Revision TKR Revision: Second Time Is the Charm

[spinfanatic]

Hi buddhabear. Neither the radiologist report or the Surgeon review of films used the term 'scar tissue' although before MRI surgeon suspected a large scar band in the petellofemoral joint. Surgeon was able to show me on films location of plica which looked like white blotches and talked about synovial thickening. Sorry I am not more helpful. Good luck and keep advocating for yourself. I'm grateful to have possible solution and hope I will be loving my knee soon!

 

[Brownie51]

Wow Spin I was surprised at your story. Having things go wrong when you are that far out is scary. I just had my 6 month mark and I figure I'm out of the woods. I know how disappointed you must be. It sounds like you have a good solution and I pray it will be your last surgery!
Take good care!

 

[60mom]

I was wondering about your surgery on Monday. I see my doctor on Thursday to decide if I need surgery on my knee to fix whatever is being impinged when I rotate on my bike. I have rested also but last night I tried again just to see and it happened again. What does your OS think is being impinged?

 

[spinfanatic]

Hi 60mom. My OS says what he sees on films is a Plica which is a tissue fold in the synovium. The Plica is irritated and catches on patellar. It is presumed to be a hereditary thing. I have no medical background and this stuff makes my head spin. Your so lucky as so many of our Bonesmarties are to have a medical background. Really looking forward to next week. Good luck at doc and let us know what he says.
And brownie thank you for the good wishes. Been reading your thread. WOW! Keep positive!

 

[maryo52]

Think of a water balloon. The synovium is like a balloon around your knee joint which is bathed in fluid. But it's not a balloon, it has folds as you mention. When swollen, the plica can get caught in the knee mechanism, which of course is a kind of hinge. I think it'll be pretty straightforward. After my last arthroscopy, I really only had, like, 3 days where my knee was sore. Then you'll be soaring (well, kind of). Don't break out the champagne yet, but be ready to celebrate a new level of recovery.

 

[spinfanatic]

Hi all. Had my surgery on Monday and all went well. OS removed 2 inch long dense piece of scar tissue/fold that was catching on equipment. Knee looked wonderful otherwise! Great color and no additional scar tissue. OS is very confident this is an isolated bad luck outcome and will not happen again. He believes if this was to be an ongoing problem he would have seen additional scarring. He was actually very relieved. Such a nice man. OS says my ROM and extension are fantastic so no need for CPM. So GREAT Moment! Finally after 7 months some really good news! I am very grateful!!!! I so want to love my knee!
Now the bad news. OS needs me to rest my knee for at least 30 days. I am to limit walking and stairs to extent possible. I am not to bend knee beyond 90 degrees. I am to elevate and heat as often as possible. Don't really understand why but trying not to second guess OS. After 7 months, I assumed I would be back to my regular activities and not relegated to bed rest. So for the time being no Pilates, yoga or biking! No 5Boro NYC bike tour this weekend. No power walks. No sailing. It's springtime in NY and this is the best time of year to be outside and play! Trying to be proactive as follow up appointment is in only 26 days/but whose counting? Not sure what happens next month as OS wouldn't commit. So in the interim, I got my light weights out for upper body and plan on going to local gym and use arm rolling machine for cardio. I had husband set up backyard for power reading. Trying to think of this as oppurtunity and remain calm and stay positive! Thanks all for listening. See you in the social room!

 

[60mom]

Thats great, other then being inactive. Prayers it goes by fast and no more adhesions.

 

[spinfanatic]

Thanks 60mom. You are just a bit behind me. I hope and pray you get resolution soon! I am fully confident you will!

 

[maryo52]

When you find out the reason for heat, let us know. I'm curious.

So glad for your results. The day I had scar taken out of my knee was a great day.

You're right: spring time is so special and you will miss some stuff you love. To me, just seeing the tree buds, the flowers, and hearing the birds is enough. So another lesson in patience, my dear!

