Revision TKR Out of options after 4 years

fender unbender

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I had my original partial knee replacement in August 2013. I ignorantly let the OS perform this without proof that it needed to be done other than him stating "I've been in there, I know what you need." Prior to this I had undergone 2 arthroscopic repairs in the last year of my torn meniscus that did nothing to alleviate my pain, one by him and the first by another OS. This all started out not because of an injury but just because my knee hurt. My occupation was 30 years of doing auto body repairs on cars, quite a physical job and terrible on my knees, lots of kneeling and bending. I thought my knee might just be wearing out.

At 3 months post op he told me there was nothing more he could do, everything was perfect in the x-rays and he referred me to a pain clinic. At 6 months post op I returned to him because the pain continued to get worse and the first thing he told me when he saw I had returned was "what are you doing here? I told you there was nothing more I can do for you, You are going to have this pain for the rest of your life." As unbelievable as this sounds, these were his exact words!

I proceeded to visit 4 more orthopedic doctors to get their opinion on what could be done to alleviate my pain and to find out what was wrong with my knee. Three of the doctors (including one from his clinic) saw my pre-surgery x-rays and told me that from what they could see, I should not have had knee replacement surgery. He was just chasing my pain without diagnosing the cause. They all added the disclaimer that of course the x-ray only tells part of the story and maybe there was more to it than that. Unfortunately all the doctors were stumped about the cause of my pain and said that by looking at the x-rays they could see nothing wrong with my knee and the partial replacement looked great. I also had a full work-up and an infection was ruled out.

For the next two years the pain continued to increase and I was up to 40mg oxycodone and 40 mg oxycontin per day. I had two bone scans performed and they showed that there was a possibility that the replacement was loose. The OS I was seeing now at the Mayo clinic agreed that there was a chance that it was loose and gave me the option of undergoing a revision surgery. He said there was 50-50 chance that this surgery would alleviate the pain. My only hesitancy was that if it didn't work to alleviate the pain, the pain I had on the inside of my knee would now be present through my entire knee.

To describe my pain, it felt like a dull screwdriver was jabbed in my knee joint and twisted. It was a deep ache on the medial side of my knee and it felt like the pain was in my bone. I did have full range of motion and no swelling of the joint. Through this whole time I had continued to work with terrible pain and my employer was not happy about me working with all the narcotic pain meds.

in December 2015 I elected to proceed with the revision to a full replacement (hoping there was something wrong with the original surgery and I would be able to sue the arrogant person OS that had told me to go away). My OS said that when removed my old implant it wasn't completely loose but he was surprised how easily it separated from my bone. It only took a gentle tap from his hammer to remove it. Immediately the old pain was gone. The only pain I now had was just the surgical pain. Within a month I had cut my narcotic pain meds in half and I couldn't wait to get back to a normal life.

Much to my dismay, at 6 weeks post op my original pain started to return. The pain now is in my entire knee and it is still a deep ache and it feels like it is in the bone. My OS at the Mayo Clinic had no idea what was causing the pain, everything looked great and there was no infection. He sent me to a spinal surgeon who did a full work up that ruled out referred pain from my spine.

My thinking was that I must be allergic to the joint but my OS disagreed because of the limited research that has been done. I went to an allergist who did a skin patch test on me and the only thing that I had a reaction to was zinc. Now I was convinced that I was allergic to the component but my OS still disagreed. It made sense to me, the new surgery removed the part of the bone that was having a reaction so the pain went away. It took several weeks for the newly exposed bone to start to have a reaction. It sure made sense to me but other than the severe pain there is no other indications of an allergic reaction, no redness to my skin or blisters etc. Jumping ahead to this week, I finally spent the money for the blood allergy test from Orthopedic Analysis and the results came back showing that I am not allergic to the metals or cement.

At this point my OS at the Mayo Clinic has told me that I need to wait for new technology and to check back with him every six months. I always thought that once you got to the Mayo Clinic they wouldn't stop until they find a cure but apparently not. I have not been able to work since my revision surgery because of the severe pain and all the narcotic pain meds that I am on. I am currently taking 90mg oxycodone and 70mg methadone. I take this between 11 am and 4 pm and by then the pain is finally under control so I have about 3-4 hours of manageable pain, not much of a life anymore. I always walk with a cane to keep the pressure off of my knee.

