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Revision TKR My Revision after a Loose Implant

Cementless

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Has anyone else been told by their OS they can live with a loose implant (no infection) if they want?
Pain/soreness around a 2 or 3 at times.
ES Tylenol 1-2 can quiet the soreness for awhile.
Cementless left TKR done on 10/19/2016.
I am allergic to the bone cement.

The femoral implant is intact but the tibial portion shows possible loosening on a nuclear bone scan. My bone did not adhere to the cementless implant. He said there was no worry about a fracture. He did give me his partner's name in case I decide to go with a revision. No guarantees the revision would work, 50/50.
 

Celle

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Well, I wouldn't live with a loose implant. Any symptoms you have now are likely to get worse.

How did you find out that you are allergic to bone cement? Did you have allergy testing that proved it?

Did you just have the cementless implant installed, or did you have a knee replacement prior to October 2016?

I'm going to ask @Josephine to advise you.
 

Nick-UK

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Agree with Celle, it can only get worse. I would get sorted sooner rather than later while you are still mobile
 

SusieShoes

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And I will pile on about it only getting worse over time. If there's movement, there's a chance of the movement causing something to happen, including more loosening. :sad:

Have you considered getting a second opinion? There are surgeons who specialize in knee revisions and problems from TKRs. Another surgeon (one not associated in any way with your current surgeon) might have a different take on what you should do.
 
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Cementless

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My orthopedic Dr is located in the medical center in Houston, Texas. (He does all the doctors who need TKRs). I really felt he was the best to do my surgery (TKR) after one of our friends had a double TKR and did great!!! Looking back, even though he has done over 5,000 TKR, I am only the 2nd cementless TKR.

I found out a couple of weeks prior to my TKR that I was allergic to the bone cement (through an orthopedic blood analysis). After about a year, my tibial bone started to hurt when I bend over to touch the ground (pressure on it). It feels sore and like it is swollen inside but not on the outside. No redness or heat, outward appearance looks normal. I have a good bend 125-130, no limp. It is painful if you tap on the side of my knee on the outside.

He ordered a CBC with differential, sed rate, and CRP to look for infection. All came back normal. I had an EMG of the left leg to see if I had a nerve entrapment. This was negative but found I had a S1/lumbar radiculopathy.

Then on June 13th, I had a nuclear bone scan and it showed loosening of the medial and lateral tibial plateaus of the left knee. My femur implant is intact. At 6 weeks there were gaps between my tibial implant and bone. At that time he was not worried because they usually fill in, mine did NOT and it became wider. He did refer me to his partner if I wanted to proceed with a revision. Limited options because it needs to be cementless.

I ask him if I could live like this and not do anything. He said yes. I ask if there was a worry my tibial bone would fracture and he said no.

We are both disappointed. He kept saying he did not have that much experience with cementless knee implants. I was so ready at the time to get it over with and I really liked him. Wished I had known to do more research with an ortho that does cementless implants.

I am a young 70 yr old female and hope I can live with this because he said it would be 50/50 whether a revision would work. No guarantees. They have to use a longer implant and take more of the tibial bone. I am going to try and live with this for now.

I ask him if there was anything I did that hurt the implant and he said no. The bone just has not grown into the implant to stabilize it. I also have osteopenia.

I am going to have a Bone density done on July 3, 2018 to see how my osteopenia is doing. Next, I found an allergist to do patch testing on me the week of July 9th to see how allergic I am to bone cement just in case. They also test the metals in the implants.

Did you know they use bone cement for the spacers in the first stage of a revision. I would be in trouble if my bone cement allergies are severe!
 

Celle

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Wished I had known to do more research with an ortho that does cementless implants.
I think you're right. I also think it would be a good idea to look for a second opinion, from a surgeon who is skilled at dealing with problem knees and who has experience of doing cementless knee implants.

You will need someone who has no connection, professional or social, with your current surgeon, so that he/she can look at your knee with new eyes and form his/her own, independent opinion.
You may have to go out of your area to get this second opinion.
Next, I found an allergist to do patch testing on me the week of July 9th to see how allergic I am to bone cement just in case. They also test the metals in the implants. Did you know they use bone cement for the spacers in the first stage of a revision. I would be in trouble if my bone cement allergies are severe!
I think it may be necessary to find out which components of the bone cement you are allergic to. There may be alternatives to the standard cement. That's something that @Josephine would know.

Cement spacers are not used for most revisions - they're only used in a two-stage revision, when an infection is present. In that case, an antibiotic-impregnated cement spacer is used for a period of months until all infection is gone, before the new metal hardware is inserted.
 
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Cementless

Cementless

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I am "mildly allergic" to the Methyl Methacrylate and Polymethyl-methacrylate-copolymer in the bone cement monomer (fluid).

Almost
mildly allergic to Titanium alloy particles and my reading on Colbalt Ions 0.0001 was inching it's way up there behind the Titanium.

I am not aware of alternatives to the standard cement because they are all made up of the above.
 

MyTest

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@Cementless Hello:
I had one Dr tell me to play it by ear because it may be loose but still tight enough to hold. He didn't want to remove it unecessarily. However, another Dr gave me a bone scan and recommended a revision since the scan confirmed it was loose. I went with the revision only because I could feel the device or something pushing against the inside when I moved my knee a certain way. I would get a second opinion to see what another Dr suggests. Not sure it's safe or healthy to have it aloose, just my opinion. Good luck
 

Josephine

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I ask him if I could live like this and not do anything. He said yes. I ask if there was a worry my tibial bone would fracture and he said no.
His agreement to the "and not do anything" is rather worrying. You don't really want to spend the rest of your life in a wheelchair and not doing anything, surely?

