PKR Reoccurrence of pain after Episealer implant surgery.

[Celina]

Unfortunatly my knee will react afterwards and be sore/hurts the rest of the day

Ice is your friend! Ice for 45 - 60 minutes several times per day

You shouldn't ice for longer than 20 minutes due to the risk of freezing your skin (even when using a towel as protection) which can result in skin and nerve damage. I must say I didn't know that at my first surgery so I definetly iced way longer. I think my knee is very used to the icing. I am icing at least twice a day (after lunch and before bedtime). I sleep with my icemachine that activates every 80 to 100 minutes for 10 minutes, sleepsaver!

 

[Jaycey]

You shouldn't ice for longer than 20 minutes due to the risk of freezing your skin

The 20 minute sessions are used in treating an injury. You are recovering from major soft tissue trauma. Always put a cloth between your skin and the ice source. This will insure there is no burn risk.

 

[sistersinhim]

I iced for hours at a time, the whole time I was sitting or laying down. I did this for a couple of months without ill effects. Icing in this way, with a cloth between the ice pack and leg, keeps the pain and swelling down. Inflammation doesn't thrive in cold conditions, that is why the icing helps so much. When inflammation is down, then so is the swelling. The cold helps to numb the knee to the pain, so that keeps the pain med consumption down. It's all good!

 

[Celina]

So after two months of waiting I recieved my MRI result yesterday. Unfortunatly the Episealer distorted the MRI so much you can't see anything medially. My surgeon didn't expect it to be this bad. So now we decided to go for the CT arthro (contrast dye) anyway.

The image below is the best image from the MRI.

 

[EalingGran]

Sorry to hear that the image is no good.
How's the pain? Is there any improvement? Does your surgeon have any idea what's causing it?

 

[Layla]

I am so sorry, Celina! What a disappointment after waiting two months to end up with that result.
Hopefully you receive some answers soon. Stay in touch, we're here for you!
@Celina

 

[Celina]

Sorry to hear that the image is no good.
How's the pain? Is there any improvement? Does your surgeon have any idea what's causing it?

The pain hasn't gotten any worse or better in the last 2 months. Only this week the weather is getting warmer and my knee is really sensitive for warmth / heat. I'm a bit scared for summer :(

It might be my meniscus but he can't say for sure without any diagnostic scan.

 

[Celina]

I feel really helpless and down. I received the CT result yesterday but it didn't show any abnormalities. For me this was the worst case scenario because I am still in the same pain, but it is still unknown why and there seems to be no diagnostics to find out. My doctor was so honest to say he doesn't know what to do with my knee now either. He said it is best to wait and hope for improvement. I can't remember how often a doctor said that to me and just as many times it didn't work. So low hopes on that it actually will improve by itself.

I read some information about CRPS, also from this website. Although I think my case is too mild to be labelled CRPS (no sensitivity to the touch and no ROM restriction) it might have to do something with an oversensitive nerve? But my knee can feel normal in the morning and then after mild activities feel hot to the touch. It actually reacts to activities or a too long time of inactivity.

It is still so strange that it was all going well, totally painfree for a couple of months and then all of a sudden. I am now thinking this RFA (radiofrequent ablation) I had before that didn't seem to work might have had some effect after the surgery and has worn off?

I am also in doubt if I could increase my activities. I know it will increase pain but being restricted for this long is just even worse. I always was worried I would make my injury worse but since everything the doctor saw on CT was good this chance is slimmer. If it would it might be clearer what is going on?

I really have a hard time to accept to just wait. Will try to do my own research and if so find the right specialist. Any advice is greatly appreciated.

 

[EalingGran]

Sorry to hear this.
I suppose the normal CT is good news really as it shows there is no major structural abnormality. But disappointing for you not to find an answer.
I wonder is something like an inflamed MCL would show up on a CT?
Might be worth trying to find a really good specialist physio/ PT who could perhaps pinpoint the cause of your pain.
In my case both my surgeon and a physio I saw whilst in hospital for something else, diagnosed MCL issue on basis of location & timing of pain. It has improved with the right exercises.
I also get occasional pain at the back of the knee which apparently is popliteus just occasionally catching on the rim of my implant.
Trouble is that some surgeons aren't really interested once it is established that the hardware/ surgery is ok.
A lot of these soft tissue issues are really irritating but will improve with the right exercise/ rest/ ice.

 

[Jamie]

I agree with your feelings that just taking a “wait and see” attitude is not the way to go. For things to have been just fine for a while and now suddenly they aren’t would seem to point of a problem somewhere. I suggest you try to find some additional surgeons who could take a look and see what they think. You’ll need to find revision or reconstruction specialists, not just regular orthopedic surgeons to get the best expertise. These are the guys that see and fix problems from previous surgeries or accident victims. Please let us know how things go.

 

[Celina]

Thank you both for encouraging me to continue my search for the cause of my knee pain. After research I now think it might be Plica Syndrome / Hoffitis. I am having an ultrasound at pt on monday to find out. I will post the result here.

 

[EalingGran]

Fascinating. Just been reading about Hoffa's syndrome/ fat pad impingement and plica syndrome. I hadn't heard of either before.
I guess it just shows how complex the knee joint is and no wonder the results can be so variable.
I hope these diagnoses prove to be helpful in counteracting your pain.
Good luck and keep us posted.

