Revision TKR Instability Question

[rah2435]

here you are driving at less than 3 weeks

I suppose since it's my left knee. But I think I should limit my driving for the time being.

 

[rah2435]

@sistersinhim I don't feel that fantastic today. I did go on that long car trip over the weekend and I think maybe I'm suffering because of it. Lot's of pain and I'm having trouble standing and walking. Still need a shower chair. :-(
I had my left knee reworked so the right one was ok to drive. But my left suffered from staying in one position too long. I tried to get out and move it every hour but... it turned into more like 90 minutes+

rah

 

[rah2435]

@Celle ok - so I went on the trip this weekend - turned out to be more like an 8 hour ride home yesterday due to traffic and weather (rain). I did ok. DIdn't do much while I was there but I did walk around - even went out for lunch. It was probably better for me mentally than physically. I hurt.

So "home" PT is done and usually I would start doing PT outside. I feel that I'm not ready for that. I'm using a cane and - the first few steps are shaky. Doing very little other than walking - trying to walk (not even 5 minutes) every hour.

I found this in the library section (I'm 3 week today)
But after the first 2-3 weeks of rest and recuperation, normal activities of daily living (ADLs) can be quite adequate for that rehab/PT

ADLs include:
~ Personal hygiene and grooming (still use a seat in the shower...standing is difficult)
~ Dressing and undressing ( I can do it - but mostly sitting)
~ Functional transfers, e.g. Getting out of bed (well - yeah, but the putting weight on the knee hurts as
soon as I get up)
~ Voluntarily controlling bladder and bowel elimination (yeah - although experiencing constipation due to meds)
~ Ambulation (Walking or using a wheelchair) (using a cane and doing VERY little)
~ Housework ( I can't really do much of this...I made myself a coffee this morning and that was difficult)
~ Meal Preparation (my wife is handling most of this - when she's here )
~ Care of pets (no pets)
~ Meal preparation and clean-up (can't do much of this right now)

So - am I doing ok? Still get lots of pain when putting weight on the knee and it's wobbly ... not too strong).

My plan for this week is to just do some walking and maybe some minor stretching. I feel like I'm progressing very slowly and I get very depressed about this. Anyway - is this a good plan ya think?
I want to put off going out to PT for at least a week.

thanks
rah

 

[sistersinhim]

I had my left knee reworked so the right one was ok to drive.

What did you have done and when was it? It's not in your signature. Driving is always stressful on new knees. I think with lots of TLC your knee will snap back soon.

 

[rah2435]

@sistersinhim I had a revision done to a left TKR that was done in 2013 and was unstable.

 

[Celle]

My plan for this week is to just do some walking and maybe some minor stretching. I feel like I'm progressing very slowly and I get very depressed about this. Anyway - is this a good plan ya think?
I want to put off going out to PT for at least a week.

Yes, it's a good idea to put off PT, for as long as you like.
It's not exercising that gets you your ROM - it's time. Time to recover, time for swelling and pain to settle, and time to heal. Your ROM is there right from the start, just waiting for all that to happen, so it can show itself.
Your knee will get all the exercise it needs at this early stage from just those activities of daily living.

During the first month after surgery, your knee needs plenty of rest, and just a little, gentle exercise. That's so all those wounded tissues can start to heal, without being upset by too much activity.

You're only just 3 weeks post-op from a very major surgery. Complete recovery from a knee replacement takes at least a full year - 52 weeks - or more. So you're only 3/52 of the way there.

Progress is going to be slow and there's nothing you can do to speed that up, no matter how hard you try, so try to stop fretting about making faster progress.
Where are you in recovery?? (TKR)

Have another look at this article:
Activity progression for TKRs
With your long car ride and going out for lunch, you've already done more than you probably should have - although I expect doing so was good for your spirits.

