Revision TKR if at first you don't succeed....<

[Celle]

I'm sorry you didn't get to go today, but maybe it's turned out for the best. IMHO, it's always best to see the OS himself and not one of his team.

 

[speccybecky]

I agree, at least you're getting to see the boss. Who was your surgeon? I had Mr Deep for tkr. Last referral for other knee was Mr Welsh who did arthroscopy to try and hold it for a bit longer

 

[puppywalker]

Mr Roberts becky.

 

[puppywalker]

Just back from the hospital. I didn't get to see the original surgeon but a rather dishy Frenchman who made Maurice Chevalier sound like he's been brought up in the BBC. However, I digress....

It seems that there are 3 tendons which go into the inside of the knee just below the kneecap and these are horrendously inflamed, hence all the pain and renewed swelling. He did tell me the proper name for it, but after 3 or 4 goes I still couldn't understand what he said - a mixture of my medical ignorance and his very strong (but very sexy!) accent! I need Josephine to put me right on what it's actually called - a 3-phrase term which sounded like Latin and was totally incomprehensible to me.

They have also taken loads of blood tests to check for infection as they can't rule that out in view of the heat in the knee and the fact that my blood sugars have been creeping upwards for several months for no good reason (I'm insulin-dependent). The doctor said that this inflammation is very often a sign of over-aggressive PT at too early a stage of recovery. He nearly had kittens when I told him about some of the things that I had been told to do!

So.. a couple of weeks intensive ultrasound and laser therapy at my local hospital, if that doesn't start to help in a fortnight, a steroid injection into the knee - oh joy - and ice, ice, ice and more ice. Ideally he said 20 minutes of ice, 15 minutes without it, 20 minutes of ice etc as many times a day as I could manage, but 7 or 8 times at the very least. At least the X-rays show that the joint is still firmly in place and intact, thank the Lord.

I asked what would happen if there was an infection but he said he didn't want to discuss that unless it happened. I'm on holiday next week, so the therapy won't start till after I come back, but my trusty CryoCuff will be coming away with me!

He also suggested that if using crutches helped me walk less painfully then I should use them and not worry about it, so I think they'll be coming away as well. I do feel a bit better, though, because I've felt for a while that something wasn't quite right and it's comforting to have the doctor agree and make a treatment plan. Here's hoping it starts to get better now.

 

[Celle]

Thank you for letting us know what the surgeon said. As you say, @Josephine may be able to clarify for you what the Frenchman said. I'm glad to hear that he does not support intensive PT - more surgeons are coming round to that point of view, thank goodness!

Now, enjoy your holiday, but do spend lots of time elevating, resting and icing that knee.

 

[Josephine]

It seems that there are 3 tendons which go into the inside of the knee just below the kneecap

I would imagine he mentioned the ilio-tibial band, the pes aneserinus and perhaps the lateral and medial collateral ligaments.

The doctor said that this inflammation is very often a sign of over-aggressive PT at too early a stage of recovery. He nearly had kittens when I told him about some of the things that I had been told to do!

I'm glad I'm not the only one that has kittens when people tell me what they're doing for PT!

Speaking if which, may I ask you some questions? It would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. And don't compare this with the bone-on-bone pain you had before surgery!

) Also don't forget to include other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how often are you icing your knee and for how long?

4. are you elevating your leg, how often and for how long?

5. What is your ROM - that's flexion (bend) and extension (straightness)

6. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

7. what kind of PT exercises and exercises at home are you doing? How much and how often?

