Bilateral TKR Superior and Inferior Patellar Enthesophytes

[GratefulNana]

i had my arthroscopy this afternoon in Vallejo, where I live, The staff was very attentive and competent. The surgeon found and removed some tissue he felt might be catching in the knee and causing the pain. He also debrided the knee. The prothesis looks well placed with no obvious problems. I am allowed to weight bear as tolerated and am not required to use a cane or crutches. Thankfully, so far I have successfully managed to walk from the car, up two steps into the house, and up thirteen very steep stairs to our bedroom.

I took my husband to ny pre-op appointment, since my first impression of this doctor was not favorable. I was still thinking of cancelling the surgery. This time around, I saw a much different person. He was very warm and friendly. We got the impression that if you want specific information about the procedure you are going to have, you have to be direct, which I was. I got the feeling this is a new protocol. The surgery authorization that I signed today had an interesting paragraph that went into some detail that the patient should explore all options available with the doctor, including not havng surgery or doing nothing. His nurse told me that I am actually lucky to have been shifted to this doctor as he is a genuinely good person, and a better doctor than the one who did my BTKR.

i was not given a prescription for pain meds again. I heard the doctor tell the nurse. She was really upset. However, she did tell me that her son is finishing up his ortho residency in Germany. Germany is no longer prescribing pain meds for ortho patients, at least where he is. I also overheard my podiatrist, who was getting ready to take a patient to surgery that he was not going to prescribe a narcotic for pain. He offered her Gabapentin. He was is a very compassionate young doctor, and he was always very good about pain management. I think the way the medical profession is addressing pain is being changed again. I wonder what the definition of pain management is now.

What my husband and I got from our pre-op meeting with my new doctor, was that he thought I am too active for a person with knee pain. He said that people with knee pain do not walk around Costco, or hike hills. My response was that my pain issues were not addressed until two years post BTKR. I told him that I was told over and over that it was acute inflammation or tendonitis. The treatment was to elevate and ice, which I was doing, and it was not working. i asked him if I was expected to just sit around all day. Just climbing the stairs in my home can set off the extension pain. The doctor feels that if you have pain doing anything, you are not to do it. If this is the new pain management philosophy, don’t keep beating me up at my regular GP appointments for not exercising on a regular basis. They can’t have it both ways.

So far my pain is manageable with ice and elevation. My quads are really swollen and painful, which is to be expected. We’ll see what tomorrow brings. Glad it is over.

 

[GratefulNana]

I had my arthroscopy follow-up appointment yesterday. The incisions are healing well. I was surprised at how neat and exact the incisions looked when the steristrips were removed. The stitches were removed last week by a different doctor and the skin was still very puckered and red.

i have my wings clipped for another four months. The OS wants me to do no exercising, including walking any distance, and he does not want me on my feet for long periods of time. It is going to be difficult to be so restricted for so long. I am still dealing with extensive swelling in my right knee also. I showed him the very large nodule on the outer side of the knee. It does somewhat impair my walking when it is really swollen and tight, but he insists that it is probably caused from my overusing it because of the left knee problems. I really hope he is right.

 

[GratefulNana]

I have been very busy these last few months trying to catch up on everything that I was not able to do following my left knee arthroscopy. I followed the post-op instructions given to me by the OS to the letter. I was determined to give my knee every opportunity to heal. The “catch” in the knee is gone. However, I still have a great deal of pain when putting my weight on the knee when climbing stars, or walking uphill. There is some pain going down the stairs, and a lot of pain walking diwnhill. Since I am looking at revision surgery on my right foot in January 2019, I have just decided to get through these next few months.

Unfortunately, I had an unexpected turn of events last Friday when I bent over to pick up my granddaughter’s metal water bottle that fell out of her backpack. My left knee gave out and I was pitched forward into my son-in-law’s car that was backed into their driveway. I managed to get a nasty shiner, stitches in my upper lip, and a dislocated shoulder. The left side of my face is purple, plus numerous bruises on other body parts, including the left knee.

