TKR Nine weeks out and still limited ROM

[Gilina]

The biggest thing is that my OS was very careful with rehab. I had no rehab for three weeks---he felt that if you exercised an inflamed,hot knee it would cause more adhesions to form.

Another thing to remember when the time comes. Thanks. Don't know if it is "normal" but TKR my knee is still just slightly warmer than the non-op knee at 4 months out.

Gilina

 

[Celle]

I'm glad BoneSmart has helped you, @Gilina .

Apart from Josephine's many years of professional experience, she has had two knee replacements herself and most of us have had either hip or knee replacements. She still attends conferences and is in touch with orthopaedic surgeons.
The moderators continue with relevant training too - so we have a combination of theoretical and practical knowledge.

It's always good to know that we've been able to help. That's what BoneSmart is here for, as well as for friendly support from fellow travelers on the recovery road.

Yes, it's normal for the TKR knee to sty a bit warmer than the other knee for quite a long time. It's a sign that healing is still going on inside.

 

[Gilina]

Yes, it's normal for the TKR knee to sty a bit warmer than the other knee for quite a long time.

Good thing to know, thanks. I don't ice very often anymore--should I still be doing that regularly?

 

[Celle]

You can continue to ice any time your knee feels uncomfortable. At a year after my TKR, I still ice occasionally, if I have had a particularly active day.

 

[Kssii]

(yet I have read here that aggressive PT can cause adhesions)

My surgeon agrees with the folks here--in fact, his nurse is fanatical about not overdoing for the the first 6 wks.!! I didn't even get out of bed the first two days and very gentle exercise at PT and my ROM is well over 130.

 

[skigirl]

I assume you read the tutorial by frank Noyes. He mainly treated patients with ACL injuries---which have a different rehab than do TKRs. He worked at the Steadman Clinic and they do not even treat knees who have had a TKR.

But, Celle is correct, the thinking has changed a lot about how to rehab a tkr. Just think though---if your knee is swollen and stiff---does it even make sense to "force" the knee to bend?? Of course not. My PT was adament all the way through---2009 was my first rehab---that you had to respect the healing on the knee and that not much could happen until the swelling was down and the knee was not hot.

Until then I did lots of heel slides and gentle bends, but nothing strenuous.

You trust your doctor and he has offered a solution to you. I think you are doing the right thing and I do agree that it is good to ask about the cautery since that is clearly recommended by many experts in this field.

 

[Kssii]

I am 4 1/2 mths. out and at this point the "new" knee is slightly cooler than the one that still needs to be done.

 

[Gilina]

I am 4 1/2 mths. out and at this point the "new" knee is slightly cooler than the one that still needs to be done.

Sounds like your other knee is bad, too. It's interesting since both my knees looked the same on x-ray, but one had been hurting for a couple of decades (the one I finally had surgery on) and the other has not been much of a problem--and it is cool. The TKR knee is only slightly warm, though it gets warmer if I'm on my feet a lot.

Gilina

 

[Kssii]

Actually the one that still need to be done had the meniscus removed in 1980!! Drs. told me both knees were a "mess" and should have been replaced about 10 years ago, but the remaining knee, while stiff and cl-icky doesn't hurt much.

 

[Hopper]

Interesting thread to read @Gilina - what are your extension and flexion at now?
I've just been pootling along with my bend stuck at 90 - don't know why I've not had more gain as I've been using the knee well. This is my second PKR and was the more damaged knee with less flexion so it may well stay lagging behind the other.
Anyhow, I've not had any physio for over a month as been away etc. I returned to physio last week and yesterday after some nice massage we found it was suddenly at almost 100. My sweet physio feels some extra ROM is there to be had and so we will gently get it!
I have to say I had a brilliant and gentle PT in the US after my first PKR. He was superb and worked in the same way as my UK one does with this second knee.
My knees are great - I'm not saying they are perfect because Im still healing so get niggles, but I am saying Im pleased with them and love being more active with less pain.
Good luck with your ROM.

 

[skigirl]

Here is the word from my OS---If you are prone to adhesions (other surgeries--duh, how did we get to TKR, or your body is prone to form adhesions) then aggressive exercise on a hot, swollen knee will cause adhesions to form.

So, since I had adhesions---my knee bled a lot in the hospital---I had no pt for 3 weeks and then table exercises---leg lifts, heel slides until 8 weeks, then began to do gentle exercise. If the knee got hot--I stopped.

 

[Josephine]

The author included adhesions as a form of arthrofibrosis, near as I can tell

Well it's even simpler than that - adhesions is the common term for the condition in its early stages. Arthrofibrosis is the medical term for the same condition in an advanced state.

