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TKR TKR problems after 6 years

Helizabug

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Argh! The thing about an “I Told You So” is “So What?” That was ‘then,’ and a lot has happened to get to ‘now.’ And if Mr. G. was right then thank goodness you get to see such a wise doctor. I mean, you could spin it that way, right?
 
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keith55

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Yes I realise that my left knee now is different from what it was in 2010. Maybe this was trauma after doing that step ups exercise and it will eventually settle down - but that doesn't explain the giving way. Also I've read that loosening doesn't always show up on an x-ray or only very subtly.
I'm hoping my GP will send me the x-ray report.
 
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keith55

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Even though I was wearing my cold gel pack ice sleeve last night in bed (and it was cold) the knee became spontaneously warm/hot. Anyone know what causes this? I cooled it down with fresh ice packs and it finally cooled down after over 2 hours.
 
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keith55

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I now have the x-ray report: (2 months of pain now!)

XR Knee Lt
Clinical History :
left TKR 2013. last one month increased pain and some
swelling anteriorly
XR Knee Lt :
No joint effusion. Previous left total knee replacement
position and
appearance is satisfactory and is unaltered from previous.


"anteriorly" means front - correct, the persistent swelling is outside (lateral side of kneecap) and below the kneecap. often (not always) where the warmth starts before putting weight on the knee when all the knee becomes warm and painful
"effusion" ? There is definitely swelling I thought that meant effusion. I was expecting the word "lucency" here i.e. bright area of bone showing osteolysis (aseptic loosening) although there is the word "appearance". What I've read has said a TKR can be loose but still in original position.

Another question: National Joint Registry et al say most primary TKRs last at least 20 years. But isn't that before a revision is necessary. It doesn't mean trouble free does it?
 
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keith55

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Without a diagnosis I don't know whether I will have surgery or not - the giving way feeling is happening more often and more worrying. I get these flare ups (see #43) esp at night which are like arthritis flare-ups. The X-ray didn't reveal any issues with the prosthetic (but they don't always do they?). The next step is a knee clinic with an orthopaedic surgeon: Htin Aung, on May 1 - maybe further scans after that. A long NHS process which is now likely to be longer - though orthopaedic outpatients may not be affected by coronavirus exigencies?

I'm beginning to wonder whether my first surgeon's (Gosal) "it's only pain" i.e. not function was good advice though I have had 6.5 years when I was able to do things I wanted to do. Am I now paying the price like the Green Knight or Dr Faustus?
 
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keith55

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I've had these red marks below the affected knee for a while now. I don't have a fever. Is this overdoing the icing (but I always have the ice pack in a protective sleeve). I didn't get these marks when I iced and elevated for months after the TKR operation. (attached as a file)

Any ideas what these are. I wouldn't be able to see a GP for weeks at the moment.
 

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Celle

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IT's hard to know what the redness is caused by - your leg looks red to the right of the incision as well.

It could be ice burns. As well as having the ice pack in a sleeve, you should also have something like a tea towel between it and your skin.

Is your leg sore where the read area is?

For now, I suggest putting some soothing cream on the reddened areas, to see if that helps.
 
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keith55

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Thanks Celle. I've washed the sleeves and thanks for the tea towel suggestion. I'm using a warm face cloth and antiseptic cream on the redness. Yes it's red both sides of the incision: on the right further up and nearer the knee. I've found out my GP surgery is doing more telephone consultations (but no face to face) and I've arranged one for next week.

Could be folliculitis?

I have a face to face heart consultancy at the hospital next week - afaik it's still on.
 

Jamie

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I don't think the redness is anything to do with hair follicles as it is too widespread. If you make sure you place a kitchen towel or hand towel between the ice source and your skin for a few days and things don't seem to improve (or if it gets worse in a few days), then you need to contact your surgeon or your GP. But since you're seeing a heart doctor next week, you also could ask at that consultation.

Your skin does look similar to a freezer burn I received last year following a shoulder surgery. I was using an ice machine and pad on my shoulder that I'd been given in the hospital. Unfortunately, I was still numb from the nerve block and didn't feel it when the pad shifted down below my dressing. Mine burn actually blistered in the center, but had redness similar to what you have on the edges. So that leads me to believe this is your problem. Those sleeves were not meant to be used directly on skin for the long periods that you ice after joint replacement surgery. This is why we recommend adding a nice, thick towel. The cold still penetrates for pain relief, but not so much as to damage your skin.
 
