PKR/TKR when NOT bone-on-bone

[cabland]

So my knees are making my life a real pain these days. My LEFT knee is "bone-on-bone" in the lateral compartment, but isn't that terrible pain-wise. Conversely, my right knee looks "almost normal" on an x-ray, but is pretty yucky. My "treatments" for it have looked something like this:

July 2021 - Had been acting up for a few months, felt something almost "give", but kept milking it.
October 2021 - Took a trip to San Francisco, walked all day first day...knee "went out" and spent 3 days on crutches in hotel. Stiff, episodes of very sharp "flop around like a fish" pain on lateral side of knee.
November 2021 - Saw Ortho, got Xray (no obvious bone-on-bone). Received steroid shot (helped for about a week).
December 2021 - Pain getting worse. Got MRI...showed "bulging" meniscus, possible tear on lateral side.
February 2022 - New Orthopedic surgeon as first one did not do "meniscectomies". Had a partial meniscectomy and chondroplasty (lateral side and patella). Had PT following this surgery...knee did not feel "right" (felt like a knot in anterior lateral part of knee. Knee cap pain began to manifest.
August 2022 - Got another MRI in June and it showed meniscus had "flipped over" in the exact spot I felt the knot...had SECOND partial meniscectomy. APPEARED to be successful.
December 2022 - Knee really hurting again....starts on lateral side radiates around knee cap, up and down thigh and calf. Got yet another MRI - does not show any new meniscus tears. Does show grade 4 arthritis in knee cap. Nothing is bon-on bone.
February 2023 - Tried Hyaluronic injection (Monovisc - single shot). No improvement.
April 2023 - Changed orthopedic surgeon as I felt like I was the one suggesting all the treatment options. He suggested it was the arthritis at this point, but nothing definitive. Got a steroid shot as a "diagnostic" (per ortho). Helped for about 2-3 weeks then back to the usual/
May 2023 - Got a second steroid shot as we were planning to head out of town for an Alaskan cruise in June and was hoping to milk it. Ortho prescribed PT for when I return.

We did do the aforementioned cruise, but it was a bit of a mess (canceled part of trip before cruise due to knee pain, constant icing, etc.). I can walk a bit, but any distance and I have to "sit and get off the knee". Same thing if I stand for any length of time or do simple stuff like mild yard work, etc. I am only 56 years old for Pete's sake and this stupid knee is robbing me of my life.

Anyway, I start PT this week, but am not really that hopeful it will help (I know, bad attitude!), so I'm sitting here seriously contemplating pushing the issue of "knee replacement" even though it doesn't fit the classic "bone on bone" pattern. Heck, I'm not even sure my insurance will approve it!

Anyway, happy to hear any thoughts or if anyone else has been in a similar situation!

Thanks!

 

[Pumpkin]

@cabland,
Welcome to BoneSmart, glad you joined us!
Your right knee has been through a lot, and none of the procedures have given you any significant relief.
IMO, at PKR or TKR would be appropriate. Often an x ray won't show much damage, when they get in there they find significant osteoarthritis.
Your knees are not going to get any better and will continue to deteriorate. It may be time to get your life back before you become even more debilitated.

PT can help you Prehab for surgery, if that is the direction you decide to go in.

New BoneSmart members like you are in various stages of their journey to joint replacement. Making the decision whether or not to have surgery and preparing for surgery can be easier once you have done your research and know what lies ahead. Here are some tools that can help you decide what is best for you.

If you are at the stage where you have joint pain but don't know for sure if you are ready to have surgery, these links may help:

Score Chart: How bad is my arthritic knee?
Choosing a surgeon and a prosthesis
BMI Calculator - What to do if your surgeon says you're too heavy for joint replacement surgery
Longevity of implants and revisions: How long will my new joint last?

If you are at the stage where you are planning to have surgery but are looking for information so you can be better prepared for what is to come, take a look at these links:

Recovery Aids: A comprehensive list for hospital and home
Recliner Chairs: Things you need to know if buying one for your recovery
Pre-Op Interviews: What's involved?


And if you want to picture what your life might be like with a replaced knee, take a look at the posts and threads from other BoneSmarties provided in this link:

Stories of amazing knee recoveries

 

[Jaycey]

IMO, a PKR or TKR would be appropriate.

I agree - time to find a surgeon who will stop all this alternative treatment and address the issue. Life is too short to live in pain!

