Revision TKR Hmm. Not thrilled with the revision yet

[eaglemom]

Here is the thoughts of the pain management physician I saw today. First off I really liked him, but man oh man he seems young. The bonus to that is he's up on all of the latest and greatest of things. I hadn't realized it but he was named a Top Doc of 2018, which I think is awesome. And he spent over 45 minutes with us - listened to our concerns and questions. That's a win / win in my book.

So he is recommending something different that what my orthopedist had "suggested." I was thinking it was a nerve block and temporary - that's what was ordered. However, after looking over my chart and talking with me and moving my knee joint around he said that's not what he would recommend. Its temporary and for my level of pain it didn't make sense. He's recommending 2 different things. #1 is a very detailed through sonogram of my leg, focusing on lower below the knee. He explained you can have spider veins that are deep thus not visible. If those veins aren't open all the way the recirculating blood is not flowing like it should. The end result is the knee swells, pain, etc. To 'fix' that its under a flora-scope and he injects into the veins opening them up. Then more blood flow equals less swelling. He said he's had great success with that and its easy peasy. #2 is a procedure where he burns / zaps the genicular nerve, I believe. He does 4 punctures , puts a band aid on and I'm done. It's done under the flora-scope also. He's had 60% success rate. Yes the nerves grow back but you usually have relief for a year or more. I've not heard of this so hopefully someone can fill me in on it. He was forthright on saying it will take the pain away, not fix anything, but won't hurt anything either. If the knee isn't hurting then I could have a more normal life and hopefully the movement will increase. Thoughts?

He also prescribed Nucynta 50 mg 2 per day for pain. He doesn't think the Tramadol is enough to totally control the pain. I was also told I can admit I'm having pain (something I have a hard time admitting). His goal is to restore as much of 'normal' to my life without a huge surgery.

Can't wait to see what everyone thinks about this. I so appreciate this message board and the people in them.

Myra

 

[Jockette]

2 is a procedure where he burns / zaps the genicular nerve

This sounds similar to Radio Frequency Ablation. My husband had this done to his lower spine a week ago. We are cautiously optimistic.

How awesome he spent so much time with you and listened to your concerns. That did not happen for me at my second opinion appointment.

 

[Belle]

#2 is a procedure where he burns / zaps the genicular nerve.

I just had a Radio Frequency Ablation on the 14th and so far very happy with my results. This is the best I’ve felt since my PKR in 2012 followed by 2 revisions. I’ve never heard of #1.

 

[KarriB]

I would be encouraged that he’s looking for the problem instead of just treating the pain.

 

[eaglemom]

Thanks for the advise. I'm just hesitant, for lack of a better word, to do the procedure. Yes I do think, hope it will help. However, my concern is that my knee has so much scar tissue. If the scar tissue is part of the problem that isn't even being addressed.

Gad maybe I'm just way over thinking this. I've not found much information on the Coolief procedure he's planning on doing. What I do find is that its for treating OA, and that certainly isn't the case. The doctor felt very confident that I'd have some pain relief. But again now I have less pain but a knee still full of scar tissue that doesn't want to bend. I'm needing pain relief and movement.

 

[eaglemom]

Can we discuss scar tissue. Scar tissue so dense that the surgeon when trying to draw fluid off the knee can barely get the needle through it.

What is there to do about it? He's suggested surgery to remove it, and then a very aggressive PT trying to keep it from occurring. That doesn't sound good to me - the knee will be mad from having surgery again, isn't it rest, ice elevation? I have a problem with swelling anyway - more swelling from a scar tissue removal and trying to bend just doesn't go together.

Agh. Stupid stupid knees.

 

[sistersinhim]

I will tag @Josephine for you. I don't know how to advise you. I know that aggressive PT causes the knee tissues to get hot, which can cause adhesions. They are the bad kind of scar tissue. You need scar tissue to heal you tissues back together!

 

[Celle]

You could have an Open Lysis of Adhesions, but aggressive PT afterwards would not be advisable.

@skigirl had this procedure and I believe she was advised to only start PT again very gently. I'll ask her to talk to you about it.

 

[Josephine]

Can we discuss scar tissue.

The term scar tissue is very badly used. What most people (including doctors and PTs) mean when they use it is actually adhesions. You can read more about adhesions in this article MUA (Manipulation under Anaesthetic) and Adhesions.

But real scar tissue is that which holds stuff together! Like when the surgeon cuts into the body all the way down from the skin to the joint. That's an incision and when it heals, it is being joined together with fibrous tissue. Mostly this is a relatively thin layer of tissue and stays pretty flexible.

But the 'scar tissue' so often referred to is actually adhesions and these can stick muscle bodies and other structures together with some ferocity.

