think it would be difficult to trust this surgeon to do another surgery.

I'm so sorry you are having these problems. If you can find a surgeon for another opinion, that would be great (needs to be a revision specialist). If not, you're just going to have to wait and follow the guidance of this second doctor you've seen. He actually makes a lot of sense.