 

[Tentcamper]

@cabland I was not bone on bone when I had a full replacement. I told my surgeon that it hurt to do anything...walking, hiking, and my other favorite things that keep me going. My surgeon suggested cortisone shots and I asked him why, when it wasn't going to heal my knee. He agreed to surgery after that conversation. We have to be our own advocate and I'm sure my surgeon thinks I'm just another cranky old woman. I truly don't care.

 

[Cyclegal]

I was wondering the same thing about being bone on bone before a TKR or PKR would be considered, either by the surgeon or insurance company. Sometimes I feel like we have to jump through hoops with stuff that maybe works a bit, or doesn't for about a year till a replacement is an option.

 

[cabland]

One of my biggest concerns is that this "isn't arthritis" causing me all this pain and I'll push for a knee replacement and that won't be the issue!

 

[benne68]

Does show grade 4 arthritis in knee cap.

Grade 4 IS arthritis. In fact, it is considered SEVERE arthritis -- the highest/worst rating on the scale.

While you may not be bone-on-bone yet, this grading means that "the joint space between the bones is dramatically reduced. The cartilage is almost completely gone, leaving the joint stiff and possibly immobile. The synovial fluid is decreased dramatically, and it no longer helps reduce the friction among the moving parts of a joint."

If you are in severe, persistent pain and your ability to function is decreased, you really are candidate for a PKR or TKR. If it was me, I'd find another surgeon!

 

[Axx72]

I was wondering the same thing about being bone on bone before a TKR or PKR would be considered, either by the surgeon or insurance company. Sometimes I feel like we have to jump through hoops with stuff that maybe works a bit, or doesn't for about a year till a replacement is an option.

I was not completely bone on bone before TKR. Was originally scheduled for a PKR but because of Lateral osteoarthritis the idea was ruled out because of lateral PKR prosthesis longevity issues.

MY TKR has been amazing and I never look back. It’s worth it to get your life enjoyment back when you are healthy and can recover more easily.

 

[EalingGran]

Was originally scheduled for a PKR but because of Lateral osteoarthritis the idea was ruled out because of lateral PKR prosthesis longevity issues.

Curious that you were told lateral pkr had longevity issues. I know it can be more complex surgery and needs someone who does plenty- but I was told my Oxford fixed lateral has a lifetime guarantee and should see me out.

 

[Axx72]

My surgeon explained that because of my slightly vagal stance and the recovery/exercise stress I was going to be putting on my new knee, specifically on the tibial fibular joint, a lateral PKR was not a good option. I definitely had concerns with this but 7-10 years until PKR revision did not sound good to me. As I had undergone 3 surgeries on the same knee, my doctor had a pretty good idea of what was going on in there laterally.

Of course everyone’s arthritic condition can be different so different surgical tactics will apply.

 

[EalingGran]

Really hoping my lateral pkr will last a lot longer than 7-10 years. Fingers crossed it feels pretty solid .. ...
I had 20+ degrees of valgus deformity from the lateral collapse of the joint from arthritis- which has now been almost completely corrected to match my good knee.
Haven't seen any actual articles saying that lateral pkr doesn't last well.Although there is an article saying that surgery in the valgus knee ( TKR ) is more challenging and prone to issues.

Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021?​

 

[cabland]

Really hoping my lateral pkr will last a lot longer than 7-10 years. Fingers crossed it feels pretty solid .. ...
I had 20+ degrees of valgus deformity from the lateral collapse of the joint from arthritis- which has now been almost completely corrected to match my good knee.
Haven't seen any actual articles saying that lateral pkr doesn't last well.Although there is an article saying that surgery in the valgus knee ( TKR ) is more challenging and prone to issues.

Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021?​

• D. Alesi,
• A. Meena,
• …
• G. M. Marcheggiani Muccioli

For your lateral PKR, did your surgeon approach from the medial side, center of the knee or lateral side? The articles you shared are very interesting!

 

[EalingGran]

I have about a 4 inch scar just slightly lateral of the midline.
It's interesting that you said your lateral compartment bone on bone arthritis is not that painful. I didn't have much pain in my knee either and my surgeon says that lateral arthritis presents very late as pain is surprisingly not that great.
I went for surgery because I had increasing valgus ( knock knee) deformity due to the lateral compartment collapsing as the cartilage was gone. I had a very swollen knee with three bursae and a very painful hip and excruciating sciatica. My surgeon said that although I had arthritis in both that hip and the spine- my pain was largely due to the crooked knee.
He was right as the sciatica has gone ( although I still have more chronic, low level lower back pain- managed by pilates) and the hip pain on the surgical side has also gone ( although still some hip pain occasionally on the good side!)
The problem with not having much knee pain pre- op was that I had much more knee pain post op for a few months!
It is only now at 8- 9 months that I am definitely in profit on the knee pain. Although I was in profit much sooner from the point of view of losing the hip pain/ sciatica/ having a straight leg and walking better.
I am pleased with my partial because I have great ROM and a very natural feeling knee but partials do need surgeons who are expert in doing them.
My surgeon is a great exponent of them and has done quite a lot of the research on the NJR ( National Joint Registry) figures. I can find you the paper if you are interested.

