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[REVISION TKR] still pain and instability

Discussion in 'Knee Replacement Recovery Area' started by Ilovecruising, Mar 2, 2019.

  1. Ilovecruising

    Ilovecruising junior member
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    Sorry for such a long post but don’t know where to shorten without leaving out crucial info. My TKR was June 26, 2018. Before that I led a very active life working as a part-time travel nurse and also enjoying the cruising life, having gone on 5 cruises within the last year. But my knee had gotten so bad with pain and a turned in knee, that it made my mobility difficult. Background of this knee consist of a car accident in 1990 which crushed the femur and the knee. Pins and plates were placed at that time.

    Now fast forward to last year. I knew it would be a difficult surgery having to remove plates and pins already there and searched extensively for surgeon that I felt good about. I called the best known orthopedic clinic around and after giving them the background and current condition of the knee, I was told that none of their surgeons would accept me. They did recommend a surgeon at UAB that they referred such cases to. I did some research on him and saw that he specializes in trauma cases and had mostly good reviews. I had to wait 3 months for my initial appointment with him. I was very nervous about the surgery and asked a lot of questions.

    I had the TKA on June 26, 2018. I did run into complications with my BP dropping during surgery and post-op. Therefore I wasn’t able to receive pain meds for about 12 hours post-op. Plus I had lost a significant amount of blood and had to receive 2 units of blood.

    Recovery was very painful and slow. I would get so weak in rehab that I would actually have to lie down. I also went through the depression phase that many of you have expressed. When I went to my 2 month checkup I expressed to the surgeon that the knee didn’t feel stable. When I put full weight on it, I would feel the knee shift to the left. Dr said the xray showed the implant looks good. He examined further by picking up my leg and passively putting it in all kinds of positions which was painful.

    He then agreed that the knee was loose because of my quad muscles being weak. So the PT and I really worked on strengthening the muscles but that didn’t seem to be helping the shifting. So when I went back to surgeon, another xray also showed no problem with the implant. Surgeon had me fitted with a brace for stability, which I wore when I was up walking.

    I had so many complications, horrible pain and instability, that I swore if I had known everything would go like it did, that I never would have done it I first place.

    Add 2 months of wearing a brace and more PT for strengthening the muscles and knee was still unstable and shifting. Xray still showed that the implant was perfect. So when I went back at 4 months, I asked surgeon what my options were since I didn’t want to have to wear a brace and use a cane for rest of my life.

    He surprised and shocked me by saying he could go back in and try to replace spacer with a larger one and if that didn’t fix it, then he would proceed with another total knee. I was thinking , okay if the first one didn’t work, what makes you think next one will.

    I was sitting there trying to take it all in and was literally in tears, but surgeon didn’t show any compassion at all. I didn’t hear, “I’m sorry the first one didn’t work as expected” or any kind of explanation as to why it didn’t work. I was just so overwhelmed that I told him I’d have to think about it.

    I was still having a lot of pain on medial side of knee. I sent a message through portal asking for a MRI of knee. He didn’t reply. So a few weeks later I asked again expressing that I wanted to make sure we had checked everything to get all answers possible before going back in there again. He replied that my ligaments were not working correctly and that I needed a hinged knee replacement.

    I took my nephew with me to talk with him at my next appointment. He then told us us that my ligaments were stretched and could not hold the knee in place and that he will have to replace the current one with a hinged knee implant, explaining that it works without the ligaments being in good shape. So I agreed and set the surgery for Jan 29, 2019.

    The surgery was done without the complications of my first surgery. When I got up to my room post surgery, my family came in shortly after. I asked what the surgeon said about the procedure and was told that he never did call and tell them anything.

    I told the RN and requested to speak with the surgeon. His assistant called me eventually and told me they didn’t have to do a hinged replacement after all. I initially was taken aback with the news since the surgeon seemed to be so positive of his diagnosis. But he told me that they replaced the femoral and spacer components with larger ones and that the surgeon was very pleased with results.

    When PT got me up to walk in hallway the next morning, I felt the knee was unstable again. Not shifting to left like it did before just moving around like it would buckle. I expressed my concern to PT which in turn let RN know. She did notify surgeon who ordered an xray that showed the implant was like it’s suppose to be. So had every xray that I’d had last year.

    I was discharged the day following my surgery to in-patient rehab. I continued to feel the instability at times when I put full weight on it. And still do now that I’m in out patient therapy. I know my quad muscles are not working correctly as I have a horrible time trying to pick my foot up off the floor and also for leg raises. It’s like I am telling it to move but it won’t follow my command and just sits there. That is such a horrible feeling and something I have never experienced before.

