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TKR Malaligned Valgus knee following TKR

1958slewis

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Hello to all from Steve in the UK.
Just looking for some advice and info please. Had my right knee replaced on November 14th because of bone on bone arthritis due to sports injuries. I am 61 years old. I had had a previous ACL replacement a few years ago on same knee but had now developed a bone spur too. On bearing weight, the day following the op, I noticed the knee was clunking and moving inwards. I was told that this was normal and that it had gone through trauma and needed time to heal, recover and strengthen. It was only really 14 days later when the dressing and staples were removed that I first noticed that my lower limb went out at a moderate angle. I have since learnt that this is a valgus alignment. I continued with all my physio exercises to strengthen my quads, and still do. My knee is always swollen and hot to the touch but I am told that this is also normal. It feels unstable and a little lax or loose to me.
I am managing to walk without aids for 30 minutes a day but I am getting referred pain in my right hip, buttock and lower right back. I can only assume that this is because I am walking differently and my gait has changed. Had my first consultant appt on 6th Jan and he confirmed that the procedure was a little more complicated and lengthy because of the previous ACL and that he had to remove the 2 screws that were in there. I explained my concerns and he examined my knee and the pre and post X-rays. He agreed that there was 'a valgus alignment of the knee' but suggested that continued rehab could help this. He told me that the clunking sound could be the plastic insert on the back of the patellar knocking against the implant. I am to be reviewed in 5 months time.
That's the background. My questions, if you can help, are these:
Will any sort of physio correct a valgus knee?
Am I doing more damage to the knee and tissue around it by continuing with my walks and exercises?
Should I consider asking for a revision procedure to correct it or is it still early days and I should wait a few months?
Has anyone else had this result and what steps did you take to resolve it?
Should I be satisfied with the outcome and put up with moderate pain, as there are no guarantees with revision work?
If I go down the line of revision should I entrust this to the same consultant or try to get referred elsewhere?
By the way, a hugely informative site - thanks.
In anticipation, Steve.
 

Jaycey

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@1958slewis Welcome to BoneSmart! My first question is are you icing and elevating that op leg? All the swelling is normal but you can significantly decrease it by icing.

I'm going to tag one of my colleagues here to answer your question about physio @Pumpkln . You are right that the referred pain is probably due to your changed gait.

And by the way - it is very early days for you. Far too early to be talking about a revision.

Here are your recovery guidelines. You may have already read these but they are a good reference.
Knee Recovery: The Guidelines
1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary

2. Control discomfort:
rest
ice
take your pain meds by prescription schedule (not when pain starts!)​

3. Do what you want to do BUT
a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you​
b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.​

4. PT or exercise can be useful BUT take note of these

5. At week 4 and after you should follow this Activity progression for TKRs

6. Access these pages on the website

The Recovery articles:
The importance of managing pain after a TKR and the pain chart
Swollen and stiff knee: what causes it?
Energy drain for TKRs
Elevation is the key
Ice to control pain and swelling
Heel slides and how to do them properly
Chart representation of TKR recovery
Healing: how long does it take?

Post op blues is a reality - be prepared for it
Sleep deprivation is pretty much inevitable - but what causes it?

There are also some cautionary articles here
Myth busting: no pain, no gain
Myth busting: the "window of opportunity" in TKR
Myth busting: on getting addicted to pain meds

We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

While members may create as many threads as they like in a majority of BoneSmart's forums, we ask that each member have only one recovery thread. This policy makes it easier to go back and review history before providing advice.
 

Tykey

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Hi Steve, it's still early days in recovery, many of us go through a phase when we imagine things aren't right, but later on we wonder what we were thinking.
Keep up the exercises the physio gives you. As you are here in the UK it's most unlikely he will try to get you to force the knee (which does more damage).
I've no knowledge of whether exercises will straighten your knee out. Hopefully someone else on here will comment. Please be patient, this is always a recovery which takes many months. I wouldn't even concern myself until at least 6 months.
Assuming it is an NHS job, it's highly unlikely they will do anything more surgical until you've done all the alternatives like physio. Ie we have to jump through the hoops first, because that's the protocol.
What sort of valgus angle do you have on your knee. Knowing your ROM value might help us.
 
