Revision TKR Instability Question

[Macknit]

It sounds like your body is doing so much adjusting for the 6 + years of difficulty that you've had. I'm saying that after many similarities to your journey.

I fell on ice last February 2019 herniating L1 and I had a spinal surgery (3 level spinal decompression for L1/2 3/4 & 4/5) just 2 months before the TKR (after 10 years of off and on back/leg pain, being told several different opinions about my alleged LLD, trying all injections and RFA, in other words, all pre-surgery options!)

Then I really struggled with pain in my back, leg, IT band, and hamstring after the TKR. Fortunately, though now at almost 6 mos. post op, I've found that the back and leg are doing much better. If I get tired or spend too much time on my feet I'm not out of the woods completely, but I am seeing forward progress, which is so good for morale.

Your back issues might just be the culprit and, of course, all the realignment of your entire musculature, etc. I'm hoping you strengthen and progress and can get to the bottom of all of this!! Hang in there!

 

[sistersinhim]

I am so sorry to hear that you are still having problems with this knee. Why not stop all exercises and see if the discomfort is less. What you are doing now doesn't seem to be working so why not try something different for a couple of months?

 

[rah2435]

Have you considered a second opinion?

I have had it looked at by another OS months ago. He took an x-ray and told me that it looked good.
Of course, he was the OS that sent me to the surgeon who performed to operation.. but I really trust him. So - if it's not my knee why is it my knee that is hurting so much?
Do I need to get a third opinion? I'm having and MRI done of my spine. I know I have back issues. I just don't want back surgery. It seems to me that the issues I've been having with my knee are causing back problems - not the other way around....

 

[rah2435]

What you are doing now doesn't seem to be working so why not try something different for a couple of months?

going to the gym - doing leg lifts, squats on a half yoga ball, table back exercises, upper body, and 20 minutes on elliptical.

 

[rah2435]

thank you @Macknit for reading through my posts. Yes - It's been a long painful road I'e been on. And I think you are correct - my body is re-adjusting to all this...or trying.

Rah

 

[rah2435]

I NEED TO VENT!!

I "kneed" help. I really have a LOT of trouble standing and walking. I don't get it. X-rays show my knees are both fine. But ... well ... I just tried to stand and talk to someone and the entire time I am trying to balance myself. I can hardly pay attention to the conversation. It's sort of like having two normal knees with no ACL. I have to keep flexing my muscles to try to keep them from buckling as I stand. I can feel the metal sliding around in my legs - buckling forward. I know I no longer have ACLs but in the prosthetics should be compensating to support me so I can stand, right?
It doesn't seem to work for me. My knees buckle and slide forward when I try to stand. I have to flex my quads, or lean on something. After a few minutes I can feel my lower back start to hurt.
WHY? I had left leg revised because it was unstable. It's still feels unstable. Is it me?
The surgeons I've seen (two of them) tell me I have to strengthen the quads. I have been! I go to the gym (which is a struggle) and squat/stretch/lift. What else can I do? Take steroids?

I know my legs are much straighter now then they have been in my entire life. I've always been somewhat bowed. I had to wear corrective shoes when I was a toddler! Maybe I'm a special case due to this? The now straightened legs are throwing off my balance? Should they not be able to keep straight without me consciously flexing as I stand?

ARGH!

thanks - I needed to write this...I feel a little better now lol!

Rah

 

[Jamie]

What does your therapist have to say about what you're experiencing? Do they still feel you have strengthening yet to go? It's possible....it can sometimes take a lot of time to regain proper strength when it is lost. Does the therapist also have you doing balance exercises. One good exercise is to stand on a thick foam pad or to step on and off the pad front to back and side to side. You probably should be doing exercises for your balance as well as quad strengthening.

What you describe does sound like a muscle problem. Are both your legs about the same in experiencing this? Please tag me with your response so I see it quickly. To do that, you type the "at" sign (@) followed immediately by my username...like this.... @Jamie

 

[rah2435]

Thanks @Jamie I'm not currently seeing a physical therapist but they did have me doing this and I am trying to continue to do this. My left leg is worse than my right. I don't know it could be nerve issues ? Am having an MRI done of my spine. My back does give me a lot of pain. Also - I now have that 1-1.5 cm. leg length difference.