 

[Axx72]

Really hoping my lateral pkr will last a lot longer than 7-10 years. Fingers crossed it feels pretty solid .. ...
I had 20+ degrees of valgus deformity from the lateral collapse of the joint from arthritis- which has now been almost completely corrected to match my good knee.
Haven't seen any actual articles saying that lateral pkr doesn't last well.Although there is an article saying that surgery in the valgus knee ( TKR ) is more challenging and prone to issues.

Total knee arthroplasty in valgus knee deformity: is it still a challenge in 2021?​

• D. Alesi,
• A. Meena,
• …
• G. M. Marcheggiani Muccioli

The decision made for TKR opposed to a lateral PKR be very well have been because of the advanced activity, cycling, would put on my new joint.

 

[cabland]

I have about a 4 inch scar just slightly lateral of the midline.
It's interesting that you said your lateral compartment bone on bone arthritis is not that painful. I didn't have much pain in my knee either and my surgeon says that lateral arthritis presents very late as pain is surprisingly not that great.
I went for surgery because I had increasing valgus ( knock knee) deformity due to the lateral compartment collapsing as the cartilage was gone. I had a very swollen knee with three bursae and a very painful hip and excruciating sciatica. My surgeon said that although I had arthritis in both that hip and the spine- my pain was largely due to the crooked knee.
He was right as the sciatica has gone ( although I still have more chronic, low level lower back pain- managed by pilates) and the hip pain on the surgical side has also gone ( although still some hip pain occasionally on the good side!)
The problem with not having much knee pain pre- op was that I had much more knee pain post op for a few months!
It is only now at 8- 9 months that I am definitely in profit on the knee pain. Although I was in profit much sooner from the point of view of losing the hip pain/ sciatica/ having a straight leg and walking better.
I am pleased with my partial because I have great ROM and a very natural feeling knee but partials do need surgeons who are expert in doing them.
My surgeon is a great exponent of them and has done quite a lot of the research on the NJR ( National Joint Registry) figures. I can find you the paper if you are interested.

Thanks for the feedback @EalingGran. Interestingly, I also have Sciata. It hasn't really bothered me much until the last few months...indeed, sometimes I'm not sure which thing is the chicken vs. the egg (i.e. which thing is making the other worse!). My lower back pain has also started to flare recently...ugh, when did I get old!?
8-9 months before seeing benefit to the knee doesn't sound great, but frankly, I've been pretty darn uncomfortable since November and that's 8 months so time can fly.

I'm not sure if we are "allowed" to post x-ray pics, but for REFERENCE my latest X-ray (April) is attached - my Right Knee is on the LEFT side of the Image (this is the knee I am asking about). Left Knee is the one that clearly is more bone-on-bone in lateral compartment (it also has a bonus "coat hook" on the femur - aka Osteochondroma). As a side note, a similar angle xray shows a materially wider gap on the lateral side of my right knee - perhaps because I was standing slightly differently - that is the second pic. Would be interested to hear if others' xrays were similar or much worse, etc.

(Right Knee is on the LEFT side of image; Left is on the Right side of image)

Reverse of above - right knee is on right side of image(note: that lateral compartment shows much more gap on right knee in this image)

 

[EalingGran]

My Xrays looked fairly similar I think- but I don't have copies.
I also had an MRI which showed a complex tear of the lateral meniscus/ large pes anserine bursa/ large supra-patellar bursa/large Baker's cyst/ stretched MCL. This might be why I took so long to be pain free. I had a very stretched MCL which took quite a lot of post op quad exercise to settle down.
To be fair my husband said I was walking better and faster by about 3 months post op, than I had before surgery. I only had residual pain on stairs until a month or so ago due to the MCL issue. By 2- 3 months I could walk 10000 steps on the flat ok. I regularly do 10-15000 steps/ day now and walk up and downstairs normally- which I couldn't do for several months pre- op either.
I didn't have a choice because my knee was definitely getting worse and impacting the hip/ back. Overall I was better off by about 3 months.
Just warning you it can be slow to feel fully right. I have been doing regular pilates as well to gradually build up my strength.

