Revision TKR Partial Revision Failure

[Cementless]

I was hoping for some more guidance since I am asking for information to tell my internist. My ortho did not want to do the MRI. I want an independent x-ray, thus an MRI.

 

[Layla]

I was hoping for some more guidance since I am asking for information to tell my internist

Please understand that your internist is the one to best advise with this since he, or she is the medical professional that holds your records / health history. We want you to receive the best possible advice and your internist should be able to provide that. In the meantime, check out the internet as time allows, you’ll find an over abundance of info to arm yourself with in this regard. Best of luck! Let us know how it goes.

 

[Jamie]

@Cementless .... it's impossible for us to advise you as to what diagnostic tests you should have over the internet. Your doctors are the experts .... in both your particular situation and what might be needed to properly determine a treatment. They may have ideas that neither you nor anyone here might have thought of. Trust in their expertise is essential. It's certainly a good idea to get multiple opinions when you are experiencing a problem, but it's always better to communicate with questions and concerns versus insisting on specific tests or trying to diagnose yourself.

Please let us know how the appointment goes.

 

[Cementless]

but it's always better to communicate with questions and concerns versus insisting on specific tests or trying to diagnose yourself.

All I am trying to do is get an MRI of my left kneecap to confirm the diagnosis of "significant osteolysis". I want this to be independent of what my orthopedic dr. said, since they read their own x-rays. I see my internist on July 19th and I plan to push for the MRI. I am not trying to diagnose myself. I do have a list of questions and concerns. I always go in prepared.

 

[Cementless]

I had an MRI of my Left knee (ordered by my internist) yesterday, 07/28/2022 and "it is not showing any evidence of complication related to my previous total knee revision", NO OSTEOLYSIS!!!
Honestly, I don't know what to think now. My revision orthopedic doctor said the x-rays done in his office showed "significant osteolysis". What now? Orthopedic doctors always read their own x-rays. Do you trust the orthopedic doctor or a radiologist? Very maddening. My knee feels like the description of osteolysis but nothing is showing up on the MRI.

 

[Jockette]

I wish we had an answer for you. It’s so hard when we get conflicting information.

 

[Cementless]

@Jockette, thank you!

 

[Cementless]

I have to wonder when I should have a kneecap revision (removal of the kneecap)? Sooner or later?
1. When I can't stand the pain any longer. It is tolerable for now.
2. Do it before it is full blown osteolysis and a break occurs?
3. Does this effect the femur and tibial components?
I know these are questions to ask my ortho, but anyone on BoneSmart have insight to this situation?

 

[Jockette]

The first and biggest factor would be if a surgeon would be willing to remove your kneecap. I would think that is not a light decision. And, if it was me, I’d want more than one opinion on that.

Usually taking care of something early is a good idea. I thought that’s what I did when I got my PKR. However, in my case, it didn’t work. 1. I didn’t have enough arthritis that required a TKR and 2. I didn‘t know I was having a controversial procedure by a surgeon who apparently hasn’t done very many of them. My results are very poor.

So, this makes me want to wait until I absolutely have to have more surgery on my knee. Granted, I’m not in a huge amount of pain every day, just discomfort and more limitations than I had before the surgery.

Just my thoughts.

 

[Cementless]

@Jockette, Here are the doctor's notes from our last visit on June 22, 2022:

"Instructions Patient Specific Counseling: We had a lengthy discussion with the patient regarding her kneecap it did confirm that it is cobalt-chrome and she does have a nickel allergy. We do not believe that the small amount of nickel that is present in the kneecap is causing the symptoms that she is having and discussed with her that revision surgery would essentially obliterate her kneecap as there was significant osteolysis. She is happy to proceed (continue as is) and feels that she is actually doing quite well. We will not proceed with any type of kneecap surgery at this point. All questions were answered today. Diagnostic Imaging Results I reviewed and discussed the results of the X-Ray(s) with the patient. After counseling the patient, we decided on the following plan for the LEFT KNEE: Observation and steroid injection."

Btw: The steroid injection was giving in my good knee...not the revised knee because it has been hurting some.

Also, my ortho doctor probably does more revisions than any doctor in the US. BoneSmart was the one that gave me his name back in 2018. He made a poor decision in letting my original patella button stay because, " it was tracking well at the time" and he didn't think it was Cobalt backed. He admitted on my last visit: "I missed one". I think he was afraid I might sue him and ruin his sterling reputation. He was OVERLY friendly and even went out of his way to hug me. I still think he is the best to do a revision of my revision...just have not made up my mind when to do it. He should have investigated more what the patella button was made of. He does at least 5 revisions/or hip/knee replacements every day. I think by the time he got to me, he may have been tired and skipped a step.

He finally admitted that he should have replaced my patella button when he did my revision Oct. 6, 2018! He thinks I would have more issues now if he tried to replace the patella button because I would lose so much more bone. In my heart, I knew this was the problem.