A month ago I went to a new OS to get another opinion about what might be wrong. He took a new x-ray and said that the femoral component had a radiolucent line around it so he suspected that it might be loose. He had me get another bone scan and the results of this showed that there was no problem. My question for him that he couldn't answer was that if it was possibly loose now, how does that explain the pain for all but the first six weeks of the replacement? And what would cause it to become loose like the original partial replacement possibly was? And what would prevent another revision from becoming loose at a future date? He also withdrew fluid and did bloodwork to check for an infection. The only thing abnormal that the bloodwork did show was a CRP inflammation of 32.

In the last 6 months my pain doctor did a spinal cord stimulator trial with the hope that this would give me some relief but it did not. All along she thought the pain was probably coming from my nerves but after this test failed to help she said "I guess the pain is not from your nerves but it is actually mechanical pain in your bone or your joint."

Now I am at the point that I do not know where to turn to next. Because the pain is so severe I cannot understand why a doctor cannot find the cause and I am hoping someone on this forum will have a new idea for me, something the doctors are missing. To make things worse, without an actual diagnosis my long term disability insurance will be ending in 4 months. There is no way that I can work with the pain and all of the pain meds that I take. Thank you for reading thru this long story.
 
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Hi Bob and welcome to BoneSmart. I truly an sorry for all you've been through. It seems to me that you've just traipsed from one incompetent to another! Yes, I know that you had surgeons from the Mayo but trust me, these places do have their share of them!
repairs in the last year of my torn meniscus, not because of an injury, but just because my knee hurt. I thought my knee might just be wearing out.
and you were dead right!
To describe my pain, it felt like a dull screwdriver was jabbed in my knee joint and twisted.
This is a perfect description of a loose implant! I may even borrow it!

Having read carefully through your story, I am in no doubt that both your post-op problems were connected with a loose implant. If you have any (fairly) recent xrays, I'd be more than happy to take a look at them.

As for you ongoing pain, my other suspicion is connected with PT. With that in mind, if I ask you some questions, would you be willing to answer them?
 
Thank you Josephine for your help. Ask away, I would be more than willing to answer your questions. As far as PT goes, after both surgeries I did have PT and I left both therapists stumped as to what I could do to alleviate the pain. They both basically said that I "passed" and had great ROM.

I have requested and am waiting to receive my most recent x-rays. I will share these with you when I receive them.
 
What an awful journey you have been on with your poor knee. Hopefully, Josephine will come up with a solution for you. You have certainly been through enough!
 
Here y'go then!

However, because of the long time period involved, I'm going to make this a little more complicated for you! What I'd like you to do is answer the questions for the first 12 weeks after the revision in Dec 2015 (Q1 through to Q8) and then the same again for right now.

It would be very helpful if you would answer each one individually - numbered as I have done - in as much detail as you can then I'll come back as see where you are ....

1. what are your pain levels right now? (remember the 1-10 scale: 1 = no pain and 10 = the worst you can imagine. And don't forget to factor in other forms of pain such as soreness, burning, stabbing, throbbing, aching, swelling and stiffness).

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

3. how swollen is your leg compared to these?
ai63.tinypic.com_eta39s.jpg


4. what is your ROM - that's flexion (bend) and extension (straightness)

5. are you icing your knee at all? If so, how often and for how long?

6. are you elevating your leg. If so how often and for how long?

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc., and

8. are you doing any exercises at home? If so what and how often?
This is the most crucial question so please help me by using the format I have left as an example
(which means please make a list and not an essay!)

Exercises done at home
- how many sessions you do each day
- enter exercise by name then number of repetitions of each
etc., etc.

Anything done at PT
- how many times a week
- enter exercise by name then number of repetitions of each
etc., etc.
 
