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TKR Possibility of residual cement on tibial component

helenium

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Hi all :wave:. My first post on the knee side! Here goes ...

I had a RTKR in January 2017. I recovered fairly well, apart from swelling and pain in one particular area which, when I’m fairly active, continues to be a problem. I discovered BoneSmart later that year, did a lot of reading, and self-diagnosed myself with an IT band problem. Nothing seemed to help, so I went to see a sports massage therapist who’d been highly recommended. She suspected an IT band problem too, but found it was not tight. She was puzzled.

When I had my next appointment with my surgeon, he said the IT band should be fine as he’d released it during surgery. I had excellent ROM, he was happy with my x-rays, but as the knee was still a problem two years post op, he referred me for a radioisotope bone scan. The result ruled out both infection and loosening.

While I was waiting for the bone scan the knee became such a problem that my GP gave me a steroid injection. Brilliant result, but surgeon was furious because of the infection risk.

Next step was a CT scan. Nothing showed on that. Back to see the surgeon in November 2019. He said there was nothing more he could do other than a revision, and that might leave me even worse off. He obviously wanted to discharge me, I was reluctant to be discharged or to have a revision, and we seemed to sit there staring at each other for ever! He capitulated, offered me an ultrasound scan which I had in February.

Those of you who have read a little about me over on the hip side will know that disaster struck just over a year ago - the stem of my hip replacement fractured inside my femur. I spent a month in hospital, mainly lying in bed, then minimal activity until February. Five months of enforced idleness, my TKR loved it! When I had the ultrasound scan my knee had had a long rest, was no trouble, and the consultant radiologist told me at the time that there was no sign of any active inflammation.

Now that I’m becoming more active, my knee responds with pain/soreness and swelling. I’ve assumed that there was nothing more to be done for the knee other than a revision. I haven’t had a follow up consultation appointment because covid struck soon after the scan.

So that I had a record for the future I’d requested copies of my hip x-rays, and I received them a couple of days ago. Almost overlooked amongst all the x-rays was a little gem - the images (meaningless to me) along with the report from the February ultrasound scan. The report says:

Normal appearance of the patellar and quadriceps tendons.

There is tiny echogenic focus just deep to the ITB tibial insertion, this measures approximately 4mm craniocaudally. There is a 2mm fat plane separating the two. No active inflammatory change demonstrated. The echogenicity possibly represents a tiny focus of residual cement along the lateral aspect of the tibial component.

Patient describes this as the focus of her previous pain, which responded to a steroid injection provided by her GP. This was non-tender on probe palpation today.


I recall Josephine once saying that bone cement sets like marble! Although “tiny”, I wouldn’t like it in my shoe, nor rubbing against anything inside my knee. Has anyone any experience of this?

Apologies for the length of this post!
 
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Celle

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Hello, @helenium , and :welome:
I'm sorry you've had to come to the knee side because of a problem.

I'm afraid I don't have any experience of anyone having some bone cement where it shouldn't be, but I'm going to ask my colleagues if they can help advise you.
 

Jamie

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Based on what you've seen in the report, I suggest you schedule another appointment with your surgeon to discuss this possibility. Then I also suggest you see at least one other surgeon (a revision specialist is best) to get an additional opinion. @Jaycey maybe able to help you locate a revision surgeon near where you live.
 
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helenium

helenium

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Thank you @Jamie. I've managed to speak to my surgeon's secretary today. Face to face appointments have just started up again and she has put in a request for me to have an appointment with him as soon as possible. She's hoping it will be next month. As far as surgery goes he has operated just twice since early March, goodness knows when I would get an NHS surgery date. I've been told that my hip surgeon has been allowed to choose just five patients for surgery up until next April.

@Jaycey
I attempted to get a private second opinion two years ago. I had a message back from my chosen surgeon's private secretary to say that he would be happy to see me, but that it would have to be on the NHS with a referral from either my current surgeon or my GP. I live in Wales and different rules apply here.

What I'm wondering is how they find out what that "tiny" thing is. Will it mean opening up the knee to either remove whatever it is or proceed with a revision? Does residual cement always mean a revision? I'm sure whatever it is has caused damage to the soft tissue, many of the painful episodes were accompanied by bruising. A private revision would be prohibitively expensive, but less invasive surgery could, perhaps, be affordable.
 

Jaycey

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Yes, to see another surgeon for a second opinion you would need a referral from your GP. This shouldn't be a problem. And I would try and get a private appointment - less wait. Then if surgery is needed you can get on the NHS wait list with that surgeon.

In terms of what needs to be done - the surgeon would need to make that call. It may be possible to remove the item using keyhole surgery. But it's impossible to predict without all the diagnostics.

If you tell me where you are and who your current surgeon is I'll do a bit of research for you.
 
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helenium

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Thanks Jaycey. I've sent you a PM.
 
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helenium

helenium

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Many thanks to @Jaycey for suggestions as to who to approach for a second opinion. Private face-to-face appointments have started up again in my area and it was surprisingly easy to arrange a consultation. I phoned the surgeon’s secretary to arrange and, given my history, a referral was not required. That could have been a lengthy process.

The consultation went well, knee examined, long chat, then I had a call later when he’d reviewed my NHS operation notes, scan reports and x-rays. Yes, I have some residual cement, and the CT scan shows it to be bigger than the ultrasound 4mm. But it's protected between the tibia and fibula, and given its position it shouldn't be causing a problem. It’s impossible to access without opening up the knee, but should he need to do that in the future he will remove it.

In his opinion the femoral component is too big and is causing all my problems. It’s a perfect fit front to back but it’s too broad, so I have a lateral overhang irritating the itb. He’s agreed to take over my NHS care, he’ll see me again in 6 months and, if necessary, I can contact him again before then. My healing left leg and hip have resulted in me being fairly inactive for quite some time and it does feel as if everything has tightened up as a result. It could be that given some more time I might be able to tolerate the overhang, but I don’t think there’s much hope of that. He's put me on his waiting list for another steroid injection (to be done in the operating theatre to minimise the risk of infection), and the way forward might be for him to release the itb again. A revision of the femoral component will be the last resort, he thinks there’s a “slimline” component available if needed. Pity there wasn’t one on the shelf the day I had my TKR.

My original surgeon must have known there was a potential problem from the moment he put the knee in, but not once has he acknowledged that it could be the cause of my problems. Thank goodness for the lump of cement, I might never have sought a second opinion and found out the cause of my knee problems. I’m a bit lost for polite words to describe how I’m feeling right now.
 

Jaycey

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@helenium Well done on getting your consultation. Yes, not the best news. But at least you are under this consultant's care and can move forward with him. I think you can take comfort in the fact that he has a plan.

I know it's probably hard, but please try not to dwell on what is not in the past. Sounds like you have an expert on your side!
 

Mojo333

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@helenium
What in the world are you doing over here?
Just seeing your thread and don't know how I missed it.:unsure:

Guess I stay immersed in the hip side of things.
So sorry you have been struggling and I hope your injection happens soon.
Hugsxxxx
 

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