 

[Cementless]

I wrote this to my Ortho surgeon on Sept. 14th:

Could you elaborate on what kneecap revision surgery would do to my Left Knee besides "essentially obliterate my kneecap". You said, my x-rays show "significant osteolysis". Would this surgery effect the femur and the tibia components? Is there a way to stabilize my kneecap without obliterating my kneecap? I am concerned the longer I wait to have kneecap surgery, the worse off everything will be. You also said, I may be worse off having this surgery. Sometimes, my knee just feels like it will give away. I will be 75 yrs old this month and really don't know what to do. I can tolerate my knee for now but I feel like it is a "time bomb" ready to go off.

Worried,

 

[sistersinhim]

 

[Cementless]

It just dawned on me yesterday why my kneecap is unstable. My original Left TKR (Oct. 19, 2016) was a Press-fit CEMENTLESS patella button. I am assuming the issue is caused from the bone not attaching itself to the press-fit patella button. Since no cement, there is nothing to stabilize the kneecap.
My revision ortho replaced the femur and tibial components in the revision with cement, no cobalt (Oct. 6, 2019) but DID NOT replace the patella button because "it was tracking well". I don't know if he was tired or didn't really think it thru at the time...but here I am with an unstable kneecap!

 

[Cementless]

sistersinhim , Jockette, Jamie, Layla My orthopedic surgeon is calling me next week to answer any questions regarding Kneecap revision surgery.
***I am asking all the experts on this board to help me with the questions I need to ask.***

So far, I have sent him this in the patient portal:

"Could you elaborate on what kneecap revision surgery would do to my Left Knee besides "essentially obliterate my kneecap". You said, my x-rays show "significant osteolysis". Would this surgery effect the femur and the tibia components? Is there a way to stabilize my kneecap without obliterating my kneecap? I am concerned the longer I wait to have kneecap surgery, the worse off everything will be. You also said, I may be worse off having this surgery. Sometimes, my knee just feels like it will give away. I am75 yrs. old this month and really don't know what to do. I can tolerate my knee for now, but I feel like it is a "time bomb" ready to go off.

Should I ask him how many kneecap revision surgeries has he done? (I know he has done A LOT of revisions).
What kind of recovery should I expect?

My biggest concern is what is my kneecap going to be like in two years? My precious husband has Parkinson's and is the one I rely on to drive me and take care of me after I have surgery. He has had Parkinson's since Sept. 2019 and each year he requires more meds. I don't know what he will be like in a couple of years (or me as far as that goes).

 

[Jockette]

I can’t think of any more questions than what you have just written. I do know that sistersinhim recovered well from her surgery and is very active since. Her surgery was done years ago.

You could ask how many of these procedures he’s done, but I bet it’s not a common one.

I understand your concerns with your husband.

 

[Layla]

Hello @Cementless
I think your list of questions so far are great. Your concerns are certainly understandable, but it is difficult to predict anyones recovery or possible issues in the future. I think your best bet is to educate yourself so you're confident with your decision and have faith in your surgeon, trusting his expertise. Sometimes we take chances in life with the hope of a brighter future. If you're a person of faith, lean into that for comfort and peace of mind. Trust that all will fall into place and realize you will have the strength to deal with any adversity should there be a need. We're here for encouragement and we care, so stop by anytime you're in need of support. Best wishes for your phone appointment with your surgeon next week. Please let us know how it goes.
A peaceful weekend to you.

 

[Jamie]

Your questions are good. People can function without a kneecap, so do be sure you understand exactly what he plans to do during the surgery. If he's going to "obliterate" your kneecap, would it be better just to remove it? Is there a risk it could continue to have problems if left in place? I agree with the input you have from Layla and Jockette.

 

[Cementless]

I had an MRI of my Left knee (ordered by my internist) yesterday, 07/28/2022 and "it is not showing any evidence of complication related to my previous total knee revision", NO OSTEOLYSIS.

It does say " postsurgical changes are present following a total knee arthroplasty. Evaluation is significantly limited due to susceptibility artifact from the hardware. Within these limits, there is no MRI evidence for complications."
"No significant knee joint fluid is detected." It goes on and on how good the ligaments and muscles look, no fracture. Recommend correlation with any recent knee radiographs.

It is so confusing. Maybe I should just leave well enough alone.

 

[Jockette]

It is so confusing. Maybe I should just leave well enough alone.

Do you have benefits from having a TKR and revision? What, if anything, is better than before you had the surgery?

 

[Cementless]

If he's going to "obliterate" your kneecap, would it be better just to remove it? Is there a risk it could continue to have problems if left in place?

My guess is because my patella button is a "press-fit cementless" patella button where bone has to grow into it to stabilize the kneecap...by removing it from the existing patella, it would break the remaining patella apart.
Logically, I would think over time it would have to deteriorate.