    With the therapist's help, I am finally able to lift it although it is not even a half inch. I am doing the exercises to keep strengthening the muscles and trying to keep the faith that the knee will become more stable with each passing day and more exercise.

    Just the thought of having two major surgeries and my knee being worse than it was prior to my initial surgery is just about too much to bear. I have read several post of people having to go back for second and third surgeries.

    Just wondering if anyone here finally got good results? Anyone have similar experience about knee not wanting to cooperate when trying to lift it and what you did to help with that?

    I am 4½ weeks post surgery and initially my pain control was really good. But for the past week it has been horrible! During the first surgery I had nerve pain for weeks. This time I was very happy not to have it for first 3 weeks but now it has started again.
     
  2. gia2cats

    gia2cats junior member

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    @Ilovecruising,

    I don’t have any feedback on what you’re going through but I hope others here with experience will be able to give you some guidance. I think it’s appalling that the surgeon never spoke to your family post op or came to see you to explain why he did what he did. How arrogant of him.
    My quad muscles did take some time to start working but it seems as if you should be there by now. Maybe the trauma of 2 surgeries ???

    I just hope that this recovery is taking its good old time and you start to see improvement. Please keep us informed.
    Sending you good, positive thoughts and prayers.
     
  3. Ilovecruising

    Ilovecruising junior member
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    @gia2cats
    Yes, he is very arrogant! Thank you very much for your reply. I know my quad muscles were weak following my first surgery but I don’t recall them being this bad. Trying to stay positive that everything will continue to improve and that I’ll have good results with this one.
     
  4. Jockette

    Jockette FORUM ADVISOR Forum Advisor

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    Hi and Welcome to Bonesmart!

    I am going to tag @Josephine
    our forum administrator and nurse director to address your concerns.

    I understand having a problem that doesn’t show on an X-ray, that’s where I am. Because my X-ray looks good no further tests have been offered.

    One knee replacement takes a major toll on our body, another one not long after takes even more of a toll as we weren’t healed yet from the first one. They cause a major energy drain on our body.

    I will leave you our Recovery Guidelines. Each article is short but very informative. Following these guidelines will help you have a less painful recovery. Please read each one and then ask any questions you have.

    Knee Recovery: The Guidelines
    1. Don’t worry: Your body will heal all by itself. Relax, let it, don't try and hurry it, don’t worry about any symptoms now, they are almost certainly temporary
    2. Control discomfort:
    rest
    elevate
    ice
    take your pain meds by prescription schedule (not when pain starts!)
    don't overwork.
    3. Do what you want to do BUT
    a. If it hurts, don't do it and don't allow anyone - especially a physical therapist - to do it to you
    b. If your leg swells more or gets stiffer in the 24 hours after doing it, don't do it again.
    4. PT or exercise can be useful BUT take note of these
    the BoneSmart view on exercise
    BoneSmart philosophy for sensible post op therapy
    5. At week 4 and after you should follow this
    Activity progression for TKRs
    6. Access to these pages on the website
    Oral And Intravenous Pain Medications
    Wound Closure

    The Recovery articles:
    The importance of managing pain after a TKR and the pain chart
    Swollen and stiff knee: what causes it?

    Energy drain for TKRs

    Elevation is the key

    Ice to control pain and swelling

    Heel slides and how to do them properly

    Chart representation of TKR recovery

    Healing: how long does it take?

    Post op blues is a reality - be prepared for it
    Sleep deprivation is pretty much inevitable - but what causes it?

    There are also some cautionary articles here
    Myth busting: no pain, no gain
    Myth busting: the "window of opportunity" in TKR
    Myth busting: on getting addicted to pain meds

    We try to keep the forum a positive and safe place for our members to talk about their questions or concerns and to report successes with their joint replacement surgery.

    While members may create as many threads as they like in the majority of BoneSmart’s forums, we ask that each member have only
    ONE Recovery Thread.
    This policy makes it easier to go back and review the member’s history before providing advice, so please post any updates or questions you have right here in this thread.
     
  5. Pumpkln

    Pumpkln FORUM ADVISOR Forum Advisor

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    Sounds like you have quadricep arthrogenic inhibition, it can happen after knee surgery or injury.
    Your PT should be able to help with electrical stimulation, and quad facilitation exercises.
     
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  6. Lindylee

    Lindylee graduate

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    I am sorry to hear what you've been going through. To havec2 surgeries and feel there is still no improvement must be soul destroying. I struggled to lift my leg to begin with and used a therapy band to lift it, gradually managing to take some weight off the band until I could support it fully. I hope you're able to get some answers and a successful outcome.
     