Can you detail it like this

Exercises done at home: 3 sessions a day
Heel slides x10 (reps)
Strait leg raises x10
Steps x10

At PT
Squats x5 (reps) x2 (sets)
Wall slides x5 x2
Clamshells X5 x2

 

[puppywalker]

Josephine, I'll try to answer all your questions;
1)The pain is when I walk or bend the knee, when it is about a 6 or 7. At rest there's no pain whatsoever. All the pain is in the front of my leg starting just above the knee and going about 6 inches down the leg. The pain is totally different to what I had pre-surgery. Before it was a grinding pain, now it's very sharp and acute. There is also quite a lot of heat in the knee as well, especially towards the end of the day, which is slightly worrying as I haven't had that for a good while now, but after what I was told today about the inflammation I guess it makes sense. What really is annoying me is that I'm having trouble getting comfortable in bed - I was sleeping through the night within a couple of weeks of surgery and have had no more such problems until a week or so ago. It's not really pain, just enough discomfort to remind me that something's not quite right.
2) 2x 50mg Tramadol in the morning to help me work out the stiffness, thereafter 2x 500mg Paracetamol as and when I really need something to help. My GP recommended that I get off the Tramadol as soon as possible and after about 4 months I figured it was time. My stomach can be very reactive to most painkillers, even with another tablet to try to ease the effects, so I try to take as little as possible. I'm a little concerned about taking more Paracetamol as I understand that long-term maximum doses are not too good for the liver. On a lighter note, there's nothing so good for taking your mind off the pain as seeing a HUGE spider running across the bathroom floor while I'm in there, believe me! I'd forgotten I could move that fast!
3) I gave up icing the knee 3 or 4 weeks ago as it didn't seem to be making much difference and the swelling seemed to be well down. I've now been told to concentrate solely on the area of the tendons rather than the whole knee as I was doing before.
4) elevation has been much the same as icing - I was told today that elevation is no longer necessary and will not particularly help with this inflammation, although I can put my feet up if I want to relax, it's up to me.
5) he didn't use the measuring device , but judged my flexion at around 95-100, which is slightly down on the 120 I'd achieved a few weeks ago, extension had gone from 0 to about 2 or 3, but as the knee has become so swollen again that's not really surprising as is so often said on this site. I'm not too fussed about the numbers and neither is the doctor - the range of movement will come back when it's ready and the swelling has gone down again -I could do it before and eventually I'll be able to do it again, it's there, I just can't access it at the moment.
6) outside activity levels are not great as walking is so painful just now. I can do all my housework, including changing beds and hoovering. Pottering around the house isn't too bad as I can sit for a few minutes when the pain kicks in and then carry on again once it eases off a bit. Walking outside is still very difficult for me - 5 minutes on a good day, on a really excellent day (very rare), 10 minutes and that's all. Some days I just can't face even trying. I'm still limping/lurching horrendously, which I've been told won't be helping the inflammation at all. Since I've been told to use the crutches again as they help me to walk without the limp I'm hoping that I'll be able to increase the walking time. I still can't walk the dogs but can just manage the weekly shop round the supermarket with a trolley to lean on. Taking heavy or bulky loads up or downstairs is hard and I tend not to try for safety reasons as I really need to hold on to the bannisters. Back to doing stairs one at a time - grrr! I can drive for about 15-20 minutes before everything starts to seize up and get a bit iffy - long enough to get to the supermarket or visit friends or whatever, but I was never much of a long-distance driver so for now I'm happy with that. At least I'm getting out and about again under my own steam most of the time. For longer journeys my husband drives as I'm still afraid that if I sit in one position too long the knee will go into spasm as it does sometimes and I wouldn't be able to react quickly enough in an emergency.
7) PT and exercises - none at all for a good few weeks now apart from a few modified knee bends lying on my side before I get up in the morning to loosen things up a bit. Because I'm now doing all the housework I figured I didn't need the formal exercises any more. Since the pain and swelling started to increase again I thought extra exercises might be counterproductive. I do the occasional straight leg lift just be sure I still can - I can! I quite often flex and relax my quads when I'm sitting knitting or watching TV and they're feeling pretty much back to normal strength now. I don't ride any more, but I reckon I could manage a good rising trot if I did.