Rah

 

[Jamie]

Then based on what you're describing, I think it's time to head back to a therapist for some help. You don't have to go to your surgeon for that. Your GP should be able to order it for you. If your leg discrepancy is actual (and not a tipping of your pelvis), then you should get that corrected with lifts to see if it would help. 1.5cm is about .6 inch, which could be causing at least some of your problems.

I'm glad to hear you're having your spine checked out as well. It can cause problems if you're having a lot of back pain. I'm sorry you're having to deal with so many things all at once. It certainly makes things more challenging to get to the bottom of the problem. More than likely it's a combination of all this together. But keep focusing on what you can do for each area and don't give up! Sometimes it just takes a lot longer than we plan to get things right again.

 

[valgriff2]

Day 18.....not such a good day today....I guess we all have to live with the ups and downs.....clunks and clicks....weird outta the blue pains. But I think it will be worth it ..keep that faith. Look ahead.

 

[rah2435]

@Jamie I hope you are coping with this COVID thing ok. I had the MRI done and it does show some spinal stenosis - especially at L5-S1(moderate to severe!). The LLD is actual - I had a scanogram(?) done to confirm it. This was done standing and came up with 1 cm. In PT I was measure at 1.5cm. lying down.
I'm getting a shot in my spine on March 30th. We'll see if this helps.

Anyway, yes it's a combination of things I'm battling. Right now we are all staying in and trying to stay away from this virus. Such weird times!!
Thanks for your help.

Rah

 

[rah2435]

Day 18.....not such a good day today....I guess we all have to live with the ups and downs.....clunks and clicks....weird outta the blue pains.

I don't know if you meant to post this here but I hope things are going ok. keeping the faith!

 

[TimeBuster]

I had back issues went to see my orthopedic Dr. and measured the length of my leg and was diagnosed with my surgical leg shorter than the other. She ordered a shoe lift of 0.5 cm and lo and behold my back issue went the way.

Hope you find the solution to your problem.

Best of luck.

 

[Jamie]

Sounds like you've made a small step forward. Who wants to have to learn patience this way??? No one! But you're doing a great job of coping with a difficult situation. Baby steps and you'll get there. Thanks for letting me know the latest.

 

[rah2435]

@Celle -

I am not going to discuss this at length, because it would be disruptive to Kimbo1's thread. If you wish to discuss it further, please do so on your own thread.

We were discussing cruciate sacrificing TKAs and instability. I would like to discuss this more with you if you don't mind doing so. I'm experiencing a lot of pain and instability in my left TKA which has been revised, ostensibly to help the instability. I didn't post any links to articles - but what I was saying was that just about all total TKAs sacrifice the ACL. The PCL is seemingly optional although the article you sent me a link to seems to suggest the kinematics are better if the PCLis sacrificed as well. Thank you for that link.
I need to find out more about all this. It certainly does feel like I have knees with no ACL ( and I do!) and I thought that the TKA was somehow supposed to compensate for this. Thus allowing someone to stand and walk in a somewhat normal fashion w/o any pain. Am I correct in tihs assumption?

thanks so much for our time. I hope I didn't anger you. I'm just trying to understand.

rah

 

[Celle]

I hope I didn't anger you. I'm just trying to understand.

No, you didn't anger me. It's good when people try to find out more. Knowledge is power.
It's just that you posted it on someone else's thread, which could have hijacked the thread, taking the emphasis off that person's recovery.

As I understand it, and I'm a RN who has had 3 knee replacements, if the cruciate ligaments are in good condition, there is no point in sacrificing them. But if either the ACL or the PCL is damaged, it is better to use a cruciate-sacrificing prosthesis. The ACL and the PCL each play a part in stabilizing the knee and, to my way of thinking, leaving only either one of them would make for a less stable knee.
Common sense says that leaving one ligament when Nature intended two is probably not a good idea.

