Revision TKR Instability Question

[rah2435]

Thanks for your input @EalingGran.

My question is should I get a new spacer in my left knee or should I get a laminectomy at L4-L5?

After my last post I've seen both my spine surgeon again and my TKR surgeon. They are both in the same practice. The spine surgeon tells me that the a laminectomy "may" take some of the nerve pain away which he now tells me is primarily in the left leg. He doesn't really see anything that would indicate enervation on the right. The MRI and the EMG don't indicate it. But I do have stenosis and arthritis in lower spine. This could be causing weakness and instability in my left leg, but probably not my right.
My knee surgeon told me that the instability that he see's (and I feel) in my right leg is probably due to a thinning spacer and could be corrected by a thicker one. Again - this leg was my "good" one and the implant has just started to get unstable over the last year. IT was done in 2018.
He checked my strength by holding on to my leg as I moved it forward and back against his resistance. He thought it seemed strong enough. He did review the spine MRI and other tests. He feels that I'm dealing with two separate issues. The back enervating the left leg and the worn spacer on the right. I mention the stenosis and he saw the MTI, EMG, Cat scans, X-Rays, etc. He agrees that though there is some indication of stenosis on both sides but overwhelming on the left. It shouldn't be giving me this much problem on the right knee.
I feel very frustrated. I don't want ANY surgery at this point in my life. However, I need to move more. I want to stand and walk!!!!
I wear Z-Coil shoes almost exclusively now. Using ordinary shoes or going barefoot - my right knee feels too wobbly and not supporting my weight well. I went swimming in a pool this past weekend and when standing in the water, I was favoring my left leg a good bit. I am able to swim laps, but when I stand I lift my right leg slightly and balance myself on my right. I should note that I also have instability on the right as well. The one has been revised twice. Once for a spacer swap and once for a revised femoral component. The initial surgery was performed late 2013. I had some femoral nerve damage following that operation. The current EMG does NOT show this anymore. However the burning in my thigh has not gone away since. Was it stenosis all along?

So I guess I'm asking for some opinions, ideas... Any advice anyone? Spacer replacement or spin surgery? Or neither or both?
Sometimes I think me dependence on the Z-Coils may be giving me issues. I got them a few years ago and they seemed wonderful. They helped me to walk again. It IS standing on springs. Maybe I'm using them too much and this is causing some issue? I can still try to strengthen my quads more?

Any suggestions would be greatly appreciated. thanks.

 

[EalingGran]

I am sorry you have these issues and it is so hard to disentangle the causes.
I understand your reluctance to have further surgery and ultimately only you can decide the risks versus benefits.
I presume you have already tried physio/ pilates for your back? I still get some sciatica- particularly after car journeys. But I can manage with pilates/ sciatica cushions.
The nerve pain has never made me feel that my knee is 'giving way'. I presume that is what you mean by instability? I think more general wobbliness would sound like a local knee issue to me- but that is just my lay opinion.
When I have a really tough decision to make, which is a close call- I try to write down the pros and cons for each choice.
Then I discuss it with my friends and family and sleep on it for a while. I find it helps me make a decision I can live with.
I was lucky though with my knee - the MRI was so bad I knew I had to have surgery.

 

[rah2435]

thanks so much @EalingGran .

It is a difficult decision. More operations make my head spin. I just want to stand and walk! ( can stand and walk but not much. I play guitar in a band. I love this - it's a big part of my life. Playing out lately has been soooo difficult.

I don't have many people I share my condition with. My wife has, understandably, grown a bit weary of listening to me as I do tend to perseverate. I hate to ask her to come to my appointments with me.

I've recorded some of my appointments, I've learned - ALWAYS get docs permission. Apparently there are people who will record a doctor's visit and the conversation can end up on the internet - with the doctor never even being aware that this is happening. It can help since our memories are often less thn reliable. "What did he say again? ...." It is understandable however that Doc's may be a bit put off about someone recording there advice. I did notice that my surgeons tone and some of his opinions even seemed to change once he agreed to let me record him. I guess anyone is going to be much more careful as to exactly what they say when they know they are being recorded.

My wife thinks I should either do some "eastern medicine" like acupuncture (which I've tried twice to no avail) or Qigong (which I tried recently and found very difficult as I tried to hold the "horse stance" for 45 minutes. I felt like my knee was going to buckle. It's especially an issue going from straight to slightly best... what ever that means.

Just this morning my wife again presented the idea that I should seek out the highest queality surgeons - not that she doesn't like the one's I'm seeing. If it were her, she says, she would seek out "the best". Go to NYC. The "best" docs are there and they may see some things that other's may not. (I do hear great things about the HSS) . I don't want to go through all this, so I am resistant.

Sigh.