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1958slewis

1958slewis

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Thanks Jaycey and Tykey for your quick replies. I am icing and elevating when necessary. I appreciate it is early days but you can probably appreciate my disappointment, having gone into surgery with a straight, albeit painful and unstable, leg and come out with a misaligned lower limb.
I just wondered if anyone else had experienced this?
My ROM is good I think, at +5 to 110 degrees, and the physio seems pleased with that. I haven’t measured my valgus angle but I imagine it is 10 to 15 degrees. See pics attached (hopefully)
6AF5C026-41D3-42A8-9E58-F7C53480A789.jpeg9AE44BEC-BE65-42E7-AB6E-CF742E39B7C4.jpeg
Regards, Steve
 
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Naturelover

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Hi Steve, I have the same issue. My surgery was November 8th, 2019. My extension is not as good as yours, I believe that I am closer to +10. I stopped PT 1 week ago and plan to return if I do not make progress on my own. My PT felt we should work towards getting full extension before we started to worry about the valgus angle. I saw my surgeon 1/2/20, he was not concerned about my extension or the valgus. He feels my knee will straighten over time. I hope that he is correct, I am trying not to worry about it, the thought of a possible revision is not pleasant.

So far I am happy with my knees function. I can go up and down stairs, get in and out of my pickup truck and can walk without pain. Last week I started back with gentle mat pilates and gentle yoga classes and found that I could put weight on my bent knee as long as I have a nice cushion. I continue to ice and elevate.

I posted about two weeks back regarding other Bonesmarts experiences with valgus and did not receive any replies...

Good luck to you and please keep in touch.
 

Pumpkln

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@1958slewis
We have had other members with a valgus alignment, they have not posted in quite awhile. I have a varum knee about 5 degrees from a previous leg fracture, I wear a lateral wedge in my shoe.
Your knee looks like its is at least 10 degrees. Your PT should be able to measure the angle for you. Also have them measure your leg length, it looks as if you may have a leg length discrepancy (LLD), which would help explain your back, hip, and buttock pain.
Am I doing more damage to the knee and tissue around it by continuing with my walks and exercises?
Sounds like you are irritating your knees soft tissue with your walks and exercise levels, your PT should be able to help you titrate your activity to allow your knee to heal, but at the same time keep you active. It is a fine line. You may want to start with cutting your walks and exercise in half.
Will any sort of physio correct a valgus knee?
PT can help you with determining your valgus angle, your LLD, and give you targeted exercise and activity guidelines to promote healing.
Should I consider asking for a revision procedure to correct it or is it still early days and I should wait a few months?
It is too early to consider a revision, you need to give it time and healing.
If I go down the line of revision should I entrust this to the same consultant or try to get referred elsewhere?
NO, find a surgeon specializing in Revisions, they have the education and background to determine what is happening with troubled knees. Look for a surgeon specializing in complex joint reconstruction or revisions. They should have no relationship with your present OS, not even golf buddies.
You can use the NHS registry to find a surgeon who does lots of revisions, you may have to travel, or pay privately for a consultation.
Has anyone else had this result and what steps did you take to resolve it?
I have a knee going in the opposite direction by 5 degrees, I use a lateral wedge, and shoes that have a neutral last. Your needs will be different as you are knock kneed and I am bowlegged. Your PT or a person specializing in orthotics should be able to assist you.

Good luck in your search for answers, keep us posted on how you are doing.
 
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Jamie

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I am sorry to hear you are having these problems. Pumpkln and others have given you solid advice and I hope you feel it helps. No one likes the idea that you must wait and see when there is obvious misalignment and pain. It will be very important to find a good therapist who has worked with this type of problem before. Do some asking and checking around before you settle on someone. It's okay to ask how much experience they've had with this problem, what their proposed treatment will be and expectations for improvement.

Please let us know how things go.
 
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1958slewis

1958slewis

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Hi to Naturelover. Sounds like you do have a similar outcome to me and that you are equally frustrated. The general advice seems to be that we both must wait it out, but keep up with our exercises and stretches. I have worked hard on my ROM and took on board everything about encouraging the leg to extend and flex. I have another NHS physio appt this Friday, so I shall discuss everything with him and moderate/alter my exercise regime to suit.
Pumpkin, many thanks for your structured breakdown of feedback and I shall take on board your comments.
Jamie, thanks for your reply. It is so frustrating being in this situation - I feel that he should have to correct, immediately, the mistake he appears to have made, by setting my lower leg at the incorrect angle, whether that was caused by incorrect positioning of the implant or by making the bone cuts at the wrong angle. I know, however, that my treatment is governed by NHS protocols and guidelines and that I must be patient and hope for a better outcome as the months go by.
Great to be able to communicate with you all and I shall report any significant progress.
Steve
 

Jockette

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I feel that he should have to correct, immediately, the mistake he appears to have made,
I would feel the same way but it probably is best to let your knee heal for a bit. This surgery causes a lot of trauma to our knee/leg which takes a long time to settle down.

Here is another member who came out of surgery with a valgus leg. The link I’m giving you to her recovery thread is in the middle of her thread, as I thought that would be a good place to start. You can start at the beginning if you want.