I know it's not easy to rest when you're used to being active, but try not to think of resting as "lying around, doing nothing." Instead, think of it as working hard, to give your knee the best possible chance of healing well.
As @Roy Gardiner says, In other words, when you are icing and elevating and watching TV, you are not 'lazing around' - you are "engaging in a carefully considered, proactively designed, heuristically programmed, dynamically structured recovery programme".

 

[rah2435]

thanks @Celle - you always have the right words!

 

[rah2435]

@Celle I was wondering if you could give me some advice. I'm 4 weeks out today and I feel like I'm falling behind.

I've decided not to do PT - all I do is short walks around my yard. Mostly because I am still very sore. Normally I would be in some PT now but I feel too sore to do it. My swelling is not very bad. Why so sore? I've been icing and elevating. I'm getting around w/o a cane or anything but - it hurts and I feel off balance.

I feel like my leg is getting so weak. Should I be doing something more? Some kind of stretches or something? I have a hard time getting my leg to zero (I'm about 10) although I can bend to about 110. I feel like I should be doing something to help gain my strength back but I'm so sore.

The front of the knee is sore and stiff (this is where I have the lax ligaments that they worked to correct) and when I straighten my leg walking I get a kind of stretching pain behind my knee.

Does any of this sound normal? Am I getting over anxious?

thanks,
rah

 

[Celle]

Hi @rah2435
I don't think you need to worry.

At 4 weeks post-op, you are still in what we call "the angry tissue" stage. Your knee is healing, but all its surrounding soft tissues were traumatized during the surgery as well; they're still upset - and soft tissues can take a long time to calm down and finish healing.

As an example, sometimes it takes longer to recover from a badly sprained ankle than it would take to recover from a broken leg. That seems crazy, but it can happen that way.

I think you may have progressed to getting around without support a bit too soon. Since you say you feel off balance and you feel as if your leg is weak, you should probably go back to using at least a cane. Your knee still needs that extra support - and you don't want to run the risk of having a fall.

There aren't any prizes for giving up the support of a walking aid early, and lots of people use them for several months. They're just a tool, to help you walk safely and with a good gait. Around the house, you can use the furniture as a support, but outdoors I think you still need that cane.
Sorry to burst your bubble about managing without any support.

I don't think you're falling behind. I think you're right where you need to be.
Maybe you're expecting too much, too soon, of your knee?
Where are you in recovery?? (TKR)

The best way to help your extension is to lengthen your stride when you're walking. That stretches the back of your leg. But you will need support to do that (it's easy to lose your balance at first) so back to using that cane, or even a walker, to prevent you from falling.

Try to walk with a heel-toe action, like this:

Your flexion is pretty good for 4 weeks.
Don't worry about your extension. At 10 degrees, it should get to zero without too much of a problem. It often takes longer to achieve extension than flexion. That's because those large muscles and tendons at the back of your leg have to be stretched slowly and gently. Try to do it too fast and you could cause minor damage.

There's no need to rush to get ROM (either flexion or extension) because it can continue to improve for a year, or even much longer, after a knee replacement. There isn't any deadline you have to meet:
Myth busting: the "window of opportunity" in TKR

Finally, you've mentioned pain/soreness several times. Are you still taking pain medication of some sort? Because I think you still need to. Cutting down the meds is OK, but you shouldn't be feeling you can't do things because of the pain.
Some people still need to take at least Tylenol for as long 4 months or so.

I hope this helps.

 

[rah2435]

@Celle - Wow! I knew I could count on you for some good sagely advice. I feel better already. I think the off balance is due in part to my LLD. the left leg IS longer (regardless of what the OS will tells me). It't better with a small lift in my right shoe.

Funny - I have ben doing that back stretch when walking. Guess it just felt like the right way to do it.
OK - so I feel better about not going to any PT. I really don't want to and ... I guess I don't need it. At least not right now. When the time is right to strengthen the muscles...then I'll do some PT.

oh as far as pain meds - I'm having trouble getting a refill from my insurance. I need some kind of "prior authorization" from my docs office. The docs office told me that this could take several days since its a narcotic (Norco) and to use Tylenol for now. :-/


thanks so much!!!
rah

 

[Celle]

OK. Until you get the Norco, make sure you take Tylenol in th most effective way. That is, 2 x 500 mg tablets (1,000 mg) 6-hourly, to a total of 4,000 mg (4 doses) in each 24 hours. You need to take the Tylenol on a regular schedule, to keep up the levels in your bloodstream.