 

[spinfanatic]

Thank you Maryo! You are so right. This is a great outcome and patience is my new best friend.
As for the heat, my OS seems to follow the Bonesmart Mantra with exception to ice. He believes ice constricts blood flow and ultimately healing. Swelling with scope not an issue so using heat. After TKR OS recommended heat over ice at 4 weeks. At that time I found heat was only as good as ice ability to control swelling so I did what was needed.
For those who have had scopes after TKR any advice on incision/portal care? I have three and they seem deeper and more sensitive than after prior scopes. Keeping ace bandage on to protect and limiting shower time. Steri strips still in tact. Thanks!
I

 

[maryo52]

I've had two scopes after TKR. Steri-strips will fall off on their own. If they hang on past a certain point you can pull them off. Maybe call your OS office to double check. Didn't they send you home with instructions?

I found that there was in fact more effusion/swelling after my scopes. Last time, my ROM went from 125 to 90 and then slowly regained 125 over a couple of weeks.

 

[spinfanatic]

Hmmm. Swelling. Not an issue yet but lots of tenderness three to four inches above kneecap. I have been respectively immobile so that could be why. Instructions for incision were not to soak and watch for any changes in color. I am to call immediately if notice any changes in incision appearance. That was about it. So I guess so far so good!

 

[60mom]

That is interesting about ice restricting blood flow. I have been wondering lately if I use too much ice. I generally ice and elevate whenever I am down which has been a lot lately trying to get this swelling and stiffness down but it is not working. My scar is also very purple. My PT said that the color of the scar is the color of what is going on inside. Purple would be more indicative of a lack of blood flow then red or pink. Today I am going to go in my spa about 4 times and while in just do some gentle leg lifts and flexion and then take a short walk and do this over the weekend. Just to see if just maybe I am over icing, I need to remember moderation. Maybe this was a aha moment. Hope your still doing well.

 

[spinfanatic]

Hi 60mom. How did the spa therapy work?

 

[60mom]

I am so excited. It hasn't felt stiff at all. Had a little pain yesterday and just iced the small area not the whole knee. I have stopped icing the whole knee temporarily. I realize I still might need that at times but I think this late in the game sometimes moist heat is what it really wants. We drove 3 hours to our daughters soccer game (they won) and 3 hours back and no problems at all. Didn't even stop up or back to stretch. Flexed it just now and it was about 120 so it as improved by 10 degrees in 2 days. Amazing what you read and it makes you think. Then you try it and it works. Thanks to you for writing about your OS and moist heat. Couldn't stop thinking about it so thought what the heck, can't hurt.

What I am curious though is if it will start catching again. I didn't start catching till 120 ROM. It continued to do that until my ROM decreased to 110 and then it stopped happening. So what will tell me if I have an issue or not is if it starts back up. When I was researching this issue I read about a lady with a bone spur and it didn't start catching till her ROM was over 120. They removed it and it went away. So I am praying that mine isn't due to that and it never catches again. But if it does at least I think it is a fairly easy fix. I've decided I need to quit obsessing, lol.

How are you doing. Do you have much pain? Hope your finding things to keep you occupied?

 

[spinfanatic]

Hi. It's been awhile and lots going on.
At 14 months, my surgeon suspects that my body is not accepting implant given chronic swelling and pain. X-ray, MRI and aspiration tests have not revealed any problem other than inflammation which is good but frustrating news. My HSS OS has started me back on a very modified exercise program to encourage blood flow and sent me for allergy testing. After allergy testing, he is sending me for second opinion with revision specialist. Other than bad knees (left knee needs to be done too), I am a very healthy, fit and slim person. This knee has been such a spoiler to a Doctor free life!
Met with dermatologist at Cornell in NY today who specializes in metal allergies and have scheduled patch testing for first available appointment which isn't until early January. Yikes! Patch test will be comprehensive and include all parts of implant (metal and otherwise) plus many other things used during operation and by hospital. Doc was very impressive!
Here is my question : I see in Bonesmart library and posts that blood testing using Chicago lab is recommended over patch test. However, my surgeon and internist believe that patch testing is the way to go and dermatologist believes blood tests cannot effectively test for nickel allergy. I have the kit from the Chicago lab to do the blood work myself and submit which is very expensive. My concern is that even if I go ahead (and I do have over 6 weeks to drive myself crazy before patch testing) and use Chicago lab, my Doctors will not consider results. What's a girl to do? Would love some input.
Happy Thanksgiving!