There's no prosthesis that allows for sacrificing one cruciate ligament while preserving the other, so removing either a damaged ACL or PCL and using a cruciate-sparing prosthesis would tend to leave a knee with just one cruciate ligament trying to do the job of two. That sounds like a bad idea to me.

I think I gave you this article last time:
Knee replacement surgery types and suggested videos
But just to refresh our memories, here are the relevant images again.

These are cruciate sparing, or cruciate retaining prostheses. The image on the left (ignore the red arrow) should have a plastic spacer with a gap in the middle that allows the cruciate ligaments to pass through it.

This is a cruciate sacrificing prosthesis. The plastic spacer has a large peg in the middle that fits into the notch on the femoral component and that does the cruciate ligaments' former job of stabilizing the knee. As with many things, it sometimes doesn't do quite as good a job as two cruciate ligaments in perfect condition would do, but it sure does a better job than damaged cruciate ligaments would do.

Don't forget that a large part of stabilizing the knee is also dependent on the muscles and ligaments outside the knee joint. It's not unusual for people early in recovery to feel that their knee is unstable and about to give way, That feeling improves as those muscles and ligaments regain tone and strength as recovery progresses.


The cruciate ligaments in both my knees are still in good condition and both of my knees have a cruciate saving prosthesis. One is almost 6 years old and the other is almost 9 years old. They are still working perfectly and they give me no problems.

There's research going on all the time, and some surgeons try different techniques in the interests of research. It's not at all unusual to find reports that seem to contradict each other and it's important to look at the date on all reports, if you can find it.

I don't think I can help you any more on this subject. Feel free to carry on reading, but try not to get bogged down in what you find. Make sure you put more faith in articles from a reputable medical source (medical journals and Pubmed), rather than from news agencies, too. And a conclusion based on a survey of a large number of cases should carry more weight than a survey done on just a few cases.

 

[rah2435]

don't think I can help you any more on this subject.

@Celle you've done plenty. My original surgeon never mentioned anything about preserving an ACL with a knee replacement when I had my left done. The surgeon who did my right TKA told me he usually keeps the PCL because it helps patients with proprioception. I assumed he meant sacrificing the ACL and keeping the PCL. Maybe I was wrong. Maybe I still have my ACL in the right. I know that the right feels MANY times better than the left. I had the left revised twice due to instability. Once was a spacer swap and the other the femoral component was replaced. Yet the left STILL feels painful and unstable. I wish I had known more about all this going back in 2013 for my first TKA. I was just sold on the idea that it was minimally invasive and I would be out of the hospital the same day. ... and back to work in 4 weeks!
That day changed me life. I came out with a LLD of 2.6 cms and a knee that felt unstable and painful. Life has not been the same since. But - I keep working on it.

thanks.
Rah2435!

 

[Celle]

You're very welcome, Rah.

 

[rah2435]

I haven't been on the forum for a bit. Things have changed quite a bit since I've last posted and it's been a weird year....
I've had two TKRs -with the left one revised twice due to instability (one was just a poly swap).
I have a question. Both my knees are cruciate sacrificed. So - no ACLs. They feel wobbly - especially the left. It's really hard to stand still. It hurts my back. I believe this isn't correct. right? Should I not be able to stand with TKRs? It feels like someone with normal knees who have torn ACLS. It makes me feel like the removed ACLs haven't been addressed by the TKRs.

Question: what is there in the TKR implants that is supposed to "replace" the "sacrificed" ACL?
I'm asking because I can't really find much on the net on this subject and I am suffering. Again, It seems like the replaced knees do nothing to support me when standing. Nothing to substitute for the ripped out ACLs. It actually was was better with my arthritic knees and in-tact ACLs!

thanks Bonesmarties.
Rah2435!

 

[Pumpkin]

@rah2435
Welcome back, sorry you are having challenges with stability.

what is there in the TKR implants that is supposed to "replace" the "sacrificed" ACL?

Most implants are posterior stabilized, here is an example, see how the spacer has a post in the rear.

When knees are too unstable for a posterior post to stabilize the knee, the next step is a hinged knee. The knee is with a center pin, providing stability, and allowing knee flexion, limiting extension, and lateral movement. This is the type of implant I have in my revision knee, it is very stable.