Check any other meds you're taking, such as cold cures, to make sure there is no Tylenol (Acetaminophen) in them. If there is, decrease one or two of your regular Tylenol doses, to make sure you stay withing that safe daily limit of 4,000 mg.
The US FDA has set a daily limit of 3,000 mg in 24 hours. That's because they fear people will not allow for the Tylenol in any other medications, and so may unwittingly overdose. As long as you check, you'll be safe.

 

[rah2435]

What the doc did for this revision, as I understand it, was to replace the femoral component and the poly and position them in such a way that my leg would be more stable. I don't know what all this means really. BUT - the leg is very stiff! He told me it would be stiff. Stiffer than a normal replacement I think. I seem to have gained some ROM but the knee really feels stiff and unnatural. I guess it may always feel this way - or maybe after some time it will get more into a normal feel ???

some ramblings....does this make sense to anyone? I'm trying to figure out why the knee feels o W-E-I-R-D.

thanks,
rah

 

[Jockette]

B

I'm trying to figure out why the knee feels o W-E-I-R-D.

Because you recently had a revision!

Where you are now is not where you will end up.

 

[sistersinhim]

You just turned over just one month out of a revision surgery. You need to have patience and let your knee heal and realize it is not a quick thing. Baby steps will soon lead to toddler steps then preteen, teenager, the finally an adult at about a year from now.

 

[rah2435]

I have a kind of general question concerning TKR's.
A TKR tries, methinks, to mimic a natural knee. Of course it can't do this quite as well as since ligaments are cut and materials like metals and plastic aren't exactly bone and cartilage. So standing, something I'm having trouble with, and walking are a little tricky. You're balancing "on top" of the femoral component, kind of. So it seems to me that the leg needs to be more straight to stand than a natural knee'd leg. Agreed?

Since I've had my knees replaced I watch how people stand MUCH more closely. It's such a natural and automatic kind of thing. They aren't really paying attention - they just stand. Their knees are all over the place. Bent, straight, crooked... it all just works.
With TKR's this seems kind of different. Most of us have to re-learn to walk and stand it seems. Muscle balance becomes more important as things like ACLs and PCLs are GONE! Our legs tend to get weaker after the surgery and yet we need them stronger really to adjust for the lack of ligaments and to take the stress of holding us erect. Thus, partially, the push for PT.

So - especially with my LLD, I really feel it when my legs are not evened out by placing a lift inside one shoe. If one leg is bent I'm a mess. It seems like I need the knees straight in order to stand right at all. Leaning just a bit to one side or having one knee bent throws me off considerably and is painful.

Does any of this make sense to anyone?

thanks,
rah

 

[Jockette]

Our legs are weaker after surgery because of the surgery. As we heal, strength returns by default. Those of us who choose to, can do extra activity to strengthen our leg after a while, but healing has to take place first. For some of us who choose not to do specific strengthening exercises, what we do in daily life strengthens our leg just fine.

It was months before I could stand still for a length of time without pain. I can stand fine now.

 

[rah2435]

healing has to take place first

agreed - but while we are healing we do lose some strength right? So once we heal and can start strengthening we have more to make up for in a sense. yes?

It was months before I could stand still for a length of time without pain. I can stand fine now.

I hear ya. I could never stand for lengths of time the first time around - possibly due to the laxity I had. I'm hoping to be able to do it this time around. I know it's going to take time. thanks!

How about the "standing on top" and not with bent knee idea? Do you agree with that?

rah

 

[Jockette]

So once we heal and can start strengthening we have more to make up for in a sense. yes?

