Revision TKR Instability Question

[Josephine]

Apparently the test is in two parts - three hours apart. So I get part one done at 11:00 Am and part two at 2:00 PM EST.

That's usual.

If that is negative then he wants to give me a shot of ... I think he said lidocaine... to see if the "pain" is coming from my knee or not.

So is that. It's a diagnostic procedure.

The thing is - I don't have swelling in that knee - it just feels very unstable and hurts.

I don't have swelling either. It just hurts at random times.

YIKES! You always seemed to have so much success with your implants. @Josephine

I've actually only ever had two joint replacements!

 

[Elad1002]

@Jockette
We all make our own decisions but it sounds like you may really benefit from a 3rd opinion. I hate to see someone experience so much limitation when there may be a surgical solution for you. I will put you in the light!

 

[rah2435]

That's so kind of you @Elad1002

My left TKR was performed in 2013. Since then I've had many "second opinions". I finally ended up with a surgeon that seemed to care - he put a new spacer in to help with laxity. But it don't really seem to solve the things. He also did my second knee (right TKR - March 2018) which turned out SO MUCH BETTER. Although recently it's been slipping!

I think I trust him. He sent me to this guy in Penn (Uni of Pa Hospital in Philadelphia) to have ANOTHER second opinion. His name is Dr Lee. This Dr told me that he will work with me to help diagnose and hopefully correct all this - if possible. He sent me to get the bone scan done which was performed two days ago - should know results soon.

rah

 

[rah2435]

@Josephine - results from bone scan:
IMPRESSION:
Asymmetric, peripheral increased radiotracer uptake surrounding the right knee prosthesis on blood pool and delayed imaging, which may represent postoperative change in an uncemented prosthesis. No focal findings to suggest loosening on the right.
No abnormal radiotracer uptake about the left knee prosthesis to indicate loosening.

thanks,
rah

 

[rah2435]

i'm writing again because this angers me. I responded via the hospitals internal email to the bone scan results .. saying "what's next" and I get this response from "not the doctor". It seems like they are confusing my left and right... among other things.
I responded to this with "why should I wait a year? I've been putting up with this for six years and it's just getting worse..."

...

Hi Rich,
You are correct, the bone scan shows no loosening of the prosthesis. I will email the radiologist to have them change the year. At this point my recommendation would be to wait until the one year mark and come back to discuss with Dr Lee. I don't know if he discussed a surgical procedure or other intervention with you at your last visit. We'd certainly like to avoid that if necessary. Are you bracing the knee? That can sometimes be helpful for instability. We are happy to see you any time to discuss further.
Mindy


From: Rich
Sent: 2/6/2019 7:53 PM EST
To: Gwo-Chin Lee, MD
Subject: Non-Urgent Medical Question

Dr. Lee,
I saw the bone san results and don't completely understand all of it - although it does seem to indicate that there is no loosening.
Also - this is on the report and is incorrect "Patient also underwent right total knee arthroplasty in 2016." This is incorrect - this procedure was performed in March of 2018. It hasn't been a year yet.....

So what's next?
thanks,
Rich

 

[Josephine]

which may represent postoperative change in an uncemented prosthesis.
No abnormal radiotracer uptake about the left knee prosthesis to indicate loosening.

No kidding! I'M confused! What he is saying is a direct contradiction or one comment to the other! Of course a "postoperative change in an uncemented prosthesis" can indicate a loosening!

Would you care to post your latest xray for me to see? The images you posted previously were actually shots out of an MRI scan.

 

[rah2435]

OMG! @Josephine - I am so angry right now... This is one of the premier hospitals in the world.

"postoperative change in an uncemented prosthesis"

and that knee - the RIGHT - IS CEMENTED!!!! the LEFT isn't - seems like they are confusing left from right.
you can google this doc

Gwo-Chin Lee, MD Penn Orthopedics

(name dropping). Looks like he gets glowing reviews! Sounds fantastic - I'm sure he is!
I think it's his staff that's the issue. After my last visit, his PA called in a script for me that was clearly meant for someone else. Some kind of nasal creme? I called and left a message to tell them this (people make mistakes) but ... no response.
I'm sorry - I just go these results and I'm still ... ARGH!!!!!!

I'll try to post some x-rays.

thanks
rah

 

[Josephine]

I'm so sorry, Rah. I can only imagine how frustrating all this must be.