 
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Jockette

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Here’s another one for you. You can skim through these threads to get an idea of others going through what you are.
 

Cjackso21

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So sorry for this frustrating outcome. I am just curious if your knee, although at a vagus angle, still feels stable? My knee felt like it was bending inward when I walked and going up stairs was super wobbly but standing is straight. My new doctor tested for stability (passively bending a straight knee left and right and pulling forward on the calve with knee bent) and discovered my ligaments are either gone or stretched. Remarkably my previous surgeon never did that test during my last years of complaining of problems. Good luck! I have found bicycling a great exercise for me but have to have my brace on.
 
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1958slewis

1958slewis

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Hiya Jockette, thanks for the replies and for steering me towards the other posts. I will have to come to terms with it and bide my time won’t I?
Cjackso, no I am not confident in it’s stability but it has not given way yet. I have been strengthening it and can descend and ascend stairs okay. I will ask my physio on Friday about a stationary bike.
Steve
 

Jockette

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Just be careful with any rehab you choose, remember pain is a signal that your knee is not yet ready for that activity.
 
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Naturelover

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Hi Steve,
How did your appointment with the physio go?

Have you had the chance to read the threads of others on Bonesmart who have/had valgus? I have called a couple of TKR revision surgeons (unrelated to my OS) they won't see me until a year after surgery. I am feeling very discouraged....

I hope that your appointment goes well.

Karen
 
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1958slewis

1958slewis

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Hiya Karen, Naturelover, Jamie, Jockette, Jaycey, and Tykey.

Hope you are all well. Saw the physio on Friday and he measured the valgus for me at 12 degrees. My ROM is now at +3 to 117, which I am pleased about. He doesn’t think that he will be able to alter the valgus too much with exercises but he has given me more specific ones, with bands, to target the right areas. He has noted all his findings should I need to request his notes in due course.
I find myself trying to alter my walking gait to help minimise the pain in my hip and buttock and to reduce the clunking in the knee. If I tighten up my quad muscle when I take a pace it can stop the clunk, which indicates to me that the quad strengthening exercises could prove beneficial.
I am still elevating and icing.
The more information I read about revision operations makes me realise that there are absolutely no guarantees. The implant is removed, which in itself could cause more bone damage, more surfacing of the bones takes place and the success rate is reduced even further. I have months to continue to work on my knee before I see the consultant again, who will be having ‘long leg alignment views’ taken. It may be that a revision is not offered on the NHS anyway.
My only concern is that, in the meantime, because of the alignment, the implant is taking weight through it on the wrong axis, which will cause uneven wear and a quicker deterioration. Time will tell.
Regards, Steve.
 

Jockette

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Bands are not good to use in this rehab, especially this early in recovery. Your knee is healing a major wound, it is not unfit or lazy, especially with a healing knee that is valgus.
He doesn’t think that he will be able to alter the valgus too much with exercises
I agree, so don’t try too hard in this area. Do some gentle things for mobility and give your soft tissues time to heal.
 

Celle

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@1958slewis - I have edited out the multiple tags at the beginning of your post. Please don't use multiple tags like that, as it makes it hard for people reading on small devices. All they see initially is a list of tags.
Also, the people you tagged are already reading your thread, so you don't need to call them to it. This article explains how to use tags:
https://bonesmart.org/forum/threads/tagging-other-members-and-answering-tags.56687/

The more information I read about revision operations makes me realise that there are absolutely no guarantees. The implant is removed, which in itself could cause more bone damage, more surfacing of the bones takes place and the success rate is reduced even further. I have months to continue to work on my knee before I see the consultant again, who will be having ‘long leg alignment views’ taken. It may be that a revision is not offered on the NHS anyway.
Almost all revision operations are entirely satisfactory and they usually improve the person's knee.

It's too soon for you to be considering a revision anyway. With a TKR done only 2 months ago, there is still plenty of time for your ligaments to tighten naturally and adjust the apparent valgus to a more normal alignment. That's one reason why surgeons are unwilling to give a second opinion before a year post-op. Many of the perceived original problems sort themselves out as time passes and the knee heals.

In any case, if you should need a revision to correct valgus, it would most likely be a balancing of ligaments, rather than a complete revision involving removal of the hardware.
 
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1958slewis

1958slewis

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@Celle - apologies for that, I was unaware of the instruction concerning tagging.
Thank you for your observations and comments. I expect my talk of a revision is more to do with my disappointment concerning the 12 degree valgus and the pain associated with me having a different gait. I will, of course, continue with my exercises and try and be optimistic about the eventual outcome.
 

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