PKR My Drama Queen Patellofemoral Knee

[EalingGran]

am hoping he will schedule a Rotational CT scan. None of my previous surgeons would order any advanced tests on my knee.

Here's hoping. Presumably a tracking problem could explain the joint feeling "off" all these years. And if it was gradually worsening it could also affect your balance.
I think joint alignment is very hard to measure in straight pictures and even apparently minor abnormalities can be significant.

 

[EalingGran]

Patellar Instability Following Total Knee Arthroplasty: A Review of Etiology, Diagnosis, and Management Strategies - PMC https://share.google/2gwYqAH5Tt1rK219S
I thought this might be relevant- although it is after TKR not PKR

 

[Jockette]

@EalingGran Thank you for that article. It confirms all the information I learned last week in my research. It explains why someone has a tracking problem, and mentions implant misalignment. I think the rotational CT scan will show that this is my problem. Every one of my symptoms point to this. A misalignment can also damage the infraptellar branch of the saphenous nerve, which explains the “pole shoved into the side of my knee” hypersensitivity I feel the second I put pants on.

Then there’s the issue of my not being able to downstairs foot over foot.

The inability to walk downstairs foot-over-foot and one’s hip pushing upward to compensate—is the definitive, textbook sign of an overstuffed or internally rotated patellofemoral joint.

Walking downstairs places the absolute highest mechanical stress on the patellofemoral joint, requiring the kneecap to handle forces equal to 3 to 4 times one’s body weight.

Why Going Downstairs Causes This Specific Failure

When you step down, your knee must bend deeply while bearing all your weight. If your implant is misaligned or overstuffed, two things happen that physically block this movement:

The "Jamming" Effect: As the knee bends under weight, the misaligned or too-thick kneecap button jams hard against the side of the metal groove. Because the track is blocked, the knee physically cannot bend any further smoothly.

The Hip Hike Compensation: To avoid falling forward when the knee jams, your brain instantly forces your body to compensate. It hitches your hip upward on that side to "lengthen" your leg, allowing you to swing your foot down to the next step without having to deeply bend the malfunctioning knee.

The "awful" feeling you get afterward is acute inflammation from the kneecap forcibly grinding against the metal ridge of the implant.”

 

[sistersinhim]

Very Interesting about that down-stepping. I don't recommend this to anyone, because I have NO kneecaps, but my OS years ago told me to hold on tightly and go down the steps backwards. None of you should try that unless your doctor says to. It just kept me safer.

 

[EalingGran]

Neuroma of the Infrapatellar branch of the saphenous nerve following Total knee Arthroplasty: a case report - PMC https://share.google/00yS8CZh7NMMD66Vp
Another possibility for the neuropathic type pain you describe when put on trousers is a neuroma of the saphenous nerve.
Damage to the infrapatellar branch is almost universal in PKR/ TKR surgery but most of us just have a numb patch which gradually improves. The nasty neuropathic pain can be caused by the surgical damage leading to a rare neuroma.

 

[EalingGran]

The damage to the infrapatellar branch of the saphenous nerve and its relationship persistent pain is interesting. I really don't notice my numb patch on a day to day level now. However, I tried the Tinel test mentioned in the case report above. If I tap with my fingernails on the area of the nerve I can still get a slightly odd tingling/ pricking sensation which is different to the normal skin area nearby. This is almost 4 years after my surgery.
Thankfully it is only ever really unpleasant for me if I accidentally knock that part of my knee. However, it shows that nerve damage can persist in various forms for many years.

 

[Jockette]

@EalingGran I had that normal numb area for a while, like most people, but it’s hardly noticeable now. This other nerve issue is extreme and always has been, since the surgery.

 

[Jockette]

Well, I had my ortho appointment today with a surgeon who does complex revisions and reconstruction. He offered me nothing, just like all the other opinions I’ve had. He did take new standard X-rays, which of course look fine. He does Patellofemoral PKRs so he was familiar with them. I asked if the implant could be slightly off alignment and he said no, you can see on the (standard) X-ray that it is right where it’s supposed to be. I asked about a rotational CT scan and he said that wouldn’t show anything. The appointment lasted a total of about 25 minutes, including the time it took to take new X-rays. He did briefly examine my knee, he pressed on it and moved it around, and said it moved fine.

I do still have an appointment with a surgeon in Philadelphia, in December, and I’m on their cancellation list, so I’m hoping to get in sooner.

I’m a bit depressed this afternoon. Every opinion I get is the same old, same old. In the mean time my knee, that has never felt right, continues to get worse.

Here is the symptom list I gave him. I don’t know how he could read all this and not consider a poor tracking issue.

I had a Left Patellofemoral PKR on March 13, 2017.

My surgeon also did a lateral release during the surgery, which surprised me because I was not aware of any tracking issues before this.

My knee has never felt right since the surgery. It constantly feels out of joint, especially when I lean forward, or turn another direction, like it’s moving out of place, toward the lower lateral side. It’s very sensitive to being in different angles, like when I sit in different chair heights. So at this point, I do suspect a tracking problem.

Since my surgery I’ve never been able to go downstairs foot over foot. When I try, my knee jams and then won’t bend any further with my weight on it, and it makes my hip go upward. If I do manage it on a shallow step, while still making my hip go up, my knee feels like something has popped out of place on the lower, lateral side.