My opinion is no, we don’t have more to make up for.

And as for strengthening I guess it all depends on what you want to do when you’re recovered. I just want to get through the day comfortably. (which I haven’t totally accomplished, but I think that’s just my poor surgical outcome.)

The most athletic I am is bowling, and I’m not sure I would actually call that an athletic sport. I bowl in a senior league with many people who are not in the best health or physical condition and yet there are some pretty impressive scores!

Someone who wants to do some hiking, not just walking, or athletic sports, etc, would want to do more strengthening to get back to those activities, but that person probably gradually built up strength as they did those activities when they started.

How about the "standing on top" and not with bent knee idea? Do you agree with that?

I’m not sure what you’re asking here.

 

[Josephine]

Neither am I!

A TKR tries, methinks, to mimic a natural knee

It doesn't try to mimic it - it replaces it.

With TKR's this seems kind of different. Most of us have to re-learn to walk and stand it seems

Not at all.

but while we are healing we do lose some strength right? So once we heal and can start strengthening we have more to make up for in a sense.

No. It's not like that. Ordinary ADLs will restore your strength and balance. That's the beauty of it.

 

[Celle]

but while we are healing we do lose some strength right? So once we heal and can start strengthening we have more to make up for in a sense. yes?

No. You lose strength because of the surgery trauma.

While you're healing, you begin to regain some of that lost strength, as you use your leg in your activities of daily living. It's a natural process that happens even if you don't do any formal exercises - you're using the muscles of your leg every time you make a trip to the bathroom or kitchen, so they're regaining strength.

Once you get past 3 months, you can start doing formal strengthening exercises, if you want to.

So standing, something I'm having trouble with, and walking are a little tricky. You're balancing "on top" of the femoral component, kind of. So it seems to me that the leg needs to be more straight to stand than a natural knee'd leg. Agreed?

Since I've had my knees replaced I watch how people stand MUCH more closely. It's such a natural and automatic kind of thing. They aren't really paying attention - they just stand. Their knees are all over the place. Bent, straight, crooked... it all just works.
With TKR's this seems kind of different. Most of us have to re-learn to walk and stand it seems.

You're not balancing on top of the femoral component. It's firmly attached to your femur and eventually will feel like part of the bone. So is the tibial component.

It's simply a matter of time. Gradually, your knee will begin to feel like a normal knee and eventually you'll even forget that it's artificial. Standing and walking will become automatic, even with an altered gait.

Both my TKRs feel so much a part of me that I usually forget they're artificial. I get quite a shock when I see all that hardware on an X-Ray.

Muscle balance becomes more important as things like ACLs and PCLs are GONE! Our legs tend to get weaker after the surgery and yet we need them stronger really to adjust for the lack of ligaments and to take the stress of holding us erect. Thus, partially, the push for PT.

I think you've misunderstood here. There are two types of total knee replacement. One type preserves the internal (cruciate) ligaments. The other type is used if the cruciate ligaments are damaged. In the second type, a special sort of prosthesis is used, to compensate for the stabilising influence of the cruciates. At no time is your knee left with only the external ligaments and muscles as its only support.

This should explain. It's from the article, Knee replacement surgery types and suggested videos

"There are two types of this implant: cruciate sparing and the cruciate sacrificing. This is to do with the two strong ligaments that cross over inside the joint and prevent the femur from sliding off the top of the tibia when the knee is flexed. They also control the bones when some rotational movements are made such as in sports like skiing and football.

Cruciate sparing
This preserves the cruciate ligaments if they are in good condition. The implants have a notch to accommodate them

Cruciate sacrificing
When the cruciates are in poor condition or even ruptured, a prosthesis is used which has a peg on the plastic insert and a notch on the femoral component to take over their functions of keeping the joint stable.

In both illustrations of the replacement hardware, above, you can see how the femoral component will wrap around the end of the femur, to hold it securely. It really isn't a matter of you having balance on top of the implant.

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