I saw an assigned ortho doctor yesterday as follw-up to my emergency room visit. She was excellent. She examined my right shoulder and tested my range of motion. She concluded that I could remove the immobilizer and begin PT. It is an interesting theory, but she feels that my fall may have come from a signal from my spine to release the knee. In 2009, I suffered a rupture of the L3/L4 disc. I was extremely fortunate in that the disc healed and I have a very healthy spine;however, I was left with spinal stenosis, which, at times is problematic. She feels that ny back may be the problem with my knee; so, she wrote my PT orders for both the shoulder and the knee. My left knee gave out, causing me to fall, several months ago before the arthroscopic surgery. I was playing on grass with my granddaughter and thought the fall was just something that happened. In both cases, I bent over to pick something up, and went down. I am very curious as to how this is going to play out.

 

[Pumpkin]

GragefulNana,
Hope your knee and shoulder do well after this most recent "adventure".

 

[SusieShoes]

It's kind of a medical mystery, isn't it? Sorry to hear you had another fall and hope this new bout of PT helps your shoulder. I hope too that you get to the root of what's going on with bending over and your knee releasing.

 

[GratefulNana]

It’s been another busy year. It ends up that a couple of months after my left knee gave out, and much pushing on my part, I finally got an MRI on my right shoulder and an appointment with an orthopedic surgeon. Upon review of the MRI. the surgeon showed me, what he described as, a large Hill Sachs Lesion and a large Glenoid Rim Fracture. These fractures have left my shoulder medically-described as unstable. He said that I was too old to operate on. Actually, I am happy he made this decision because I have met several individuals who had shoulder surgery who are unhappy with their results, and I have been fortunate to have rehabbed my shoulder to a point where I have been able to maintain almost full range of motion.

Unfortunately, my left knee remains problematic nearly four years post BKR, and arthroscopic surgery in 2018. I saw the orthopedic surgeon last Friday, regarding the knee catching again and showed him the bruising on the medial side of my knee. I also described to him the pain that I have been having for several months in my left hip. He determined that I have bursitis in my left hip caused by my knee issues. He previously did an arthrogram on my left hip and found it healthy. He is now recommending another arthroscopic surgery to once again clean out the knee.

It is interesting to me, and frustrating, that after BKR, one knee is more problematic than the other. Why does one knee continue to grow scar tissue, and the other does not. Since Kaiser Hospitals in my area are teaching hospitals, we have to give authorization at the time of surgery to allow another doctor to train during our surgery.
I wonder, since my bilateral knee surgery was completed in one and one-half hours, which is an unheard of short period of time in speaking with individuals that have had only one knee replaced in that time or longer, if two different doctors operated on me simultaneously. It was not disclosed to me at the time of surgery that a second surgeon would be assisting, nor was it disclosed in my medical records, of which I obtained a copy. It just makes me wonder how one surgeon can replace two knees and meet with my husband following my surgery within the total time span of one and one-half hours, fully showered and dressed in street clothes, ready to leave on vacation. Just wondering...

 

[Jockette]

I’m sorry you still have such problems with that one knee. Your theory about a student doing the replacement sounds reasonable, I would wonder the same thing. Is there a way to find out if that is true? Not that it would change anything for you now, but it would be nice to know.

I’m surprised that you don’t have a choice about whether or not you consent to a student doing some/all of the surgery.

Has revision ever been mentioned?

 

[LindaO]

Interesting...Have there been tests to determine if there is movement in the prosthesis or anything?

Could you decline consent for a student to assist?

Keep us posted on any updates! Best of luck!

 

[lovetocookandsew]

@GratefulNana I also have Northern California Kaiser (and have had Kaiser since 1976!), and have never signed anything about allowing a student to train during any of my surgeries. Maybe your particular doctor does that so has you sign a consent? Anyway, you also have a right to see your records, so maybe ask your OS if he had someone assist, and how. He can see your records, hospital and all, while you're talking to him so he should be able to answer you. If not, you can request to see them or get copies, etc.

 

[GratefulNana]

Thanks for your responses. A revision has not been mentioned. Multiple x-rays taken since the 12/28/2015 BTKR, according to the Orthopedic Surgeon, show no movement. When I had arthroscopic surgery and arthrocentesis last year, no problems were found with the prothesis, and no infection was found. What was found was a significant amount of scar tissue, which was removed.

