Revision TKR Painful, failed PKR = TKR Revision

[jeano]

Although Tylenol does for me now, it sure didn't for my pre op OA pain. I will only add that I tend to think your pain will improve if you back off as much as feasible as regards activity and give yourself more time to heal. Right now I've got my leg up, ice on, and wishing I was a couple weeks further along because it would be a perfect day for a ride. Fortunately I don't have enough energy to go and bite off too much. Having said that, I am sick of resting. Last knee I decided to ride for the first time after I trimmed hoofs, it was, darned if I'm gonna maintain this horse in riding condition and not USE him! Hoofs need done this weekend...

 

[Jamie]

What you are noticing with pain meds is true. There really isn't much of anything that will touch the pain of arthritis. I'm like you, Jeano.....Tylenol never did a thing for me until I learned to take 1000mg doses. Suddenly it's a good thing.

MoTownGirl.....With both my knees, I held out hope that maybe all I needed was a PKR. The thing to do is find a good knee surgeon who does both. You know, they really can't tell 100% from the xrays what they may find when they get into your knee. In both my knees there was significant arthritis behind the patella that never showed up until surgery. Of course, with that and the medial damage, I needed TKRs and got them. What you wouldn't want is a surgeon who only does PKRs who gets into your knee and puts that in when you really needed a full replacement.

It's a gamble to get a PKR instead of a TKR. And frankly, it has worked beautifully for some. If you go that route, you'll just need to be mentally prepared that it will take about the same amount of recovery time and effort and arthritis may continue to develop and require a conversion to a full TKR.

 

[SJL]

@Jamie @Josephine

Perhaps this thread can be re-titled(?) by a moderator: “Persistent sharp pain after PKR = trouble.”

4-month-later update: I first found this board in Sep 2014, after two partial (medial) knee replacements 6 wks apart, the 2nd of which (Jun 3) was being especially troublesome with persistent, sharp, medial tibial pain (same now at 34 weeks). I like the idea of keeping this thread SHORT for efficient perusals by others, so I don’t really need comments -- I know I’ve been lost for hours trying to go through lengthy threads of others’ journeys.

In mid-Dec after my late-Nov, 6-month visit, I finally received requested copies of all post-surgical x-rays and was alarmed at what I saw when I compared half-month, 3-month, and 6-month progress side-by-side for the troubled knee (my annotated composite photos follow -- photos of computer screen, so some visual patterning distortions. Final left-knee photo montage is for comparison). From the start, I’ve never believed this Right-knee recovery path fell into the “normal” spectrum, although the doctor kept saying "give it time and have patience."

The surgeon, who probably never compared the x-rays like this, still discounts and dismisses my difficulties and says these observations are invalid because there is variability of orientation. I can tell the differences due to THAT (mostly rotation around a vertical (leg) axis), and it doesn’t explain what looks to be increasing tibial-implant tilt and gap formation relative to the flat tibial plateau, with lysis (darkening on x-ray) of adjacent bone. This shifting is obvious already at 3 months (early Sep), in my non-expert opinion! Trouble and extra-pain started on this 2nd knee (compared to the 1st knee) almost right away after surgery. The OS seems annoyed with my “micro-managing.”

I don’t believe there was anything excessive with my post-surgical PT & activity levels, but rather that this thing “went bad” nearly from the start (a bleed at 30 hrs). 29 of the 34 weeks have been torturingly painful, with just one 2-week interval (late Jun) and one 3-week interval (Oct-Nov) when I thought I might be “turning the corner” on recovery and did walking without much discomfort or "paying-the-price aftereffects." Dashed hopes each time. This pain can be described as needle-sharp, stabbing, like a dentist drilling into the pulp of a tooth, like an infected festering deep sliver, like an ice pick or gunshot attack, etc., etc.