Besides which, a loose metal implant most certainly can cause damage to the bone. Bone doesn't like movement and it will either wear away in the presence of it, what doctors call remodelling, or sustain a 'stress' fracture which is a fracture occurring in the absence of trauma. Then it really would be painful!
he said it would be 50/50 whether a revision would work. No guarantees.
That's about right for any revision, my dear. So it's still not the end of the world.
They have to use a longer implant and take more of the tibial bone.
Well they don't take 'more' of the tibial bone really. The longer stem is only marginally longer than the standard tibial implant (on the left) - like the one on the right that just give a greater area for bony integration

TKR cruciate sacrificing-horz.jpg
longer stems.jpg


I am not aware of alternatives to the standard cement because they are all made up of the above.
You may not be aware of alternatives but there are some! Like this one that is coated in ceramic, designed specifically for people with metal allergies

anti-allergy implants.JPG


Did you know they use bone cement for the spacers in the first stage of a revision. I would be in trouble if my bone cement allergies are severe!
Yes we do know that. But since infection is not an identified problem, your need for them would be somewhat academic!

However, you are getting your problems and consequences muddled up. There are many reasons for failure of bony integration into the hydroxyapatite and these include
1. osteopeneia and/or osteoporosis
2. ill-prepared site which should include a 'power wash' of the exposed bone to rid the area of fat globules, blood and blood clots and fine bone debris
3. taking NSAIDs in the first couple of week - NSAIDs are known to inhibit the development of bone stem cells i.e, bone growth​
 
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Cementless

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Josephine, as of today I have no issues walking and I am not in a wheelchair, no limp, no aids, good bend 120-130 degrees. Both the regular X-ray (AP & lateral) and nuclear bone scan say "possible loosening of the medial and lateral tibial plateaus of the left knee with moderate uptake noted". Femoral component is intact.

I do have osteopenia and was giving Celebrex 200mg ( NSAIDS) twice a day for the first month and then 200mg once a day the second month.

The implant that was used was the cementless DePuy Sigma LCS Rotating platform: The SIGMA® Cementless Knee System is available to your surgeons for their cementless application needs. It utilizes POROCOAT® Porous Coating, which is a small-bead Co-Cr-Mo porous coating that provides a three-dimensional network of interconnecting pores created when metal alloy beads undergo a sintering process that causes neck-like connections to develop between the beads as well as promotes the fixation of these beads to the substrate material (implant). They did not think I was allergic to the metals.

At my 6 week appointment/x-rays there was a gap between the implant and my tibia, which he felt would fill in...it did not. 19½ months later the gap was larger.

cementless 2.jpg
 
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Cementless

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There is also "mild periprosthetic lucency along the margins of the tibial component raises the possibility of prosthetic loosening. No evidence of loosening of the femoral component." 5/25/2018

upload_2018-6-30_10-38-57.png


The bright white spots show moderate activity in the nuclear bone scan which means possible loosening.
 

Josephine

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You only posted the lateral view - don't you have the AP view as well?
I don't read MRI scans.
 

Josephine

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Oh that's MUCH better - thank you!

So now I can see the loosening quite clearly and I've marked it out in this snippet. You can see the black line (space) around the implant

AP view a.jpg
 
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Cementless

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Josephine, the radiologist and OS were more concerned with the white line that is around the outside margins of the tibial implant (the long part/stem part). How did you mark the picture with the red arrows? The OS was hoping my own bone would fill in the black shaded areas.....it has not.
 
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Josephine, I am going to post my AP and lateral x-rays at six weeks. You will see the gap there at 6 weeks on the lateral view. The OS said he was not worried because it would fill in....it did not (as we see).

2016 12 01__resized_MED    L KNEE 6 weeks TKR.jpg


2016 12 01_1_resized AP view L KNEE.jpg
 

Josephine

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I've never known the bone to start growing again. It's a once only event. But I was interested to know that the radiologist and OS were both concerned about the halo round the stem because I was too but for some reason I chose to focus on the other areas.

This was the spot you meant, wasn't it?

AP view a.jpg


I think that's indicative of a toggling stem, meaning it's moving and remodelling the bone inside where it's toggling to and fro. Most definitely it needs to be revised.

And I used my photo editing suite to do the arrows. It's a free one called Photoscape and very versatile.
 
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Cementless

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Yes, the white lines! I can't believe my great OS said I could live with this if I wanted to.....mentally I can't handle a revision at this time. He didn't seem to think the tibia would fracture. I can tell there is something wrong with my knee. It hurts when I turn over in bed, feels better when I walk. I don't rest well and I can't get in a comfortable position. If it hurts too bad, 1 or 2 E S Tylenol calms it down.
 
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Josephine, I have been reading your knee surgery posts. I have a question for you. Prior to my TKR, I did not have a lot of pain but was bone on bone. Afterwards the pain was horrible!!! I was on Norco 7.5 with 325 Tylenol for 6 weeks. It made me so depressed and constipated that my OS switched me to Tramadol 50 mg. I took that for a couple of months, reducing it to 25 mg. I noticed your OS prescribed Tramadol up to 150 mg/up to 600mg in 24 hrs.
Did you ever take Norco? If and when I ever have this revision, I would rather have the higher doses of Tramadol, I think. Thanks for all your insight.
 

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