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  7. Ilovecruising

    Ilovecruising junior member
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    It will be 5 weeks tomorrow since my revision and the pain tonight is almost unbearable. Last night was a good night but not tonight. I did go to therapy today but I try not to overdo it with the exercise. Iced immediately after plus rest and elevate. Does anyone else feel like it’s one step forward and two steps back?
     
  8. Lindylee

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    I didn't have revision but definitely felt I went back a step or two by Week 5 and had to cut back hard on exercise, rest, ice and elevate more. I'm now week 6 and seem to be back on track. It seems to be a common theme reading other posts and I wonder if we get to 4 weeks/1 month and think we can do more than we should. Take it easy for a few days. Our knees are very quick to let us know we've overdone things.
     
  9. Didot

    Didot junior member

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    I totally understand your frustration. It’s a huge thing, this surgery and I’m now almost 7 weeks down the track and mostly battling to see any light at the end of the tunnel. One thing for me though, my quads also did not work at all - could not move/lift my leg for about 5 weeks, but recently have felt a tingling through my thigh at times and think I’m in touch with that muscle again. Need to strengthen it now. Such a mission.... I get very depressed often.


    Sent from my iPad using Tapatalk
     
  10. skigirl

    skigirl SUPER MODERATOR Moderator

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    I did have some looseness in my left tkr after surgery. At two years I began having pain and my surgeon went back in to change to a larger spacer. He found extensive adhesions and felt that some of that was from the small movement from the joint.

    For you, It seems that you will continue to have some instability until your quad wakes up and gets back to work. Was your quad fully functioning before the revision? It is hard to think of two major knee surgeries , so it seems that your quad is going to need some encouragement to wake up!. electrical stimulation will help and you will need to work with your Pt for a while. An external support might make you more comfortable in the meantime.
     
  11. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    That's a common solution to such a problem and most often it works extremely well.
    Surgeons don't usually say things like that and they would be unable to give reasons for the loosening as nobody really knows why it happens.

    As for you asking for an MRI scan, I'm not surprised the surgeon greeting the request with silence. Surely you know by now that doctors don't like to be told what to do by anybody, much less patients!

    But I do think this doctor has shown a degree of harshness and disdain that was unwarranted. He chose a process of treatment that turned out to be unsuccessful and even then was unable to be honest enough to discuss it all with you.

    Any doctor who has chosen to use a hinged knee should have done extensive investigations and planning. There should be no need for him to change his mind to a lesser prosthesis. That's just plain bad planning. I think your only hope now is to find a revision surgeon who will give you good advice.
     
  12. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    I'd really like to offer you some structured advice but in order to do that, I also need to ask you some questions. Are you willing for me to do that?
     
  13. Ilovecruising

    Ilovecruising junior member
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    @Josephine! Yes! I appreciate and will carefully consider any advice or recommendations you can give.

    @Jockette. Thank you very much for your reply. I have read several of the articles and will continue to read more over next couple days.
     
  14. Ilovecruising

    Ilovecruising junior member
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    @pumpkin, thank you for your reply. I actually had to look up Quadricep Arthrogenic Inhibition to see exactly what that was. And I believe you are right about that. My PT is doing the majority of the exercise that I looked up for this and she also does the NMES to stimulate the muscles. So it seems that maybe we are on the right tract but maybe it just takes time. Are you aware of anything else that helps this other than electrical stimulation and quad strengthening exercise? Thanks for your insight on my situation.
     
  15. Ilovecruising

    Ilovecruising junior member
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    @Lindylee, I see where you had a similar problem of raising your leg initially. Glad to read that it is much better now. Thanks for the tip about raising it with a band. I’ll give that a try.

    @Didot, it looks like you are about two weeks ahead of me in recovery. Sorry to see you also had a problem with your quads. That seems to be a problem for quite a few of us. It is reassuring to see that yours is improving regardless of it being a slow go. But I would like to ask you this also: do you feel like your knee is unstable at times? I had that with my TKR and did extensive therapy to try to strengthen the quads at that point but the instability stayed with me thus the need for the revision. Just frustrated that it seems like I am now going through the same thing all over again. It is so depressing at times. Please continue to update on your recovery.
     
  16. Ilovecruising

    Ilovecruising junior member
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    @skigirl, thank you for your reply to my post. Before my original TKR surgery last June, my quads were working fine. No problem with lifting leg at all. After the TKR, I did experience significant weakness in the quads. I did about 4 months PT focusing on my quads following TKR. However I don’t remember it being near this bad. And I believe I would remember if I totally could not get my foot to pick up off the floor. As that is a pretty scary feeling when you are telling your knee to pickup and you are just staring at it and it just sits there. Even with extensive exercises working on my quads and seeing no improvement in stability, that’s when I decided on the revision.