I think the two “better periods” were when the body tried to heal around an unstable implant, when I really backed off from “actual living.” The outer thigh (tensor) muscle on the troublesome R leg also has shortened by 5” relative to the other leg (per PT evaluation), adding a lateral element of pain because I cannot walk properly on it. Overall pain is now worse than the OA I started with 2 years ago.

I’m having a “total revision” on this knee in early March 2015 with a different surgeon. Whether that might be necessary on the other (1st) partial replacement (Apr 22) remains to be seen. The nightmare has been unbelievable and has caused me to “put life’s paperwork in updated order” because this isn’t worth living with. Add me to the club of believing that partial replacements are better in theory than in practice. If able, I’ll report on how the “total revision” compares to the original “partial.”

 

[skigirl]

What a journey you have had!! I really wanted a PKR also--I had it in my head that I would get better motion in my knee---but they are so tricky, they have to be just right and need an experienced surgeon who does 100 or more per year. That person is extremely rare since most folks go to the TKR.

In view of your situation, I think you have made the best decision. The recovery will seem long to you, but you have just spent so much time with this knee already. It will be a relief to have a strong, stable knee. I could feel the difference in my knee when I got up to go to the bathroom right after they wheeled me in from the recovery room.

I hope you have the same experience. I am sure the pain you describe has been horrific.

 

[Clipless]

I was also looking forward to PKR, however my OS changed his plan to TKR when he was "in there" and saw advanced arthritis throughout. So anyway I wasn't all that surprised when I came too and got the news. Just a little disappointed, I guess.

I'm so sorry PKR hasn't worked out for you- here's hoping you'll be on the right track soon.

 

[cjf1222]

Please do not give up hope. Long term pain can cause awful emotional feelings. You have probably read Nana Moon's posts and the horrible pain she had until her revision. She has improved so much since then. This is something that will be fixed. The first surgeon just denied he made mistakes. Seems to be a pattern with a lot of OS. It WILL be better. Blessings, Christie

 

[shelli22]

And that is almost identical to my story. Similar pain issues which I described as definitely bone pain following a partial replacement. I was unable to return to work as I have to be assessed by my work prior to returning (physical assessment). At one point the surgeon felt I had turned a corner (I didn't ). The following review it was decided I may have to have a double partial as the lateral meniscus was ragged and there was an 'anomaly' on X-ray. Prior to that the lateral side was perfect. Following arthroscopy and more weeks of waiting for the miracle recovery it was decided that the partial had failed and I had to have a total. I have since had the total seven weeks ago. Still having bakers cyst pain and pain on medial side but it's early days yet so I'll give it the benefit of the doubt. I hope your upcoming total knee replacement resolves your issues and look forward to reading your progress! I wonder if the partial sometimes results in more pressure on the opposite side as we compensate by altering our alignment in an attempt to avoid pain or damage. Complicated things knees!


Sent from my iPad using BoneSmart Forum

 

[skigirl]

are you using the same surgeon?

 

[Josephine]

Whoa! There is significant and serious movement in the tibial component.
It's more than evident that it is loose.
You need to get a second opinion on this ASAP.

 

[SJL]

@Josephine @skigirl @Clipless @cjf1222 @shelli22

Thanks for your perusals and comments. And especially those of you just out from newest procedures yourselves!! Before I got in to see this NEW ortho in mid Jan 2015 (#5 for me) -- a high-volume tkr surgeon who also does pkr-to-tkr revisions -- I had another (my * Ortho #1, from 2011 & 2013) decline to even look at the images and meet with me while I was there in the office because he "doesn't do revisions" (although his online description says he does and my appointment clearly was made with that purpose). 75-mile wasted round-trip on that one. So, other than 2 veterinarian friends who saw these x-rays and also mentioned "lysis" and "necrosis," I've just had my own observations and those of other "lay people." My pkr surgeon (Ortho #4) looks at these same montages and sees no problem ("they aren't exactly the same orientation"), despite my awful recovery-history symptoms. I gave her the benefit-of-the-doubt for 6 months, trying to be patient for "healing" to complete more -- healing which quite likely would never complete! She's been very good at making me feel like a whining child and a schizophrenic.