 

[EalingGran]

Have you had MRIs?
My plain direct Xrays did not show very much initially. It was only when my surgeon requested Xrays in flexion and MRI that all the damage was clearer- and surgery seemed the only option.

 

[cabland]

Have you had MRIs?
My plain direct Xrays did not show very much initially. It was only when my surgeon requested Xrays in flexion and MRI that all the damage was clearer- and surgery seemed the only option.

Yes, I've had 3 MRIs - 12/2021, 06/2022, and most recently in 12/2022. I also have the surgical notes from the second partial meniscectomy.

A few highlights from second surgery and most recent MRI are below. The way I interpret this is the patella and the femoral ridge it rides in have significant arthritis. Interestingly, the surgeon noted arthritis on the medial femoral condyle and tibia it rides on, but that was not noted on the most recent MRI. I THINK something was noted on an earlier MRI - not sure. Honestly, I think the MRIs are only as good as the individual interpreting them and I'm never sure what I'm gonna get!

08/04/2022 - Surgery Notes
Findings (note: Bolding is MINE and focuses on "arthritis" or lack thereof vs. meniscus issues)

1. Medial Compartment: Examination of the medial compartment showed an intact medial meniscus. There was grade 4 chondral damage to he weightbearing surface of the medial femoral condyle and medial tibial plateau. There was damaged articular cartilage with exposed bone. There was synovitis in the medial compartment. The synovium was diseased and inflamed and appeared to impinge with range of motion. A major synovectomy was indicated.
2. Lateral compartment: Examination of the lateral compartment showed a complex tear of the anterior horn and body of the lateral meniscus. There was a flap tear anteriorly with an associated horizontal cleavage tear. A partial meniscectomy was indicated. The lateral femoral condyle and lateral tibial plateau were intact. There was no synovitis in the lateral compartment. The synovium was diseased and inflamed and appeared to impinge with range of motion. A major synovectomy was indicated.
3. Suprapatellar pouch: Examination of the suprapatellar pouch showed grade 4 chondromalacia of patella and femoral trochlea. There was damaged articular cartilage with exposed bone. There was synovitis superomedially and superolaterally....

12/23/2022 - MRI Notes

Findings:
Bones and Cartilage: The knee remains aligned. There is no acute fracture. Decreasing marrow edema is noted within the lateral femoral condyle and tibial plateau. No aggressive osseous lesions. Mild marginal osteophyte formation within the lateral tibial plateau and to lesser degree the lateral femoral condyle.

Grade 4 chondrosis of the patellofemoral compartment is chondral fissuring subcortical cyst formationwithin the median ridge.
Minimal chondral irregularity without full-thickness chondral fissure or ulcer within the tibiofemoral compartment.


IMPRESSION:
1. Postsurgical changes of partial meniscectomy of the lateral meniscal posterior horn and body without evidence of tear of the anterior horn.
2. Mild osteoarthrosis with up to grade 4 chondrosis within the patellofemoral compartment.
3. Small Baker's cyst.
4. Decreasing likely reactive edema within the lateral tibiofemoral compartment.

 

[EalingGran]

This is the conclusion of my MRI findings. The more detailed reporting did talk about some "deep chondral fissures " on the medial and patellofemoral compartments but overall it is reported as moderate arthritis.
Wonder if your Grade 4 in those compartments suggests a lateral PKR might not be enough? I would be asking my surgeon about that and whether the level of arthritis in all three compartments meant a TKR.

Complex tear affecting the anterior horn and body of the lateral meniscus with severe lateral tibiofemoral chondrosis.

Moderate medial tibiofemoral chondrosis affecting the weightbearing medial femoral condyle.

Severe pes anserine bursitis. Semimembranosus bursitis demonstrated in addition and there is a Baker's cyst as described.

Moderate patellofemoral chondrosis.

Large knee joint effusion with synovitis.

 

[Mutti3]

@cabland
just as a side note to how fast a knee can become bone on bone very rapidly. Had a X-ray of right knee in September 2022. Still had a bit of cartilage.Returned to OS last Thursday with severe knee pain. i was shocked that the medial side was completely bone on bone. The story is you can lose cartilage very rapidly. Be your own advocate, tell your OS you want a replacement! Life is to be lived pain free! If your insurance requires prior authorization, they can submit for review.