This is much more complicated! I answered them all and after I posted them my wife caught that I didn't completely read your question and I only answered for how things are currently, oops! All of my answers at 12 weeks are the best I can remember and they are in bold.

1. what are your pain levels right now?

1. At 4 weeks my pain was a 4, at 12 weeks it was averaging a 6 (I probably thought it was more at the time but compared to my pain now I had to readjust my pain scale)
1. Current: It is an aching pain. I primarily have the pain when standing or walking but it also hurts if I sit for an extended time (30+ minutes) and it ranges from 5-9 and today it is an 8.

2. what pain medications have you been prescribed, how much are you taking (in mg please) and how often?

2. Prior to surgery I was taking 60mg of oxycodone a day and for the first 4 weeks after surgery I was tapering off of it. Then the old pain returned and by 12 weeks I was back up to 60mg a day.
2. Current: 30mg oxycodone at 12pm, 2pm, & 4pm; 20mg methadone at 12pm, 2pm, & 4pm; 10mg methadone at 6pm

3. how swollen is your leg compared to these?

3. moderate
3. Current: Knee is slightly swollen.

4. what is your ROM - that's flexion (bend) and extension (straightness)

4. ROM was 0-115
4. Current: ROM is 0-130

5. are you icing your knee at all? If so, how often and for how long?

5. It seemed like I was always icing it. Probably 6 times a day for 20-30 minutes.
5. Current: No icing.

6. are you elevating your leg. If so how often and for how long?

6. I did not intentionally elevate my knee other than sitting in my favorite recliner.
6. Current: I don't intentionally elevate it but I do spend most of my day sitting sideways on my couch because that gives me the most pain relief. So I guess I can say that I spend ~6 hours a day elevating my knee.

7. what is your activity level? What do you do in the way of housework, cooking, cleaning, shopping, etc.

7. My activity level decreased quite a bit between the fourth week and the 12th week As soon as I was physically able I was back to a limited normal life, At 4 weeks my wife had spinal fusion surgery and I was her primary care giver so I did all the shopping etc while she was laid up. This all slowly changed as my original pain returned and increased in severity. I cannot recall exactly ,but I was still able somewhat to help out with normal household activities at 12 weeks.
7. Current: Between 4pm and 6pm after all my pain meds kick in, I try to do some limited activity around the house. I force myself to go out once a week to do a little grocery shopping and use the shopping cart as a walker. Any walking that I do, I lean heavily on my cane to keep the pressure off of my bad knee.

8. are you doing any exercises at home? If so what and how often?

8. I did not start any PT until 5 weeks after surgery. After my original knee surgery in 2013 I was fully dedicated to PT. I pushed myself hard and was doing all sorts of exercise. I made sure I did all I could to have a successful and speedy recovery. I often wondered if pushing myself like I did had anything to do with my persistent pain. After reading the articles on Bone Smart I realized that I did not need to push myself. After my revision surgery I decided to go the conservative route in regards to PT. It wasn't until after 4-5 weeks when my old pain started to return that I decided to go to PT. I wanted to make sure I wasn't doing something wrong and assumed my surgeon would not take my pain seriously if I was not in PT. I went thru PT for around 5 weeks and the therapist kept trying to refine my exercises to relieve my pain but always with no success. I do not recall any of the details of what exercises nor the frequency.
8. Current: I currently do not exercise because I am happy with my full range of motion and mobility other than the extreme pain. I am neither over weight or out of shape, plus most exercises cause me pain.
 
Thank you so much. That was all very helpful.
1. It is an aching pain. I primarily have the pain when standing or walking but it also hurts if I sit for an extended time (30+ minutes) and it ranges from 5-9 and today it is an 8.
Oh that's bad!
2. 30mg oxycodone at 12pm, 2pm, & 4pm; 20mg methadone at 12pm, 2pm, & 4pm; 10mg methadone at 6pm
No Tylenol? You could add in 1,000mg 4 times a day provided there is none in the oxycodone.
3. Knee is slightly swollen.
Okay
4. ROM is 0-130
Something to be thankful for, I suppose!
7. Between 4pm and 6pm after all my pain meds kick in, I try to do some limited activity around the house. I force myself to go out once a week to do a little grocery shopping and use the shopping cart as a walker. Any walking that I do, I lean heavily on my cane to keep the pressure off of my bad knee.
Gotcha!
8. I currently do not exercise because I am happy with my full range of motion and mobility other than the extreme pain. I am neither over weight or out of shape, plus most exercises cause me pain.
VERY pleased to hear this.