* In my saga, Ortho #2 was my 2013 MRI/arthroscopies/hyaluronate surgeon (who does not do replacements), and Ortho #3 was who I CHOSE for 2014 replacements but who "rolled me over" to her partner (Ortho #4) for pkr instead of tkr. As #3 and #4 are in the same practice, #3 also needs to be out of the picture now.​

I first came here to Bonesmart with my story AFTER the 3-month x-rays, of which I didn't get my own copies until after the 6-month ones were taken. I know I would have made these same "shifting-prosthesis" observations from side-by-side comparison back then in Sep. Is Ortho #4 incompetent (denial) in not seeing this? I will ask Ortho #5 to note evidence of the problem when he does the revision-to-tkr surgery on Mar 10.

 

[Clipless]

Though I'm better at reading chest x-rays, I see changes that I don't believe can be explained by xray angles or technique.

 

[Clipless]

The Moderators can help you find a good revision OS.

 

[Jamie]

As I'm reading all this, SJL has a good revision surgeon and is scheduled for a TKR in March. So @SJL ... bravo for you!!! You hung in there until you finally found someone willing to observe the obvious and help you. It's so sad that a person must go through all this to get to a competent person, but it happens that way sometimes. I'm happy you stayed with it and didn't give up.

Your other knee looks good in the xrays and you say it's not giving you any trouble, so maybe it will last for a while before you need a full TKR. Hope so!!

 

[Josephine]

Is Ortho #4 incompetent (denial) in not seeing this?

I would rather say he was being evasive with fear of litigation in mind!

 

[skigirl]

I agree with Jo---it is too bad too, My own surgeon admitted that if he had known me better he would have put in a thicker spacer at the beginning----I think that when a surgeon is frank, there is less inclincation for the patient to sue. When a doc is so evasive and defensive, it makes you angry. Anyone can see the problems on your xrays, but he is afraid to admit it.

 

[SJL]

@Jamie @Josephine

11 months since my "pre-tkr-revision of a pkr" posting exchanges. Perhaps we could change my thread title (again please?) to "Painful failed PKR = TKR revision; lawyers don't care!" This concludes my chapter and keeps my thread short for perusal.​

Revision (Mar 10, 2015) of failed-from-the-start pkr (Jun 3, 2014) to a tkr is good. TKR is a twice-as-long, 10" incision (40 staples, 1st jpg below), and extra-rugged tkr devices (2.5" tibia anchor) were required (2nd jpg below). The removed tibia "partial" component was "grossly loose" and contains interesting evidence. Surface bruising from this 2015 revision tkr (ortho #5) was much less than for either pkr of 2014 (ortho #4), although tkr surgical invasion was much greater. Overall post-surgical leg swelling, as expected, was greater for the tkr. TKR recovery was not much more difficult than for a pkr (and the bone pain went away!!), but current max flex is a little less than that in the remaining pkr knee. IT-band "stretching" recovery in the failed-pkr leg is still underway from the 9 months of improper painful walking during ortho #4's period of denial.

Another irony is that I was a bit nervous about ortho #5 because he had just a "'C" average (A through F) in some online reviews. But he was superb -- keep in mind that there probably are more people inclined to write reviews if they're angry for whatever reason. His low marks were largely due to long waiting-room times and comments about "assembly line" operations. He was THAT good that he could handle multiple replacements in tandem per day. And my 1st visit was 100 minutes after scheduled -- and worth it because he took the time needed with each patient. With lots of revision experience, he said he believes most failed partials are due to (lacking) "surgical technique" and he doesn't do partial replacements anymore. Whatever your research and care in choosing who/what for knee surgeries, there is always the contributing "random factor" in determining successful outcomes.

