TKR Post Op Complications

[Josephine]

I had already cut back on walking to a quarter mile at a time twice a day.

That's cutting back? Honey, you and I have got to have a serious talk!

I'm going to ask you some questions and 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 compare this with the bone-on-bone pain you had before surgery!

) Also don't forget to include 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 often are you icing your knee and for how long?

4. are you elevating your leg, how often and for how long?

5. What is your ROM - that's flexion (bend) and extension (straightness)

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

7. what kind of PT exercises and exercises at home are you doing? How much and how often? (and detailed details would be appreciated, please! **Reps, sets and sessions** and all that)

** If you're not familiar with this, it goes like so:
1 lift of your leg = 1 rep (repetition)
5 reps and then a brief rest = 1 set
5 sets and finishing = 1 session.

 

[Dawgster]

Josephine, I had my surgery in March, it is now November. My OS observed a slight patellar clunk in March post surgery, anterolateral synovitis in April that was supposed to resolve by July, I had an ultrasound to rule out DVT in July because of significant swelling in my calf. Now I have scar tissue lateral to my patella that is clicking and grinding whenever I bend my knee, flex my quads or gastrocnemius. It is not stiff in terms of limiting my range of motion but it is very painful when flared up.

1. Pain levels:

Before my surgery, I scored it a 5 or 6 BUT I was falling down without warning and tired of all the time. Pain level right now? 4 or 5 and I am tired all of the time. When it is really irritated it is a 6-7 when I walk.

2. Pain Meds

None. I cannot take oral NSAIDS. My GFR is under 60 from NSAIDS overuse (it should be 100 or above for my age). I still have about a dozen 10 mg vicodin from my surgery 8 months ago that I break in half and reserve for really bad nights. Voltaren gel is what my OS has told me to use but did not prescribe. Thank goodness I still have a large tube of it.

3. Icing my knee

I have a cold therapy machine from my surgery. I was using it at night because it was convenient but the medical assistant at my OS' office got upset when she found out I was using one and told me to use a cold pack 4 times a day for 15 minutes, I find this to be a hassle. A cold therapy machine for 3 hours works better for me in terms of convenience and effectiveness, but I am going along with plan for now.

4. are you elevating your leg, how often and for how long?

I have elevated my leg for 48 hours straight. I never used to have to elevate it at all (from July through October). I now do it 4 hours a day to reduce the swelling.

5. What is your ROM - that's flexion (bend) and extension (straightness)

As I stated, it is 0-140/150 (depends on the day)

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

I don't clean the house, cook occasionally, shop occasionally, and wash clothes once a month (I have a lot of extra clothes so I don't have to do it as frequently).

7. what kind of PT exercises and exercises at home are you doing? How much and how often? (and detailed details would be appreciated, please! **Reps, sets and sessions** and all that)

I finished PT months ago (like July), I had my surgery in March, I don't understand this question at all. However, quad sets are killer as they aggravate the clicking area and will set off a new bout of swelling. Don't do the recumbent exercise bike as it will set off a new bout of swelling and gigantic pain, have no PT assignments at all since July other than walk.

I did start walking the dog twice a day after my father had his stroke 2 weeks ago, he can't do it anymore. He was walking her in the morning, now I have to do that.

So, after 8 months, I am supposed to be doing PT (and if you read back my PT clinic is terrible, I have to go ten miles one-way in heavy traffic to another PT clinic, that is what I had to do to finish it originally?), not sit (so how am I supposed to work), etc.? I have other people ask me why I am so limited after my surgery when they can play pickleball, tennis, basketball, go hiking/backpacking, long distance bicycling, skiing, (fill in the blank) six months after their surgery and I am still stuck at trying to walk? My OS has not recommended more PT, I would have to go to my primary care doc and get a new referral authorized for PT per my insurance company, I can't just go order it up.

As for a quarter-mile of walking, that is the distance I walked a month after surgery. I don't think I am being unreasonable eight months after surgery to have expectations beyond that distance. My PT wanted me walking a mile 6 weeks after surgery, I didn't reach two miles until five months after surgery. I have not been pushing it.

This just sucks. I told my OS I had one goal, I wanted to take my dog on moderate walks on moderate terrain and I am now 8 months out and it isn't happening.

 

[kneeper]

It does stink, but I do wonder if cutting back to only essential activities for a while will help things settle down a bit.