The doctor never mentioned the IT band - I thought that caused pain on the outer side of the knee and what I'm getting now is all on the front and inner side. He examined the new round flat swelling just below the kneecap and said he thought it might be an allergic reaction to the stitches, which threw me a bit as I would have assumed any allergic reaction would have shown up before now and this has only appeared in the last 2 or 3 weeks or so and only in that one spot. However, I'll let that one go for now as he gave me enough other things to think about for one day! He was most emphatic that he wanted me to go to the hospital for therapy rather than the usual health centre PTs and if their PT has caused this, I heartily agree with him.

 

[cairistiona60]

Where is the Golden Jubilee? Is that new? I remember the Glasgow Royal and the Western Infirmary.

 

[SarahJane]

Glad you got some answers and a treatment plan. It's affirming when the doctor doesn't discount your pain and listens to what you say, isn't it? I hope your test results come back OK.

Just a thought: I've asked people to write things down for me, if it's a diagnosis or terms I'm not familiar with. Stress impacts my ability to remember things, and doctor's appointments can be really stressful. I've never had anyone give me a hard time about asking. I think they understand and want you to know.

 

[puppywalker]

Christine - the Golden Jubilee is on the North Side of Glasgow, not very far from the Erskine Bridge. I'm told it was originally built as a private hospital with a hotel next door largely for people from the Arab states, but the NHS took it over - I imagine about the time of the queen's Golden Jubilee, hence the name. The hospital itself is very splendid - almost like a luxury hotel in it's own right and is considered to be the Scottish National Hospital and centre of excellence.

 

[speccybecky]

I'm so glad you've at least got some answers and know that your implant is good. Hopefully, it'll be the tendons and no infection will show up but sounds like they are covering all the bases. I wonder if it was Mr Frédéric Picard you saw? I have heard good things about him.

@cairistiona60 I had my op here because my local NHS (Lothian) would have breached the Government waiting times, most people go to their 'local' NHS hospital and are offered Golden Jubilee if they don't want to wait any longer. I also, with my husband, got to stay in the attached hotel ,free of charge, the night before surgery as I had to be there early in the morning. They said it worked out cheaper than a bed in the hospital!

Enjoy your holidays and hopefully be sorted out when you get back.

 

[puppywalker]

I think his name was Picard. A really nice guy.

 

[cairistiona60]

I can't remember what that hospital was called when it was first built. My ex husband did contract work as a radiographer there. He got paid a ton of money for doing hardly any work. There were about two patients in the whole hospital. Glad to hear it is being used.

 

[Celle]

@Josephine , puppywalker has answered your questions, in Post#127, above.

 

[puppywalker]

was it not called the Clydebank Hospital or something like that?

 

[Josephine]

2) 2x 50mg Tramadol in the morning to help me work out the stiffness, thereafter 2x 500mg Paracetamol as and when I really need something to help. My GP recommended that I get off the Tramadol as soon as possible and after about 4 months I figured it was time.

When did your GP tell you this? It's faulted thinking. Much better to take what you need when you
need it. I know some GPs get very leery about their patients being on prescription meds but all the evidence si that people taking them because of pain, do NOT get addicted. See the Youtube in this article Myth busting: on getting addicted to pain meds

I'm a little concerned about taking more Paracetamol as I understand that long-term maximum doses are not too good for the liver.

That's also misguided thinking. Paracetamol is one of the safest and most effective pain killers available. Provided you stick to the recommended safe levels of 4,000mgs per 24hrs it's perfectly safe. Another thing - if you take anything, it's always a good idea to take them ti good effect otherwise you're exposing yourself to possible side effects and not getting any benefit. As with any meds, for persistent pain, you need to take the meds on a regular schedule to get maximum effect otherwise what's the point! with paracetamol, that's 1,000mg every 6 hours.

My stomach can be very reactive to most painkillers, even with another tablet to try to ease the effects, so I try to take as little as possible.