Got another question for you though

Can you indicate the site of your pain using this chart?

knee-references-horz.jpg
 
Can you indicate the site of your pain using this chart?
After my revision surgery my pain is located in CLF3&4, DLF3&4. After my original partial replacement my pain was located in CLF3 & DLF3 . Ironically, I told my doctor that I was worried that if underwent a revision surgery that the pain would be on both sides and this is exactly what happened.

No Tylenol? You could add in 1,000mg 4 times a day provided there is none in the oxycodone.
I forgot to say that I occasionally do take Tylenol, probably 1000mg every other day. I get worried about taking it everyday for several years when it doesn't really do anything noticeable for my pain. I just take it out of desperation when the pain is really bad just incase it helps even a little.
 
CLF3&4, DLF3&4.
Sorry, this is not a proper reference - I need one 3 letter from th column and one from a row. And I need to know what site it is now
I forgot to say that I occasionally do take Tylenol, probably 1000mg every other day. I get worried about taking it everyday for several years when it doesn't really do anything noticeable for my pain. I just take it out of desperation when the pain is really bad just incase it helps even a little.
That's why it doesn't work for you. You have to take it regularly every 6hrs for it to work.
 
Currently the pain as located at:
CLF3
CLF4
DLF3
DLF4

On your advice, I will go back to taking Tylenol every six hours and see if this helps.
 
So this is your pain site, yes?

bob.jpg


As for your xrays ... thank you for these. They made all the difference.

Your first xray doesn't show the top end of the femoral stem - do you have an xray that shows it?

Plus there doesn't appear to be any bone cement. Did the surgeon tell you if he'd used it or not?

But I think it's possible that much of your pain is coming from the patella which not only is very crumbly looking but has some fracture lines in it. These need some looking into.

left sunrise (3).jpg
 
Plus there doesn't appear to be any bone cement. Did the surgeon tell you if he'd used it or not?
This is from my surgical notes: " The three components were cemented into place with antibiotic-containing bone cement."

That is a very interesting observation about the patella. No doctor has ever made a comment about my patella. I will follow up on that.

pain location.jpg Yes, that is where my pain is located and to be more exact, the area in yellow is more precisely where my pain is located.

Here is a larger xray that shows the femoral stem.

members pic 1.jpg
 
This is from my surgical notes: " The three components were cemented into place with antibiotic-containing bone cement."
Well that's interesting because I can see no cement in the femoral implant at all and only a bit in the tibia.

But can you post that last picture full sized? It's rather small and when I try to enlarge it to see detail, it pixilates!
 
That's great, thank you! Well it confirms what I said. No bone cement. However, I just reread your first post and found these interesting comments
He took a new x-ray and said that the femoral component had a radiolucent line around it so he suspected that it might be loose.
This is what I see and I also think it's a loosening signature.
And what would cause it to become loose like the original partial replacement possibly was?
This is an entirely different situation.
And what would prevent another revision from becoming loose at a future date?
That the surgeon uses appropriate skill and application when doing the surgery.

For one thing, what you have is a constrained knee implant which is usually used in cases where there is a previous history of bone loss, infection or severe deformity or ligamentous instability. A loose partial knee fits none of these scenarios.

However, this wouldn't be the cause of your present issues. The implant should have been cemented in place, it's not designed to bond with the bone like uncemented devices are so I suspect that it IS loose and you need it redone again! Sorry for the bad news!
 
I can't begin to tell you how grateful I am for your help!

Since I am having such terrible luck selecting orthopedic surgeons, do you have any recommendations for me in the Minneapolis, Minnesota area?
 
Well as you can see, I'm in the UK but my colleague @Jamie might be able to give you some suggestions.
 

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