 

[Josephine]

You're not alone ... read this Seriously grave consequences of aggressive PT

 

[Dawgster]

Josephine, you have confirmed what my suspicion is - my original PT caused some real and long lasting damage. I could use an exercise bike before I was injured doing squats. What amazes me is how aggressive they were about achieving ROM only 3-4 weeks post surgery since extension was 0-5 degrees and flexion was 120, my OS was thrilled. But the physical therapists and aides were like drill sergeants, barking at me if I didn't get right on it I wasn't going to have a good outcome. I called up the head of the clinic before I got on this forum and told her exactly what my opinion was of their practice, she convinced me to talk to the physical therapist and try again. After having a very stern talk about how I could not trust him if he would not listen to me about what machines and exercises hurt me (in particular the squat machine), I asked him what his plan was: this, that, and then we can get you back on the squat machine. I told him you haven't heard a word I said so we are done talking, I won't be back. Alas, the damage was done, I didn't realize it was going to be so long-lasting.

Getting through the next few months is going to be a chore. I've done some reading, it appears that now I have to wait for all of the scar tissue to form, then they will inject it with cortisone, and maybe clean it out arthroscopically as well as adjust the patellar clearance.

I am also looking for clinics where I can get a second opinion in the future and options for treatment of the scar tissue, I will probably go out of state where I have friends and family to a major university medical center.

At least I have still have my ROM.

 

[Dawgster]

I thought I might post an update on what I have pursued since my last post.

The pain I described got consistently worse. I finally could not stand it anymore and observed that at its worse my knee became dusky and just went to my PCP for a referral to an orthopod in the giant group practice. He actually was my 2nd choice for my TKR. I saw his PA Jan. 2 after my app't with my PCP on Dec. 29 (I could barely walk during the run up to Christmas).

Mere days after my surgery I could not use a stationary bike, it killed me. I could not use the shuttle machine or a recumbent stationary bike in the weeks after my surgery without resulting lateral patellar pain as I have described. I have always had a feeling that my knee would give way and a couple of times it actually did. Even though I can completely straighten out my knee, at rest, it tended to slightly contract.

To make a long story short, it got to the point I could not carry without pain even 5 pounds 10 months post op. Forty-eight hrs. after my Jan 2. app't, I was carrying 8 lbs when I had a ripping pain in my knee and it actually felt more free but extremely sore. Ten days later it still tended to rest in a ever so slightly flexed position, so I went back to the wall exercise to stretch my hamstrings followed by fully flexing my knee and I had a rippling internal tearing of adhesions (I know what this feels like after having a frozen shoulder). My knee no longer likes to stay slightly flexed but boy is it sore.

Yesterday I had my consult and 2nd opinion with the orthopod. He wants to see my full length pre-op xrays since I had a shattered leg from a skiing injury, but after watching me walk and an exam (my patella does not track correctly and my fibula clicks when actively or passively moved), he thinks that I probably need a revision for a lateral release. He said he would have brought me in for an immediate MUA, but felt that it is no longer necessary.

He also was of the opinion that my original OS should have seen me sooner (still have not seen him BTW, they are too busy to work me in). I have an upcoming app't with the OS who did the TKR, I am 75% sure I don't want to keep going to that clinic, but how do you tactfully tell them you are not coming back?

BTW, both docs can read the EHR and thereby go over each other's notes.

 

[Pumpkin]

I am 75% sure I don't want to keep going to that clinic, but how do you tactfully tell them you are not coming back?

You can tell him at your appointment that you are seeking a second opinion, if the response is positive that is good, if not, just do not go back.
The only time you would need to tell them you are not coming back is if they call you for an appointment, then you tell the scheduler you have transferred your care to another OS.
You do not need to tell them you are not going back, just don't schedule any more appointments.
It really is up to you and what you are comfortable doing. Since the office is not responsive, and will not fit you in when you need to see the OS, do not feel bad about whatever you decide to do.
Good luck, hope you find a solution to your problems,

 

[Jamie]

@Dawgster ... how are things going for you? Would love an update if you can....

 

[Dawgster]

Thanks for the reminder question. I am kind of stuck anyway making a decision.

Exactly two weeks ago I saw my original OS. I did not rant and rave about not being able to get a followup appointment while in excruciating pain and unable to walk. Instead, when they were ordering a new set of x-rays, I said they had been done already and explained that I saw my primary care provider when I was in dire straits so he referred to me to one of the group practice joint replacement OS. The linked electronic health records had my images and notes, so he went and read them

My original OS thinks I need 3 months of PT and then he will consider replacing the spacer because my knee is loose. He gave me a prescription for 6 weeks of PT, however (go figure) and see him in 3 months. No mention of a lateral release to address soft tissue imbalance. He mentioned that he put in a 9mm spacer and the next size up is 11mm, but since I had 145 degrees of flexion, I could probably accommodate it.