 

[sistersinhim]

You have every right to be angry. This treatment is unacceptable. We're just a number to so many of these organizations. I hope you can post your xray for Josephine.

 

[Jockette]

I would be very angry, too.

 

[rah2435]

I got a more pleasant response today:

Hi rah,
I'm sorry for the confusion. That medication was not meant for you so I apologize. Please disregard. In any case, the bone scan does not show any abnormalities in either knee in regards to loosening or infection. We are certainly trying to understand your pain which is the reason for the bone scan in the first place. Let me inquire with Dr Lee about what his thoughts are and we can move forward from there. It is unclear from his last note what the plan is moving forward so I will get back to you.
Mi....

So she owned up to the script - that makes me feel better. (Could be a BIG mistake though - reminds me of a scene from "It's a Wonderful Life" )

I feel awful though. It's been so long since I was able to walk or stand normally. I wish someone could find some answer. I'm getting to a point of giving up - almost.

My wife wants to travel to Europe this summer. Wow! I wonder how I'm going to make it to the car! I DO make it... the knees do "work". The left one is just screwed up. It feels wrong, it always did. And the more I walk the more it hurts and the more it hurts my back.

But no one seems to be able to find a solution or a cause other than "it's your back". Well - my back has gotten much worse every year since I had the left TKR in 2013. So, yeah my back is now a mess but - which is it?

I don't want back surgery. I've seen spine surgeons and they agree I don't NEED back surgery and I am rambling - sorry. The pain management folks want to give me a radio frequency nerve ablation in my back. I'm frightened of this!

Xrays? I'll look....

rah

 

[Jockette]

It feels wrong, it always did. And the more I walk the more it hurts

My partial feels the same. Having this surgery was the worst decision I ever made.

The pain management folks want to give me a radio frequency nerve ablasion in my back. I'm frightened of this!

My husband had this done several months ago. It was not a big deal, but it did nothing to help his back pain.

I was also offered this treatment back in 2010 and I said no. I’d had 10 shots in my back in 6 months and not one helped. So I was unclear about just which nerve they were going to burn.

Somehow my back got better and now I do my best to avoid doing the things that set it off. Of course, I can’t always avoid things, but I do if I can.

I’m glad you got a nicer response from the team and that they are going to look into your issue further.

 

[Josephine]

That medication was not meant for you

Wow! That's a bit of a boo-boo and no mistake!

 

[rah2435]

I apologize - the only x-rays I can seem to find are from 2015 when I had the spacer swapped on my left knee - and also a scanogram to measure leg length.

@Josephine - question: My left leg was cruciate sacrificing. (no pcl) what would have happened if the surgeon, when making the spacer swap, put in a spacer for a cruciate retaining knee and not a cruciate sacrificing knee (which I have)?

thanks,
Rich

 

[rah2435]

 

[Josephine]

My left leg was cruciate sacrificing. (no pcl) what would have happened if the surgeon, when making the spacer swap, put in a spacer for a cruciate retaining knee and not a cruciate sacrificing knee (which I have)?

It's impossible for him to do that because the tibial tray is fashioned for the one that was used. Note the different style and size of the notch in the femoral implant. That would tell him. Besides which, he would know from a) your notes and b) the spacer he removed!

 

[Josephine]

Rah, I'm sorry but your images are not of sufficient quality for me to see what's what. Not of diagnostic quality. The entire image is a good resolution but the actual xray in the middle is not and when I try to enlarge them, they become very fuzzy. I need an image of the xray which is the same dimensions as the entire image.

 

[Jockette]

Since we’ve been comparing notes a bit I thought I’d let you know I had my second opinion yesterday and the surgeon took new X-rays and he’s confident my implant is not loose. He zoomed in on the X-ray when showing it to us and showed us where there would be a shadow if it was loosening.

I asked if a bone scan would show anything and he didn’t think so, so he didn’t order one.

He read my list of concerns and he feels my issue is a nerve issue. He also thinks there could be imflamtion, so gave me a script for blood work to look for that.

My next step is to make an appointment with a neurologist to investigate the nerve issue.

 

[Josephine]

I asked if a bone scan would show anything and he didn’t think so, so he didn’t order one.

@Jockette I did explain to you before that bone scans don't 'show' anything, just a flare where there is extra cellular activity as in bone destruction or infection. If he gets a positive from the scan, the surgeon has to work out the reason for himself with blood tests and such.

 

[rah2435]

ok- I'm still trying with these x-rays.... @Josephine are these any better?

rah