My biggest fear I suppose is going through another surgery and having little or no benefit from it. If I thought that some kind of PT or exercise program would do the trick I would take that track.

I apologize for harping on and on. Just feeling overwhelmed - again...
thanks everyone.

 

[Jockette]

I’m sorry you’re still having such issues. I have a PKR, done in 2017, that has never been right, so I understand.

Just throwing this out there, have you ever had a metal allergy test? Not saying that's what it is. But the test would rule an allergic reaction out. (And no, I haven’t done this myself)

For anyone who would like to get a full metal allergy test prior to any joint replacement surgery, you can get the test done in the USA by ordering the test kit from https://www.orthopedicanalysis.com/testing/order-testing-panel . You want the Orthopedic Panel Test 2. Once you get the test kit, your GP (or any lab) can do the blood draw and send it in for testing. You will have to have a doctor's order for the lab to run it.

I understand you don’t want any more surgery, (I don’t either) but HSS is very good. I think you can get an online appointment to start. Have you ever seen someone outside of the practice who has done your surgeries? When the current practice can’t come up with an answer, sometimes fresh eyes might see something different.

And, as in my case, sometimes there just isn’t a fix or answer for us. I stopped looking after 3 second opinions, (all in different areas from where I had my surgery) and an online conference, where they just don’t know what to tell me because all they can see looks good. Mine is “manageable” but it sure would be nice to feel normal!

 

[Layla]

HSS is very good. I think you can get an online appointment to start.

Here is some info on that...if interested -

Following is a link to an online consultation with HSS, Hospital for Special Surgery, which is the top rated orthopedic hospital in the country. They are located in NYC, with other east coast locations, but will review cases remotely. Click or tap on link -> HERE

 

[rah2435]

@Jockette - thanks for your reply. I think we've talked before...hmmm.
Anyway - I was tested for metal allergies years ago after my first TKR. There were issues and I suspected everything. Seems like it was mostly due to femoral nerve damage .. at least at the time. I also came out of the surgery with one the operated on leg now almost 2 inches longer. It's been a crazy ride for me.

Have you ever seen someone outside of the practice who has done your surgeries?

I've been to several. My initial TKA, left leg, was performed in 2013 by a Dr. Shoifet at Virtua in South Jersey. It was minimally invasive. I had lots of issues afterward and went to several surgeons for opinions. This included Cooper in South Jersey to Penn in Philly before settling on Regional Orthopedics - Dr. Steven Kahn and Dr. Jefferey Gleimer. Of all - the doc's at Regional Ortho seemed most attentive and professional. Dr. Kahn performed the spacer swap on my left knee and the TKR of my right. Both results were great. After a year the left was lax again so Dr. Kahn sent me to Penn for a revision. A Dr. Lee at Penn performed this in 2019. It's still not great and now my good knee (right) is giving me issues.

Mine is “manageable” but it sure would be nice to feel normal!

I know that feeling - however mine has moved beyond the "manageable" state. And I fear it's having repercussions on the rest of my body. Or is it the other way around.... ? My back can only get worse if my knees are failing I think. Or maybe it's my knees can only get worse if my back is failing. (you see the frustration!)

I appreciate you taking the time to read and respond to my post.
thanks again.

 

[rah2435]

@Layla Wow! thanks very much!

 

[EalingGran]

apologize for harping on and on. Just feeling overwhelmed - again...
thanks everyone.

Don't apologise- we are here for venting and talking through tough decisions.
If you are interested in non-surgical options then have a look at my pilates teacher's free sessions on YouTube.
Google Katja pilates and they come up.
I find her lower back sessions help with my sciatica. She has a huge range of free classes. Some exercises may not suit your body/ issues but there may be something that helps to strengthen and support your back or knees.

 

[Pumpkin]

@rah2435
Just my opinion, your unstable knee could be irritating your back, stabilizing the knee may help your back. This would be a good question for your surgeon(s).

I agree with others, an online consultation with HSS is a good idea.

With your knee becoming lax over time, it may be a spacer, or something going on with your tendons. Another question for your surgeon(s).

 

[rah2435]

thanks @Pumpkin I appreciate your opinion. Yeah - bad knees will have a debilitating effect on your back - your entire body. The issue is, what is causing the instability and how can I correct it - if at all.
I am looking into HSS on-line.

A note - I noticed that the surgeon who revised by left knee, Dr Lee, is on the board there. He was at Penn in 2019. Dr Kahn sent me to him to look at the laxity in my left knee. I was told he was the go-to guy for revisions. Upon examining my left knee his thoughts were:

1) it could very well be my back
2) my MCL/LCL were not doing a good job keeping my knee stable.