By this do you mean you get acid stomach? And your doctor has prescribed you either lansaprozole or omeprazole? If this is the case, then the only meds you are reactive to are NSAIDs which includes ibuprofen and diclofenac. You should read this to understand these drugs and see the very huge list of NSAIDs that are available! Medications: acetaminophen (Tylenol, paracetamol) and NSAIDs, differences and dangers

3) I gave up icing the knee 3 or 4 weeks ago as it didn't seem to be making much difference and the swelling seemed to be well down. I've now been told to concentrate solely on the area of the tendons rather than the whole knee as I was doing before.

Exactly!

4) elevation has been much the same as icing - I was told today that elevation is no longer necessary and will not particularly help with this inflammation

It might, it might not. You can only try it and see!

judged my flexion at around 95-100, which is slightly down on the 120 I'd achieved a few weeks ago

Gotcha

6) outside activity levels are not great as walking is so painful just now. I can do all my housework, including changing beds and hoovering.

okay

7) PT and exercises - none at all for a good few weeks now apart from a few modified knee bends lying on my side before I get up in the morning to loosen things up a bit. Because I'm now doing all the housework I figured I didn't need the formal exercises any more.

Correct!

Since the pain and swelling started to increase again I thought extra exercises might be counter-productive.

Also correct!

He was most emphatic that he wanted me to go to the hospital for therapy rather than the usual health centre PTs and if their PT has caused this, I heartily agree with him.

Well, I'd be a bit leery about this. I wouldn't think there are any exercises that will help. In fact, I'd go so far as to suggest that you'd be much better off going to see a chiropractor as I've found them to be much better, much more hands on, when dealing with these issues. I've had many of the thigns you've described and my chiro has dealt with them superbly and, more to the point, quickly!

He examined the new round flat swelling just below the kneecap and said he thought it might be an allergic reaction to the stitches, which threw me a bit as I would have assumed any allergic reaction would have shown up before now and this has only appeared in the last 2 or 3 weeks or so and only in that one spot.

1)The pain is when I walk or bend the knee, when it is about a 6 or 7. At rest there's no pain whatsoever. All the pain is in the front of my leg starting just above the knee and going about 6 inches down the leg. The doctor never mentioned the IT band - I thought that caused pain on the outer side of the knee and what I'm getting now is all on the front and inner side.

I need you to tell me where this pain and the lumps are. Can you tell me the exact site using this chart?
Please note the instructions in the smaller image

 

[cairistiona60]

@puppywalker i remember now, it was just known as HCI. At least that was the name on my ex husband's pay slips.

 

[puppywalker]

@Josephine - Sorry I haven't got back to you before but we were away on holiday. I take on board your comments about painkillers. I'll try taking the Paracetamol at regular intervals for a few days to see if they're enough to keep the pain under control. There's no point in going for the big guns if Paracetamol can handle it. I'm on Lanzaprazole as a regular medication anyway as my stomach can be a bit iffy at the best of times. I've had a couple of suspected ulcers, although nothing showed up on testing and exams, but I've been told to take the Lanzaprazole anyway as it does seem to keep things on an even keel.
I have to go to the hospital not for rehab exercises but for laser and ultrasound therapy.
The pain is at D and E LF3, the lumps (I seem to have acquired a couple more smaller ones as well) are at E LF3. The whole of the scar is pretty tender but I don't know how much that is just normal healing at this stage, the lower half is very sore to touch.

 

[Josephine]

I'm on Lanzaprazole as a regular medication anyway as my stomach can be a bit iffy at the best of times.

The only drugs you have to be concerned about in regard to inflammatory issues listed in the article I gave you a link to. Opioids generally don't cause these problems and neither does Tylenol.

So you pain spots are here?

The orange spot could possibly be Pes Anserine inflammation which can spread several inches around the local tissues

 

[puppywalker]

well, over 3 weeks since my "urgent" hospital appointment. I still can't get anyone to tell me the results of any of the numerous blood tests they took and it doesn't appear that any referral has been made for the laser and ultrasound therapy I was told I needed to have done quickly! Icing the knee hasn't made any difference, I'm back on Tramadol and unable to walk more than a few yards. I am not a happy bunny!