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keith55

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Hi Jamie,

I think the redness is slowly going away now I'm using a kitchen towel to protect my skin. It's a slow process though.

Another request for wisdom:
I googled the surgeon I'm due to see on May 1 (unless it's cancelled - a diabetes eye test on May 6 was cancelled). I found a worrying write up about him on ratemds.com. It was anonymous but why would a patient bother to write it?

So I was thinking of paying for a private consultation with my first NHS surgeon (whom I also saw privately) - Harminder Gosal. He does far more knee revisions and TKRs than Aung.

Gosal did oppose my having the operation (after having offered it and I was put off by my GP!) but did give me good advice about pain management and conservative treatment.

So since Aung is the first surgeon I'm due to see over this knee problem would he do the operation (if needed) unless I take some action? The surgeon who did my TKR (John Mackinnon) has retired recently.

Also if I pay to see Gosal I should get an earlier diagnosis - maybe by the end of next week.
 
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keith55

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According to my GP it would be Aung to do the operation - though the NHS May 1 consultation might be cancelled.

So I've booked a private consultation tomorrow with Gosal which means I'll be on his waiting list for a NHS operation and sooner than seing Aung in May.

Now to work out what to say and write it down.
 
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keith55

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I saw Mr Gosal yesterday morning. He will send me a letter shortly (and to my GP)

He thinks the possibilities are:
1. Problem with the plastic spacer between the metal parts
2. Aseptic loosening
3. Infection though he thinks this unlikely but must be checked

He doesn't think it's a loose body from the X-rays. The idea of a loose body came up back in 2010 when the knee was first x-rayed for arthritis but he wasn't convinced then it was loose. I told him the swelling and pain centre is where the bone spurs are (or were). I can't feel the bone spurs now because of the swelling.

Next steps (back on NHS so long delay):
1. Blood test
2. CT scan
3. Possible extraction of a sample of the effusion (I've forgotten the word for this) depending on 1 and 2 (ah it's "aspiration").

He didn't think the TKR was loose but this doesn't cut out aseptic loosening. He wobbled my kneecap around but said the wobbliness was "normal".

In the meantime I have to "tough it out". He confirmed the red marks were ice burns and agreed that using a tea towel was a good idea. He did say "we'll get to the bottom of this" i.e. work out the diagnosis.

When he asked "any further questions" I couldn't think but of course I could have asked him how best to tough it out in terms of caring for the knee, preventing further deterioration and pain management. However, with arthritis I ended up just using paracetamol to avoid the side effects of supposedly stronger meds (I didn't find codeine any stronger). Icing and elevating works best for me for pain management.

Still he maybe underemployed with the covid19 affecting his orthopaedic work, so I could reply to his letter and ask - no harm trying.
 
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Jaycey

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Still he maybe underemployed with the covid19 affecting his orthopaedic work, so I could reply to his letter and ask - no harm trying.
The issue is not whether the consultant has work. It is that theatres that are normally ring fenced for orthopaedic work are being converted to intensive care units. Unfortunately it's just not a great time to need "elective" surgery.
 
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keith55

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I meant replying to a letter I write.
 
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keith55

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This is more of a general question about instability or giving way of a knee.

What is actually happening when a knee feels like it is giving way?

Is it the prosthetic itself (which Mr Gosal and the radiologist say seems secure) or is it something to do with the muscles, tendons or ligaments? Can someone who doesn't have a prosthetic in the knee experience instability?

Though there is no directly associated pain, it is very disconcerting, especially when you get two or more in quick succession. Do people have falls from this instability?
 

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What is actually happening when a knee feels like it is giving way?
Combination of muscle weakness, cartilage tears, and/or ligament instability, allowing the knee to give way. (See below for a list of possible ligaments involved.)
Do people have falls from this instability?
Yes, people fall, and may start using an assistive device such as a cane, walker (frame), crutches, or wheel chair to prevent falls.
Can someone who doesn't have a prosthetic in the knee experience instability?
Yes, if the ligaments of the knee or torn or stretched the person may have instability, giving way, and/or pain which may lead to falls.
Scenarios in an intact knee may include injury or rupture to the following tendons, ACL (anterior cruciate ligament), PCL (posterior cruciate ligament), MCL (medical collateral ligament), LCL (lateral collateral ligament), and patellar tendon. A cartilage tear can also cause knee instability.
Depending on the prosthesis you have, injury or rupture to any of the above ligaments can cause instability. Here is an article about the different types of knee implants.
 

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