On the other hand, on February 26th (next week), I see the 2nd opinion OS, he wanted to see how I am doing after iliotibial band stretching and after I got my pre-op x-rays (which I have done). He didn't think PT was going to help.

Going up and down stairs is still a killer and walking on pavement is just as bad. I have done both recently which means the swelling has returned. Additionally, I have incredible pain extending distally from the anterolateral knee compartment. I was starting to gain strength in my quads for the first time since my TKR but it is swelling throughout the knee again since my visit one week ago just by going up and down a long series a stairs several times (it was unavoidable). The superior tibiofibular joint is incredibly painful, I get a knife-like stabbing pain to the point it feels like it is on fire. I can’t sleep on my left side, the weight of my left knee on the lateral side and/or my right leg on top is too painful. Additionally, I have had tightness and pain from an area that may be from the popliteal tendon ever since I had my surgery.

Plus I have spent three hours hassling with my insurance company over which PT clinics are covered in the past week so I haven't started PT. I am sitting on the decision at the moment - do I bother with PT, do I switch surgeons, do I have surgery now. I finally came to the conclusion I need to hear what the 2nd opinion OS has to say and what my insurance company will allow.

If I solicit advice, I do listen. Last time I asked, a member of this board suggested that I just not make a followup appointment with my original OS, which is what I did. I am in a quandary: will PT help (I tend to think not)? Do I do surgery right away (I dread having to go through rehab all over again)? What are the risks of a revision surgery with a lateral release (infection seems obvious)? I have a ton of questions.

What I have arrived at is this: I will probably go with the 2nd opinion OS. He paid attention to the fact before my surgery I was knock-kneed and pronated bilaterally, the tremendous amount of alignment issues I had from my old skiing accident (every time I brought this up to my original OS – my foot turned in, my leg was shorter, my tibia bowed out, and I had common peroneal nerve damage with a slight foot drop he just would say we will address that in surgery), and listened to my concerns. I don’t, however, like the PT clinic associated with the group practice – they just blew off the problems I had in rehab without trying to address the problems I was experiencing (but that is a bridge to cross later).

Is there information anyone can provide that would address the questions I have raised concerning revision surgery that involves a lateral release with a spacer replacement?

 

[Dawgster]

After all of the above, none of the proposed actions were done. I had a follow up appointment 2 days ago. Spacer replacement is out of the question - I need one mm but Stryker Triathalons only have 2 mm increments. In the opinion of my new OS, it is not worth the risk of infection, blood clots, and potential nerve damage to revise it merely for a spacer.

Additionally, he has seen patients who had problems with Stryker Triathalons that is similar to what I am experiencing. My situation is exacerbated by trauma 40 years ago that caused my knee to require replacement: My tibia bows out, my toes turn in, and my tib/fib are 1/2-3/4" shorter; in other words, the appliance used may not have mattered at all, I would have had problems with all the deformities in my lower leg. I am just going to have to live with it.

His recommended course of action is to get me to the point of one good knee. At the time of scheduling of my first TKR, both were in need of replacement and I had to pick one, so I selected the worst one. The ongoing problems have only made my right knee worse. Because my leg is shorter on the left, my right hip has a frayed or torn labrum, and my hip is incredibly painful. His thinking is he can resolve the hip problem with one good knee and relieve stress on the original TKR by doing the 2nd one now.

I have to admit that I am apprehensive given the discouraging result of the first one. My pain relief has been 60-75% but I have pain using stairs and going down a steep incline. For my first TKR I was incredibly hopeful and optimistic. I dread doing the 2nd one given the commitment you have to make in terms of pain and work.

This time the appliance will be a Zimmer Persona and I am scheduled for June 30 - I don't want to spend any time dreading this any more than I have to and I would like to be back on my feet

 

[PolarBear60]

I think there's some logic to the argument of giving you one good knee. Get yourself as ready as possible, physically, mentally, and residentially. I hope this procedure will give you more satisfying results, then you will be in a better position to deal with the other knee. If you are able to find the right PT place, they should be able to help you with both legs, even though their focus will be on your new one. They will understand the value of synergy in your body.


Jean

LTKR (Stryker Triathlon): 21 April 2015
Right Knee Arthroscopy: 25 July 2006
Left Knee Arthroscopy: 10 February 2005