I have not had good balance since my surgery and the last year or so it has gotten much worse, especially on uneven ground. I have almost fallen many times, but recently my foot bumped into my ottoman and I did fall.

I also feel like I’m not always able to pick my left foot up enough when I take a step, and I almost trip. This is a recent addition to my symptoms.

My knee, especially in the lower, lateral area is hypersensitive. The minute I put pants on, even now at 9 years post op, it feels like someone has jammed a pole into the side of my knee and left it there. This feeling persists until I take the pants off. Even while taking a shower, my knee reacts to the water hitting it.

By the end of the day it feels so unstable that I don’t even want to walk on it. I am beginning to use a walker more often, because of my balance issues. Leaving my house is becoming a challenge because of all these symptoms, which is affecting my quality of life. I feel very vulnerable and unsafe when out in public.

You are my fourth second opinion over the years and I am requesting different imaging than the basic X-rays every other surgeon has done and found nothing wrong. Something feels very wrong with my knee, it always has since the surgery, and now more so than ever.

 

[Layla]

Jockette,
I'm sorry this appointment didn't provide much in the way of answers. It has to feel disheartening, which is understandable. I do hope you are able to get into your December appointment early via a cancellation and have better luck with your fifth opinion OS.

Was this fourth opinion surgeon able to answer any of your questions? I hope after his evaluation he was able to address each concern you raised and explain what he believes is causing the problems and what next steps should be to find answers. If he didn't, I would have pressed him on each symptom you shared.

Have you considered a visit with a neurologist for an evaluation to see if the balance issues or the inability to pick up your foot at times is actually related. As another option, you could schedule a visit with a physiatrist who specializes in chronic post surgical pain, especially if your fifth opinion doesn't produce something different than the first four opinions.

I wish you comfort and hope the next appointment comes soon and brings more clarity.
@Jockette

 

[Legseleven]

Oh @Jockette I'm so sorry, how disappointing, I hope the next one is better. You’ve been a real trooper over this, and you deserve to be heard and offered a solution. Thinking of you lots and lots.

 

[EalingGran]

@Jockette I am so sorry that your very clear history did not get the response you need. It really does sound as though a tracking issue would perfectly explain your ongoing difficulties.
I take it there is no way you can get a rotational CT scan independently of seeing another specialist? In the UK the private hospitals will do tests independently and you can ring round and get the cheapest quote.
If that is impossible in the US is there anywhere in Canada or Mexico? There are some great hospitals abroad. My husband is currently getting a cardiac MRI on the NHS and there is an 8 week wait. We were asking the consultant we saw about travel issues/ insurance and mentioned we had been in Thailand over the summer. He said it was a pity we hadn't known about the problem then as MRIs of all kinds were very cheap and of excellent quality in Bangkok!

 

[EalingGran]

Have you considered a visit with a neurologist for an evaluation to see if the balance issues or the inability to pick up your foot at times is actually related.

This may be a good idea. Neurologists tend to spend a bit more time listening to histories and examining patients than orthopaedic surgeons. Even if they didn't think it was primarily a neurological issue- they might refer you for a rotational CT if you demonstrated the problem of going downstairs.

 

[Jockette]

I went to a neurologist for the nerve damage in my right foot. I brought plenty of information so he could diagnose my problem (which is much worse today) and he told me I was overthinking it. Seriously?

 

[Layla]

Very discouraging, but were you experiencing increasingly worse balance and the inability to lift your foot as high as you need to when you saw the neurologist? Maybe see a different neurologist?
You've certainly had run of bad luck with physicians. I'm sorry for that, Jockette.

 

[EalingGran]

Are you close enough to see one of the specialists @Jamie knows at HSS?

 

[Jockette]

I live about 3 and a half hours from HSS. That’s an option, but I hope it doesn’t come to that. New York City traffic, (@benne68, how did you find driving there?) I guess I could start off with a virtual appointment.

I truly hope one of the surgeons at Penn Medicine in Philadelphia can take care of me. I’ve been to Rothman and the surgeon there wouldn’t look at my knee past the standard X-ray that “ looks fine” just like all the other revision surgeons I’ve seen. However, I’m sure if their knee felt like mine, they’d look for an answer.

 

[Layla]

I live about 3 and a half hours from HSS. That’s an option, but I hope it doesn’t come to that. New York City traffic

That's certainly understandable. IF it comes to this are you able to take a train, then a taxi once in NYC to make for a more relaxed, less stressful trip to HSS. Given their reputation, it may be well worthwhile?

 

[sistersinhim]

Something is not right. It seems all the OSs you have seen don't care about the soft tissue that is being affected because of what sounds like a tracking problem. I had those growing up, and I know what that feels like. The removal of my kneecaps took care of that problem, but caused lots others. I will continue to pray for a correct diagnosis for you! God bless you!

 

[benne68]

(@benne68, how did you find driving there?)

I went to one of HSS's regional hospitals rather than into NYC. Same docs, same quality of care.

Have you looked at their New Jersey facilities? Still a long drive for you, but driving in the suburbs is not as bad as driving in Manhattan!

 

[Jockette]

Have you looked at their New Jersey facilities?

They have one in Paramus. It’s about 3 hours from me, and it would be on the NJ Turnpike almost all the way, so that’s much more doable.

I’m still hoping for Philly, that’s only 90 minutes from me, with no traffic.