    We again are focusing on the quad muscles with exercise and electrical stimulation. I do have a brace that was given to me before, so maybe I’ll try wearing that again. Thanks again for your input and your support.
     
  17. Lindylee

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    When I was first asked to lift my leg after surgery and it refused to move, the PT said that it was common and sometimes no rhyme or reason other than our brain trying to protect us from pain and it would come. It was ages, or seemed it, before could lift my leg off the floor and I still can't lift it very high, but am confident/hopeful! that it will happen in time. The therapy band really helped. Sometimes I think it's about rewiring our muscle memory until,it takes over automatically once more as the quads in my operated keg were always stronger than the other one and I've never had a problem lifting that!
     
  18. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    Here y'go then!

    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 forget to factor in 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 swollen is your leg compared to these?
    ai63.tinypic.com_eta39s.jpg

    4. what is your ROM - that's flexion (bend) and extension (straightness)

    5. are you icing your knee at all? If so, how often and for how long?

    6. are you elevating your leg. If so how often and for how long?

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

    8. are you doing any exercises at home? If so what and how often?
    This is the most crucial question so please help me by using the format I have left as an example
    (which means please make a list and not an essay!)

    Exercises done at home
    - how many sessions you do each day
    - enter exercise by name then number of repetitions of each
    etc., etc.

    Anything done at PT
    - how many times a week
    - enter exercise by name then number of repetitions of each
    etc., etc.
     
  19. Ilovecruising

    Ilovecruising junior member
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    @Josephine
    1. Pain level at the moment is 3 but varies considerably as this time. Last night I would have given it a 9

    2. I am prescribed Oxycodone 5mg (1 tablet q 12 hours)
    Also Tramadol 50 mg x4 6 hours, however I usually only take 1
    Oxycodone at bedtime. If I continue to have pain I will take another Oxycodone or Tramadol in 4 hours. I hardly ever take one during the day. The max that I have been taking in a 24 hour period is 3 pills a combination of the two. (Usually 2 Oxycodones and 1 Tramadol)

    3. Moderate swelling

    4. Flexion 112, extension 2

    5. Usually only once a day for 30 -45 minutes

    6. Yes, I elevate a lot. I would say at least 6 to 8 hours a day. Elevate in my recliner.

    7. My activity level is fairly low. I make myself a simple breakfast and assist my helper with dinner prep. I get up to go to restroom, to get myself a snack, to let dog outside, make my bed and sometime do laundry. I drive myself to therapy twice a week.

    8. Exercises at home 5 days a week 2 sessions per day
    Straight leg raises x10
    Pressing knee on pillow x10
    Knee lifts x5

    Out-patient therapy twice a week, 1 session
    Stationary bike 10 minutes
    Press ball between knees 25 repetitions
    Tie band above knees and stretch knees apart x25
    Standing and holding onto bar 20 repetitions each of following
    Marching left then right leg x20
    Mild squats x20
    Heel raises x20
    Stand on right leg, swing left to side stand on right leg, kick left backwards x10
    Stand on left leg, swing right out to side x20
    Walk over 6 cones one at a time, raising left leg over each one, back and forth x2, repeat raising right leg x2, walk sideways in front of cones back and forth x2 (6) cones about 6” high lined up several feet apart on the floor. I stand right below cones then I start walking picking up my surgical leg above the cone to clear it as I walk over each cone (without hitting it or knocking it over as I walk) I do (2) complete cycles doing this with my left leg then my right.
    Climb steps x10
    Right leg up, left leg up, right leg down, left leg down, repeat using opposite leg then repeat off to right side, repeat off to left side x20
    Table exercise with electrical stimulation x10
    Straight leg raises, raise when comes on, hold and lower x20
    Place knee on rolled pillow, press knee into pillow when firing starts, hold until stops x20
    With leg on rolled pillow, toes pointed facing me, raise and lower leg when firing starts and stops x20
    Put my feet on huge ball and raise my hips off of table s10
    With my feet on huge ball, roll ball toward me as far as possible while bending knees 10 repetitions
    Stimulation along with icing 30 minutes
     
  20. Josephine

    Josephine FORUM ADMIN, NURSE DIRECTOR Administrator

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    More detail required for all these - no reps given

    Plus what are
    'walking over cones'
    'Place knee on rolled pillow, press knee into pillow when firing starts'​
     

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