He replaced my femoral component and thought this was going to fix things. I wish it did. I think highly of him but he may have been wrong in this case.
The right knee was still doing really well back then.
Not sure that I would choose him again but I do believe he is a great surgeon.

 

[EalingGran]

my MCL/LCL were not doing a good job keeping my knee stable.

I have a chronically overstretched MCL from a previously very valgus leg. I was advised to strengthen the vastus medialis ( medial quad). Strengthening this muscle has definitely helped with the pain I previously had on stairs.

 

[rah2435]

thank you again @EalingGran.

I've tried a lot of strengthening exercise over the years. Until a few months ago I was doing regular 3x a week PT. I really haven't been doing much lately except a bit of Qigong. Maybe a more isolated exercise routine aimed at things like the VMO would be successful.

I found some exercises for stability, such as what I'm experiencing, on youtube. It calls for standing on one leg, holding on to a surface for balance and doing ver small bending/squatting motions. This is where I have the most issue - going from straight to slightly bent. It's awful! It feels very unstable. I tried to do some anyway...maybe it will help given time.

I found what appears to be an excellent channel on youtube featuring exercise routines and other information directed at knee replacement patients (Total Therapy Solution). One of the videos seems to directly relate to the issues I'm having e which seems to directly focus on what I'm experiencing : 3 best exercises for an unstable knee.

I'm going to give this a try.

thanks

 

[Pumpkin]

@rah2435
Recommend you have someone coach you on the 3 exercises, they need to be done correctly to avoid irritating your knee.

 

[rah2435]

Well everyone - i guess I need to more this thread to the post-op area. I went ahead with the spacer swap in right knee. Surgery was performed last week - Oct 15th. According to surgeon operation was a success. Thicker spacer (13?) was put in and surgeon is confident the knee will be more stable. Much thanks to @Pumpkin and @Layla for their support.

I know it's only one week but I thought my recovery would be faster. It is really sore! Especially the area of my quad front above the knee area. It REALLY hurts to bend back and to put weight on it. My ROM is ok - looks like I can get it straight and bend to past 90. With some help I think I did 110.

I have a good bit of bruising around incision and back of lower thigh. Not scaly - just red, discolored, probably bruised. I guess this is somewhat normal? I have a walker but I am getting around using a cane. I can't really walk very much - just trying to get around the house.
I'm getting some in-home PT. They were out last Week once. I was told that I looked well and had no limp when I did walk. It just feels like it got worse two days after surgery than it was in the hospital. Maybe the spinal wearing off.... I don't think there's any infection... I would be able to see this right?

I know it's early but I am very anxious. When I see the bruising and the swelling my mind goes to worse case scenarios.

Anyway, I am now home and recovering. I was trying not to take opioids but I couldn't hold out. Too much pain. Vicodin it is. And it does help.

I'm doing almost no PT - just trying to walk a bit , heel slides moving... PT is coming again today I think...

Am I being too anxious in thinking I should be experiencing less pain by now? It was a spacer swap - no sawing or drilling.

Thanks everyone for your support. Let's hope healing progresses quickly!

 

[EalingGran]

Am I being too anxious in thinking I should be experiencing less pain by now? It was a spacer swap - no sawing or drilling.

It's still fairly major surgery I reckon- as they must have to move things out of the way to remove and fit the new spacer. So not surprised you are in pain.
I think it is totally understandable that you are anxious given all you have been through.
Good luck.

 

[Pumpkin]

I'm not surprised you are still having pain, they opened you up, moved your patella out of the way, took out the old spacer, put in the new spacer, tested your knee for stability, and patellar tracking, once everything was OK, they closed the incision. Not as major as a full TKR, still invasive and very irritating to the soft tissue.

Give it time the bruising will disappear, soft tissue will heal, your ROM will increase, and you will start feeling better.

 

[rah2435]

@Pumpkin and @EalingGran good advice. Patience is so difficult sometimes.
I know I need to get my quad strength back. The knee feels unstable still - but differently. The front of the quad is REALLY sore. and weak.
Maybe my quads were weakened from the instability i had. I moved back to the walker.

But I hear you. I will wait until it's healed to start worrying about strength and ROM.

Thanks so much!

 

[Jockette]

Not as major as a full TKR, still invasive and very irritating to the soft tissue.

And they did all this less than a week ago!

 

[rah2435]

@Jockette - Tuesday Oct 15th.

 

[eaglemom]

Let's just take a deep breath here. Your less than a week from a major surgery. No, it wasn't a TKR, but they moved your knee every which way and all of the soft tissue is really really inflamed and mad. Please do use your walker if you feel more stable using it.

When do you see the surgeon again? Or, if you have questions for them, please don't hesitate to use the Patient Portal or call them. If you need home health, contact the surgeons office and please inquire about it. It never hurts to ask.