Scar tissue so dense that the surgeon when trying to draw fluid off the knee can barely get the needle through it.

This scar tissue is the real stuff, that which heals wounds. There are occasions when it can take on the characteristics of gristle and can often be as tough as bone. That's why the needles can be bent!

What is there to do about it? He's suggested surgery to remove it, and then a very aggressive PT trying to keep it from occurring.

I wouldn't advise it. He is muddling up the two kinds of 'scar tissue' which is very disquieting for a doctor!

 

[kneeper]

Interesting point about the veins. It could be worth investigating to see if that is part of your issue.

 

[eaglemom]

I'm having the vein sonogram next week. Then I'll see which was to proceed. I'm an information / facts / research kind of gal - sometime very helpful and sometimes very overwhelming!!!

Thanks everyone for your thoughts. And Josephine for your detailed description. Information and knowledge are power. Power to decide what is the best thing to do. If anything.

 

[Jockette]

Information and knowledge are power. Power to decide what is the best thing to do. If anything.

I like how you put this. Especially the “if anything. “

That’s where I am right now. The “if anything” part.

 

[eaglemom]

I had an appointment with the orthopedic surgeon to 'review' everything. I will say the ortho was surprised the pain management doctor (whom the ortho sent me to) was recommending a different procedure. After chatting about it quite awhile the ortho said "both procedures achieve the same end result, but I'd ask him to perform a block not the type of RFA he's proposing." I didn't know how to respond so I simply said the two of them need to decide which one. That's when the ortho said "oh no no, if he's recommending this, that's what I want him to do. I just want to understand the 'why' this is what he's chosen is best for you."

Tomorrow I'm having the 'vein mapping' done. At that point I'm going to start asking serious questions about the RFA type of procedure. Will more questions, I keep going back and forth on it and really the ortho made some excellent points about having it done. We also discussed if this doesn't fix the problems what type of surgery he'll perform. We discussed the difference in scar tissue vs adhesion's. What he is doing is everything possible without opening up this poor knee again. And that I can certainly appreciate.

So that's the plan........... for now and always subject to change.

 

[eaglemom]

I forgot to add something. I measured -19 to 110. The surgeon side if I could even gain 10 degrees he would be happy. That's I'd be able to walk better, be able to do steps, etc.

 

[eaglemom]

Hope someone responds. Color me blue. The vein mapping was a bust. All it did was say I needed a machine on my legs to "push the excessive fluid" from your leg(s)." Everyone knew that. The veins he thought were okay, just so much fluid in the tissue of the lower leg.

Some guy comes to the house to fix me for the leg compression devise. I was shocked so didn't ask as many questions as I should have. I'm to wear it for 3 or 4 months. I didn't ask but assume for a certain amount of time. It makes no sense to me a sore knee now will have mechanical compression on it.

When I arrived home they had called to schedule the Cooleef RFA procedure. I asked about the compression device and the knee after the RFA and she said she didn't see a problem. Hmmm. My knee needs ice daily, now we're adding some compression thing and then have a procedure on top of that. My poor knee. (And I'll admit to being somewhat overwhelmed by all of this.)

Thoughts? Ideas?

Who knew this knee would be such a diva? Certainly not me.

 

[Jockette]

Forgive me for asking, is this for the right knee? That poor knee has been through the mill!

I don’t know what to tell you, Let’s tag @Josephine

I’m sorry this has been such an ordeal. It makes my unhappy experience look like a piece of cake.

 

[eaglemom]

Oh dear Jockette, I guess I just assumed everyone knew it is indeed my right knee. And yes its been worked on far too much to be this awful still.

I'm sorry you've had a rough not complete recovery either. Our surgeries aren't that far apart - several months is all. I will second what you stated: I want Josephine to do my surgeries!!!

 

[eaglemom]

I just received a call that they want to do the RFA next Wed. Apparently the swelling is concerning.........

 

[Jockette]

Do they think the RFA will have really good results? Do they think it will reduce the swelling?

 

[eaglemom]

Frankly Jockette, I think its a not a goer. The pain management doctor said he has a 64% success rate with TKR's for about a year of relief. I asked about a revision knee and he didn't give me an answer - my mind was spinning because none of this was what I expected.

My orthopedic surgeon really wants me to do this. I'm doubtful but...... The surgeon's thoughts are IF I get pain relief, possibly the swelling will dissipate and then I'll be able to bend the knee properly. Per say this will do nothing for the swelling, but rather lead to more bend. I'm one who tends to swell and I make enough scar tissue/adhesions for an army. Ugh.

It absolutely gags me having another procedure - and one that's not permanent to boot. But the thought of opening up the knee terrifies me!! So I'm really left with the choice to do this and "wait and see."