As far as signing off on having a resident/training doctor assist with my surgery, I have obtained my medical records from the surgery, and there is only one doctor listed as being the attending surgeon. No one is listed as assisting. The operating Ortho Doctor was the lead doctor in setting up this particular hospital as an Orthopedic Hospital for Kaiser. He explained this to me before my surgery. At the time, all elective ortho surgeries were being performed in the county in which I reside at this facility. Unfortunately, there was a terrible disconnect between the operating surgeon’s instructions for my care, and the care that I received. Not one nurse or physical therapist assigned to my care had taken care of a BTKR, and it was a horrible situation that I found myself in. After the investigation into my case, Kaiser quit performing BTKR at this facility. The facility never became an ortho hospital, but continues to perform ortho surgeries.

I have had both of my feet ”rebuilt.” Unfortunately for me, a more drastic surgery had to be performed in February 2019 on my right foot, with my left foot scheduled at that time to be done in December 2019. Problems with the right foot developed with the screws and other issues, so I am now scheduled for January 2020, with the left foot surgery being placed on hold. All of these surgeries had a resident doctor assisting. The difference between the Ortho Doctor who performed my BTKR, and my Podiatrist, is arrogance. The Podiatrist is straightforward, and he is a teaching surgeon. He always introduced the training doctor to me. The Ortho Doctor brushed me off repeatedly when I told him of my problems with my left knee. He told me that he “ fixes other doctors mistakes,” he does not make them. He then told me that he was sending me to another Ortho Doctor who specialized in hips. He said that he was certain that the problem was a hip problem, not a knee problem.

The new doctor is now my Ortho Doctor. He performed an arthrogram in January of 2018 and found my hip to be healthy. He then performed the arthrocentesis and arthroscopic surgery on my left knee in February of 2019. This doctor is approachable, and staff loves him, including the operating room staff. I have confidence in him. If the knee is stable, but continues to develop scar tissue, I don’t have any idea what my options are. I will have to have that conversation with the doctor after my next arthroscopy.

Take care

 

[Jamie]

I'm sorry to hear that you're still having problems with your knee. But I am glad to know you have a different surgeon now. It doesn't sound like your previous doctor was adequately engaged with your situation.

Am I understanding correctly that you're going to have additional foot surgery this January and your knee issues are on hold?

 

[GratefulNana]

Thanks for your response. Yes, my knee surgery is on hold now because, for some reason, my foot surgery date was changed. My Podiatrist is doing a lot of teaching, so I suspect, with his limited surgery schedule, that someone with a more compelling need bumped me.

My right foot has become very painful due to the screws in the big toe that were used to “freeze” it. It was hyper mobile. After the Weil procedure, I developed a floating fourth toe, as well as some other tissue issues that need release/“cosmetic” surgery. So, it is extremely painful to wear shoes for any length of time.

I need to be able to walk without pain in my right foot before I deal with knee issues.
I had a lot of swelling after last year’s arthroscopy.

I was really hoping to be traveling during this phase of my life instead of sitting around icing surgical sites year after year. LOL

I’ll get there.

Take care

 

[Jockette]

I was really hoping to be traveling during this phase of my life instead of sitting around icing surgical sites year after year. LOL

I’m sorry. I hope you find a solution and get to do that traveling.

 

[GratefulNana]

I have been having ongoing knee problems since my bilateral TKR in December 2015. Two days ago my right knee swelled up twice it’s size unexpectedly in the evening after a very routine, quiet day at home and became unstable with weight bearing. The knee was, and still is, very painful and somewhat swollen and continues to feel unstable. I contacted my ortho doctor yesterday and he ordered x-rays of my pelvis/hips and right knee. He reported back to me that there was no change from 2019 in my hips with mild arthritis and that my replacements are intact. He ordered some Mobic for me and said he hoped I felt better soon. This was through the Kaiser Permanente messaging system. However, the radiologist sent a message to me stating that small superior and inferior patellar enthesophytes were found. From researching, it appears that enthesophytes cause exactly the symptoms that I reported to the doctor.

I was wondering if anyone else has had experience with this condition and how it was handled. I have already had arthroscopic surgery on my left knee to clean up scar tissue post tkr. My left knee had become swollen, painful, and unstable. My left hip has developed chronic trochanteric bursitis after two ortho doctors were certain that my left knee problems were referred pain from my hip and strongly suggested that I have an arthrogram, which showed that my hip was healthy. I initially had bilateral tkr because of patellar tracking, and bone on bone problems.

It has been frustrating going through a bilateral tkr only to find that nothing has changed except that my legs are now straight.