 

[Celina]

I was really having high hopes the Plica Syndrome was what was wrong with my knee but the ultrasound showed nothing abnormal. Bad news since I now still don't know what is causing my knee pain. She said she can only see the structures on the surface of the knee and not deeper inside (blocked by other tissue). Actually my pain feels deeper in my knee.

I am now looking into the more scary and long-term diagnoses of arthritis and nerve damage. I've read that trauma (including surgery) and foreign body (including knee-implants) can cause rheumatoide arthritis. Also after every surgery it took 8 to 10 months before pain started again. Might be that this condition was there all along:
- Microfracture in May 2018 - 4 to 6 weeks no/limited weight bearing - pain in Novembre 2018
- Autologous chrondrocyte implantation in May 2020 - no/limited weight bearing for 6 weeks - pain in Januari 2021
- Episealer implant in May 2022 - 4 weeks limited weight bearing - pain in Januari 2023

My orthopedic surgeon and his colleague are currently the only two doctors who perform this Episealer implantation in the Netherlands. So it is hard to get a second opinion. Besides that I think the implant is positioned well but something else is going on. It might not be an orthopedic problem but maybe more in the range of Rheumatology. One easy diagnostic that I haven't had done yet is blood tests (general, infection and RA related) so I will call my GP to either get those done or get a referral to a rheumatologist (or both).

 

[Jamie]

Good luck….you’re smart to pursue all possible options so you can take advantage of the process of elimination for the pain in your knee. If you have rheumatoid arthritis that was undiagnosed before, it’s possible that surgery can cause a flare. Please let us know how things go.

 

[Celina]

Finally some good news! My knee pain has changed from a 5 to a 2 (VAS), mostly just constant irritation. I still am not completely sure how that happened. I started taking some supplements a few weeks ago and I try to limit my icing now. I have a lot less need to ice because my knee doesn't get that hot anymore. The main problem now is nighttime. I still wake up with a painful knee that keeps me awake, so therefore I still use my ice machine. During the day I feel when I need to move and if I do it all stays manageable. I am finally able to do some leg exercises at pt with limited pain afterwards and the next day. I hope the restrengthening my leg does make it even better. Finally got some hopes up!

 

[Jaycey]

Such good news @Celina ! Sounds like you are finally seeing some good progress. Well done on staying persistent!

 

[EalingGran]

Glad things are improving. Sorry that sleep is still an issue. That was one of the last things to settle for me. I think even small amounts of pain feel much worse at night when there are no other distractions. I have insomnia anyway since the menopause so I take some sleeping medications- either herbal valerian, a small dose of an over the counter sedative antihistamine or melatonin. I also have some zopiclone which my GP gave me post -op, which I save for going away. I find if you vary them and keep the dosage low then you don't get tolerance and they continue to work.
I know some people don't like to take any sleep medication but I find lack if sleep intolerable and it was really bad post my surgery when there was pain as well.
It sounds as though whatever caused your setback might be settling- fingers crossed!

 

[mendogal]

Glad things are improving. Sorry that sleep is still an issue. That was one of the last things to settle for me. I think even small amounts of pain feel much worse at night when there are no other distractions. I have insomnia anyway since the menopause so I take some sleeping medications- either herbal valerian, a small dose of an over the counter sedative antihistamine or melatonin. I also have some zopiclone which my GP gave me post -op, which I save for going away. I find if you vary them and keep the dosage low then you don't get tolerance and they continue to work.

100% this - I alternate between an herbal tea blend that includes valerian; 50 mg diphenhydramine; 6 mg time release melatonin.

 

[EalingGran]

Interesting @mendogal that we have independently found the same sleep strategies! I suspect a lot of people our age are doing this....

 

[Celina]

Unfortunatly most of my improvements were due to taking as much rest as possible. I finished at the psychologist and am currently in sickness law. That means that I am on the couch with my leg up or in bed for nearly the whole day. The supplements do help against the heat but my knee is still very painful at times and irritated nearly all the other times. I am glad PT is still going ok although my knee needs about a 24 - 30 h recovery from it which feels ok for me as long as it helps. I have no problem to fall asleep but the long time of inactivity irritates my knee. With the ice machine I can manage to prevent pain and continue normal sleep for most nights. I do really bad on any type of medication. I once used 0,25 mg Lorazepam and 12 h later while driving I still felt floating xD .

After doing more research I really think it is some soft tissue issue. It might be irritation or impingement likely from the scar tissue after multiple surgeries. Besides the "Infrapatellar fat pad syndrome/impingement" there also are a few others. This is a long shot but do you know anybody who has/had "posteromedial knee friction syndrome" or "Hoffa's posterior fat pad impingement"? My latest pre-implant MRI report does say something about medial Hoffa fat pad scarring, i don't know the exact location (will ask next week).

I am currently trying an Ibuprofen treatment but after almost 2 weeks the only difference I notice are side effects (nothing severe so I will continue for now). I decided to send a message to my hospital and they replied with a phone consult for next week with the nurse practitioner. If the cartilage and implant are fine it is time to search for a specialist in soft tissue. I am wondering if a sports medicine specialist might be more experienced than an orthopedic surgeon in soft tissue issues? I think it is helpful in rehabilitation that my knee is not prone to swelling but now with this diagnostics all seems to be minor on the outside. I also have full ROM with is less likely with any Impingement but I am a bit hypermobile so maybe that explains it?

I know this are a lot of very specific questions and finding answers is a long shot. I struggle to find clear information on the Internet but I am not giving up. So if anybody has any advice, ideas, anything. You are so very welcome to share them! Thanks, Celina.