He makes several comments which are at odds with things I have learned here--like if post-op PT isn't aggressive enough/done well enough, you can form scar tissue (adhesions), i.e., it's the patient's fault, and therefore have a loss of ROM (yet I have read here that aggressive PT can cause adhesions). Sometimes I think too much conflicting information is just too confusing--and upsetting.

Yes, as others have said, 2008 is old news. Plus ACL repairs are a whole other situation to knee replacements. Sadly there are still a lot of institutions that subscribe to the 'hard work', 'no pain, no gain' philosophies which are terribly dated and just plain cruel. Don't you fall for that.

Don't know if it is "normal" but TKR my knee is still just slightly warmer than the non-op knee at 4 months out.

There is a big difference between warm and HOT! Warm is perfectly normal, hot is not!

 

[Gilina]

Well, now I'm depressed. Maybe it's because I expected my OS to be more upbeat about doing the arthroscopic lysis--or something, but I came away from my appointment this morning very discouraged.

ROM is actually worse than it was 2 months ago (down to maybe 70 from 85). His answers to my questions were somewhat different than what he had said earlier (about out-patient surgery vs staying overnight), and the list of possible complications was somewhat daunting (e.g., unlikely, but may end up worse than I am now). Won't be able to drive, etc. He indicated a somewhat long recovery. By then it will be snowing here and I will have shoveling to do. He said they make 2 to 4 small incisions, depending. (more scars--yippee). And, he changed his stance on pain from PT--had previously told me not to cause myself pain--now acts like pain is part of the deal with PT. Argh! Maybe he was negative because I can't stay in the hospital overnight for the CPM machine and 2 PT sessions (already told him before those PT people are never touching me again).

Mostly what got me was when I asked about methods/tools.

@Josephine So, I mentioned snipping and cauterization tool--he said yes--but also said they use the shaver tool a lot. I had read (or been told on this forum, not sure) that that tool is bad and too avoid it, that it causes too much bleeding and tissue damage and ends up causing more scar tissue--and said so. He didn't think so. Sigh. So, I am not happy. Seems like I can't even look forward to a positive outcome from the lysis the way I feel right now. But, I can't continue to be limited as much as I am if I ever want to be able to function normally.

@skigirl Tagged you in case you know anything about the "shaver" tool.

Wish I hadn't missed--or that he didn't use--that 3 month window for MUA. :-( Just not feeling good about the whole situation.

Gilina

 

[Gilina]

after some nice massage

I wish they thought about massage here instead of the rough, incompatible with a bad back stuff they do. It was not productive what they did to me--just the opposite.

Gilina

 

[Gilina]

Oh, I forgot. In a conversation with my GP, I mentioned the "4000 mg a day of acetaminophen is OK" recommendation for pain I have seen and been told many times. She said "No way" unless you want kidney or liver damage. Also, so a report recently that research now seems to show that patients are better off with morphine than NSAIDS, regarding statistical heart attack and stroke complications. Opinions keep changing on all drugs/medications it seems. Makes you wonder if anything is safe.

Gilina

 

[skigirl]

Gillian, I have had the same thoughts about what is safe to take for pain. I mostly use a synthetic morphine called Tramadol ( trade name: Ultram). It is fairly mild and I don't have the side effects of the more serious drugs. I have 25 mg tablets, which I sometimes cut in half. Jo uses this drug for her TKR rehab, but in a larger dose.

My rheumatologist feels that it is a fairly benign drug---she is leery of NASIDs. However, every time I show up in an Arthropod's office, I get the recommendation to take them.

For the Lysis--- my doc was the same as yours about knowing everything already. I have looked at a lot of websites and considered a lot of doctors who specialize in arthofibrosis. Almost all of them recommend cautery for removal of adhesions. They feel that the shaver causes bleeding.

Here is my list of docs who specialize in Arthrofibrosis, just in case you live near one of them.

Dr. Colin Eakin, Palo Alto Medical Foundation, California

Dr. Steadman, Steadman-Hawkins Clinic, Vail, Colorado

Dr. Peter Millet, Steadman Hawkins, Vail (as of 10/1/05)

Dr. Lonnie Paulos, Salt Lake City

Dr. Frank Noyes, Cincinnati Sports Clinic, Ohio

Dr. Wojitys, Ann Arbor, Michigan

Dr. Jason Folk Steadman-Hawkins Clinic of the Carolinas Greenville, SC

Dr. Shelbourne, Indianapolis, IN

Dr. Flandry, Hughston Clinic, Georgia, Alabama

Dr. Gill Boston Mass. General Hosptial and An asst. Prof at harvard

Dr. Tomas Sculo HSS

Dr. Answorth Allen HSS

Dr. Henry A Finn Weiss Memorial Hospital Chicago

Dr. Charles Bush-Joseph---Rush University Med Center.