Legal challenge: Since late Feb 2015 (prior to revision), I slowly have been attempting to get legal consultation for possible medical negligence, substandard care, and/or surgical error concerns regarding (pkr) ortho #4. As have I also gotten installation information from the partial-manufacturer (Zimmer). Xrays (previous posts of 2-wk, 3-month, and 6-month images) clearly showed the tibia implant shifting (confirmed by surgical revision report), and the following jpg xray taken of both pkrs in Jan 2015 shows surgical asymmetry -- the failed (right knee) device had a femur implant (bigger than that used in the left knee) further rotated outward relative to positioning in the left knee -- perhaps creating greater point pressure on the subsiding, corresponding inner side of the tibia implant. The removed tibia partial component (last 2 jpgs) shows one of the two (short!) tibia anchor pegs (on the side where the increasing xray gap is visible) never had its (too smooth) cement coat bonded into the bone and that the tibia receiving holes were drilled 25 degrees off vertical even though the prosthetic anchor pegs are perpendicular to the tibia plateau surface. The latter is somewhat comparable to the "square peg in a round hole" sort of discordance. Also, the cement was uneven, with much having squished out the back side of the tibia component (which looks like it must have hung over the back of the tibia bone).

So far, 4 med-malpractice attorney groups have declined to represent, giving no reason and usually not even wanting to see documents/images or meet in person. Other people have suggested to me that Colorado's $300k cap on "pain and suffering" combined with my limited direct expenses (as a retiree with insurance) make these sorts of cases a poor $ investment for lawyers (even though I doubt this situation's clear evidence even requires "professional witnesses"). Attorneys don't even want to comment on the plausibility of small-claims court action or other ways of sanctioning or reprimanding (e.g. State Medical Board complaint) a substandard surgeon. Thanks to this Forum, its members, and its moderators for providing REAL experiences and interactions that can actually help save a life (or at least some sanity). May you all eventually reach a satisfactory outcome.

 

[newlybionic]

Wow. What a horrible journey that you have been on. I hope you're doing well and you are able to find an attorney to represent you. You've provided excellent information. I've been having sharp pains in my knee since a TKR over 5 months ago. I'm off to OS number 2 in a few days. You've demonstrated that persistence will pay off.

 

[skigirl]

I am so sorry that you have had to go through all of this. I hope that at least having a functional knee will help your live a more fulfilling life.

 

[Josephine]

I think the two “better periods” were when the body tried to heal around an unstable implant

I've heard of surgeons saying this before and it just doesn't happen !

Add me to the club of believing that partial replacements are better in theory than in practice.

Sadly yes. You're my 30th case in 3 years.

he said he believes most failed partials are due to (lacking) "surgical technique" and he doesn't do partial replacements anymore.

I agree 100% and have always said as much.

Xrays clearly showed the tibia implant shifting and shows surgical asymmetry. The device had a femoral implant b igger than that used in the left knee and further rotated outward relative to positioning in the left knee -- perhaps creating greater point pressure on the subsiding, corresponding inner side of the tibia implant.

In other words, it worked loose - as I said back in January! These things do and trying to analyse why they have is immaterial at this stage.

Also, the cement was uneven, with much having squished out the back side of the tibia component.

Absolutely. In most cases it's the tibial component that comes loose first and because of that, the bone starts to degenerate as well because of the unnatural pressure.

So far, 4 med-malpractice attorney groups have declined to represent, giving no reason

I would suggest that the reason for this is that loosening is a well known and frequent occurrence in all joint replacements and however much we 'know' it's due to inadequate surgical skills, it's not something you can actually prove in court. If he used an implant that was too big, too small or a left instead of a right, that you can prove but loosening is something that happens to all surgeons. However, your retrieved implants do tend to support the notion in my eyes. They look dreadful!

 

[skigirl]

It is so frustrating to deal with lawyers---I remember all too well during my divorce that the lawyers were torture. Also, it is a fact that in a court judgement neither side gets what they want. Everyone leaves unhappy, it seems. If you are feeling well and your leg is improving, maybe it is time to just begin to live a more active and healthy life again.