 

[sistersinhim]

I had to look up knee enthesophytes, which were caused by overworking the joint. Have you tried resting it for a few weeks or a month? I'd say it's definitely worth a try.

 

[Celle]

It has been frustrating going through a bilateral tkr only to find that nothing has changed except that my legs are now straight.

I know it probably feels that way right now, but it's not really true. True, you have the enthesophytes, which have developed recently, but you still have two knees that have had the damage caused by osteoarthritis removed and replaced by the prostheses, with the plastic spacer acting instead of damaged or missing cartilage. That should have taken away the knee pain that would have continued to get worse.

I don't recall anyone else coming to BoneSmart with enthesophytes so, like sistersinhim, I looked it up.
The basics are: An enthesophyte is a bony spur forming at a ligament or tendon insertion into bone, growing in the direction of the natural pull of the ligament or tendon involved.

Knee enthesopathy is usually linked to overuse or stress put on your knees. This type of enthesopathy often results from conditions such as patellar tendonitis. Patellar tendonitis is also called runner's knee. Pain with this condition is usually worse when you're exercising and putting stress on your knees.

So, I agree with sistersinhim's advice, to rest as much as you can. You might like to ice your knees as well.

I do have some concern that the radiologist contacted you and told you what he had found. It would have been better if you got this news from your surgeon, with whom you could have discussed treatment options and a prognosis. You should discuss these with your surgeon.

 

[Celle]

By the way, I've merged your new and old threads, so we have more background information on your knees. This then allows us to look back on your previous progress and it acts as a sort of diary for you.

 

[GratefulNana]

Thanks for merging my previous posts and for the research. The ortho doctor should have told me about the enthesophytes when he contacted me, as he had the radiologist’s reports before they were sent to me. I read the message from the doctor first and went to sign out when I saw there were two other messages. The messages were from radiology. This must be a fairly new protocol by Kaiser. My concern was that the doctor had the information and made a decision not to mention the enthesophytes to me as the cause for my discomfort. I am losing trust in this doctor. He and the operating surgeon for my bilateral tkr decided that my knee problems were caused by my hips. For my age of 74, my hips are healthy with only mild arthritis. Until the left hip arthrogram, there was absolutely no pain at all in my left hip, and the joint was found to be healthy. I just came out of two months of pain and discomfort from a bout of trochanteric bursitis in my left hip, which first started directly following the arthrogram. I have done nothing as far as overuse of my right knee other than it bore the brunt of my hip bursitis recovery due to weight bearing limitations. The ortho doctor seems to want to replace my hips, and I am opposed to the idea. He has not proven to me that they are the problem. Why would I replace healthy hip joints?

I am resting and icing the knee during the day and icing before bedtime. Most of the swelling is gone; however, the knee is still very painful and stiff. Hopefully, everything will heal in a few days. I am hoping that this is not going to become a chronic problem.

I had never heard of enthesophytes before. There doesn’t appear to be that much information about them. I was wondering what the long-term prognosis is.

Thanks again for your help.

Diane

 

[tinwoodwoman]

Hi Diane, aka @GratefulNana

I am only 2 months out from BTKR and I'm reading recent posts from our clan. So I read much of yours. I just want to say, I'm sorry that all these years later, you are still struggling with your knees and getting mixed messages from the professionals. You are really smart to do your own research and come here for help from such experienced moderators. I am glad to hear that rest and icing are helping and hope this is not chronic! Maybe someone else will come along who can answer your questions.

 

[GratefulNana]

Hi @tinwoodwoman

How are you doing? Hopefully, well. With all my much later post-surgical issues, I was extremely fortunate with a relatively uneventful recovery. I actually had more mobility than others, who only had one knee replaced, when I attended PT. I was released fairly quickly.

I appreciate your kind words. The more I thought about my ortho doctor’s response to me regarding the results of my X-Rays, the more I realized that he has a responsibility to explain the full findings, not dismiss me with a truncated version. So, I politely thanked him for the Mobic prescription, and mentioned to him that I had received a message from the reading Radiologist that stated that enthesophytes were found in the inferior and superior areas of the right patellar along with fluid in the knee. I asked him if he could please explain what the findings mean and if I could expect to experience any long-term issues. Hopefully, I will receive an answer next week. So far, my knee is on the mend, but I am still having some swelling and pain. I just want to be informed as to what I may be dealing with. I am an active person, and try to roll with setbacks.