Dr. Michael A. Terry Northwestern U Feinberg School of Medicine

Dr. Juan J. Rodrigo Baylor Schott and White Hilcrest Medical Center Waco, TX

Dr. Thomas N Lindenfeld Cincinnati Sportsmedicine and Orthopaedic Center

Dr. Friedrich Boettner HSS New York and the United Kingdom

Dr. Ajai Cadambi Texas Hip and Knee Center Forth Worth, TX

Dr. (Mr) Glyn Evans London Orthopedic clinic

Dr. Simon Tan St. Vincent's Sprotsmed Darlinghurst, Australia

Dr. Philipp Traut Bad Oeynhausen, Germany

If you Google Frank Noyes, he has a series of articles on Adhesions (scar tissue).
Also Peter Millet is one of the men who does not think you should have an open Lysis of adhesions.
Steadman treats arthrofibrosis, but they will not treat it after a TKR

Also Dirk Kokmeyer, a PT wrote tutorials on Arthrofibrosis Rehab that I found really useful

You might consider the two who are at Rush in Chicago. A pain to go see them, but let's face it you are talking about the rest of your life -- I think you can spare some time for that.

 

[Josephine]

@skigirl Tagged you in case you know anything about the "shaver" tool.

Hey! I'm the OR nurse around here!

The shaver is a bit like a Dremel tool that artists use for fashioning models and artwork from wood. The dilemma is that some surgeons, well meaning of course, seems to think that if they smooth off the rough surfaces in your knee to 'get rid of' the arthritic damage, while all they've done is advanced the arthritis by some weeks or months! I've scrubbed for heaps of them and never thought it was a good idea, often challenging the surgeon about it. But they are convinced it's the right thing to do, never mind that the patient ends up in more pain and needs a replacement sooner rather than later! So I say to you and anyone else reading, have an arthroscopy and a washout by all means, have a mensical trim as well, but do tell your surgeon NO SHAVERS! Add it to the consent form if you like. You're allowed to!

 

[Gilina]

Almost all of them recommend cautery for removal of adhesions. They feel that the shaver causes bleeding.

Exactly what I remember reading previously. Unfortunately, all those docs on your nice list are too far away--I am a caregiver and really cannot travel away from home. Leaves me in a odd position. My insurance may not allow me to change docs anyway and it would be awkward in an area with a limited number of docs.

Looked up those names--I had read some of those articles before and couldn't find any writings of the others. Will look more in a few days. Behind in my other work.

I mostly use a synthetic morphine called Tramadol ( trade name: Ultram)

Ultram has some problems for migraine sufferers, so I guess I can't use it.

but do tell your surgeon NO SHAVERS! Add it to the consent form if you like.

That is what I want to do--not sure how that would go over (I don't exactly care, but I know how patients get treated if they don't allow themselves to be ordered around. Used to work in the hospital.)

I'm having arthroscopy for lysis of adhesions after TKR. So, he would be using it on soft tissue not bone--actually, that sounds worse! He did mention that the tools could scratch the implant resulting in the need to replace parts (revision?) sooner. It's tempting to just live with the discomfort and limitations I have at this point instead of going through more with all the potential complications. Maybe his negativity wore off on me. I'm all stressed out again and feel like I have too much to think about. Hope I can sleep tonight.

Thanks for the responses. I may have more questions once I ponder for a bit.

Gilina

 

[Kssii]

I am so sorry you are having all these problems. As to the morphine with migraines, might work; my daughter-in-law was on it for ten months and she has migraines. (Abdominal adhesions that they finally removed--kept telling her she had gallbladder trouble!!) Over all I have to agree, doesn't seem to be a "safe" painkiller--guess we could just chew on a stick of wood. (This is what one doctor, after reading the latest warnings on tylenol, said was left for chronic pain sufferers.)

 

[Josephine]

Over all I have to agree, (Tramadol) doesn't seem to be a "safe" painkiller

On the contrary. Being a synthetic opioid, it has a better safety record than most other opioids and a better record of effectiveness though there will always be certain people for whom it is not effective. That's the same with almost every drug, not just analgesics.

This is what one doctor, after reading the latest warnings on tylenol

With respect to your doctor, the US is very much a over-protective, nanny state where these things are over controlled for virtually no good reason. I could go on but I don't want to bore you! Suffice it to say that paracetamol has been in use in the US and UK since 1950 and has an unparalleled record for effectiveness and safety provided the instructions are adhered to. It's the same with NSAIDs - they are marginally safe but people who get problems like kidney damage or gastric bleeds are invariably found to be taking way past the recommended dosages. This can also be a problem when the public buy cold remedies without checking what they contain - many contain acetaminophen and/or ibuprofen which should be taken into account in the daily dosage.