 

[maryo52]

I had explored the allergy theory as well. The Chicago lab, as I remember, has lots of material on their website. Plus there are physicians linked with the lab or who work with total joint patients with metal allergy. From what I had read, the blood test is the gold standard.

So out of curiosity, I looked into it just now. I do a lot of research on this website (which requires only registration to access): http://www.ncbi.nlm.nih.gov/pubmed/23590796

And then I found this research study out of Lenox Hospital and I see you're in New York. Looking at research and those associated it can provide good leads for clinical care. http://www.ncbi.nlm.nih.gov/pubmed/23590796

Best of luck sorting it out. And if it's any comfort, I have what's called "recurrent synovitis" of nonspecific origin (doctorspeak for "I don't know"). It seems to be a common aftermath to arthrofibrosis.

 

[maryo52]

Here's the text of the abstract:

Severe persistent synovitis after cobalt-chromium total knee arthroplasty requiring revision.

Thakur RR, Ast MP, McGraw M, Bostrom MP, Rodriguez JA, Parks ML.
Source

Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA.
Abstract

Implant-related hypersensitivity is a well-established cause of failure after total hip arthroplasty but is a rare complication after total knee arthroplasty (TKA). It remains a relatively unpredictable and poorly understood cause of implant-related failure. This article describes 5 patients (6 knees) who presented with persistent pain and hypertrophic synovitis after TKA using a cobalt-chromium component. Extensive perioperative workup, including white blood cell count, erythrocyte sedimentation rate, C-reactive protein, joint aspiration, and intraoperative cultures, ruled out infection as a cause of the symptoms. All knees demonstrated appropriate ligamentous balance and were well aligned, with all components noted to be well fixed at revision. In all patients, the clinical condition improved dramatically after revision to zirconium femoral and titanium metal-backed tibial components. Pain and functional outcome scores improved in all patients. Intraoperative histopathology revealed a thickened synovium with either a predominantly lymphocytic or histiocytic monocellular response. Final pathology confirmed that no infection was present in any patient. The goal of TKA is to produce a well-performing, pain-free joint. When patients present with recurrent pain and synovitis after TKA, infection must be excluded. When infection and instability have been excluded, metal hypersensitivity should be considered as a cause of primary TKA failure. In these patients, revision to a zirconium femoral component can provide predictable and effective clinical improvement.
Copyright 2013, SLACK Incorporated.

 

[spinfanatic]

Thank you Maryo. I am thinking it is a nickel allergy as two of my sisters have tested positively and suffer big time with it. One allergy has caused severe auto immune problems and the other psoriasis. Because of them, I have always been aware and careful with my skin and have never had any problems. I mentioned this to my OS before surgery but in his 3000+ TKRs he has never had a patient become allergic. And since I have never had any symptoms, it seemed like a long shot. But hind sight is the real lesson in life. Your articles are fantastic and encouraging. Patience and a game plan is what I need now.

 

[spinfanatic]

Patch tests for metal allergies were completed this week and WOW I am very allergic to cobalt and nickel. The test sights on my back are red, swollen and blistering and I am developing ancillary rashes elsewhere. Dermatologist says I am indeed hypersensitive to cobalt and nickel but this alone does not prove my angry implant is failing due to metal allergy. He said the only way to know is to do a revision and see how body accepts new implant. He says he sees upwards of 80 patients a year (seemed like a lot) who require metal testing due to implant failure of which half test positive. He says he has limited follow up with these patients so doesn't know if revisions where done and how successfully.
This has been a long journey for me. Beside todays chronic pain and swelling, I have a paralyzed vocal chord which I woke up with after surgery and required an arthroscopy at six months to clean up scar tissue due to Plica. I am very concerned that a revision will create new problems. My hope is find a revision specialist who will look at the whole picture and not just the new problem. I have scheduled a meeting with my OS after new year to discuss. Any thoughts from fellow Bonesmarties would be appreciated. My head is spinning; sadly not my legs!