Revision TKR Tibia break after knee revision

[BridgetJ]

I am a very positive and optimistic person but this journey is seriously testing both of these qualities.

Long story (not sure how to make it short) 3-wheeler accident when I was 20 years old resulted in serious infection and 2 surgeries at the time. One to repair the compound fracture, install hardware and cast. Next day another surgery - hardware removed (due to infection). Bottom line, lucky to have my leg as surgeons actually discussed amputation at the time with my family.

Fast forward 10 years after being told I would not walk without a limp, ever run or do all the things I love, I did them all! Yes, my leg was not pretty and over 20 degrees valgus but that did not stop me. At 30 years old, the severe angle started causing knee problems and so I had surgery to straighten my leg.

At the time, the best they could do was about 9 degrees. Served me well for over 2 decades until the pressure finally took its toll - severe arthritis and no cartilage. Underwent TKR May 2018 and surgeon was able to straighten leg nearly 11 degrees! I was elated and optimistic.

I could resume skiing, cycling and hiking. Unfortunately things never got better - had 2 MUAs (June 2018 and Aug 2018). Seemed to get worse every day after and pain was excruciating. Referred to a surgeon at USC who said this knee needed to be replaced again.

April 16, 2019, total knee revision. Surgery went well but once in recovery they realized when the tibia was moved forward an artery was damaged causing a blood clot. Back in for another surgery to remove blood clot. Vascular surgeon could not perform angioplasty (tried for over an hour but too much scar tissue) so I had to have a bypass. Incision from my bikini line to my knee and then another down my calf.

I am 16 days post surgery and am scared. I can only bend about 70 degrees and not quite full extension. Will this work? I am sad/mad. Will I be able to do the things I love with my family and friends ever again? I am in pain. Will this leg ever feel normal? I maintain a positive attitude by focusing on my blessings but I have my moments.

My husband, family and friends are all super supportive. I feel like I need to put on a positive front - I am tired of this long journey....certainly everyone else is tired of hearing about it also.

I have read all the threads on pain management, recovery, etc and I find them all helpful.

I guess my question is how will my recovery be impacted because of the bypass surgery? I feel like I am not doing as much as I should because I am so weak and tired. I was in ICU for a couple days because of the bypass/blood transfusion and when I was finally released my iron level was extremely low (7). I have been eating an iron rich diet and taking supplements and now am up to 10.7. I walk each day on crutches and am up to 1.5 miles. Besides that and some light housework, all I do is sleep and rest, ice and elevate. Should I be doing more?

I am just hoping someone has had a si lab perspective and can offer insight. Thanks in advance.

 

[Jaycey]

@BridgetJ Welcome to BoneSmart! You have had quite a journey with this knee!

Please remember that you have just had 2 major surgeries. Of course you are exhausted and weak. Your body has experienced major trauma. All you should be doing is icing and elevating as much as you can during the day. Stop all that walking until your knee calms down. Light housework can wait. Focus on healing and recovery.

Here are some articles that might offer you a bit of guidance through this recovery.

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 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 a 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 history before providing advice.

 

[2tkr]

Hang in there. I am so sorry to hear about your agony. My 2nd TKR was this past Feb 19. I’m finally starting to see a tiny light at the end of the tunnel. I’m still exhausted, my sleep pattern is still on hiatus(hence chatting at 4:48am). But life is becoming livable again with each day. I read somewhere that it takes a year for your new knee to go unnoticed. Again, you will feel better every day. But when you have a weird feeling in your knee, remember that you are fine if you can put your full weight on one knee. And give your body a year, it will go by super fast.

 

[BridgetJ]

I am 23 days post surgery. I can get around the house (slowly and uncomfortably) without crutches. I did my daily outside walk with only one crutch but felt my form suffered. How long should I be on crutches?

 

[FCBayern]

I would say until you can walk (although slowly) with a normal gait.

 

[Jockette]

There is no set time, keep using them until you feel you’re walking better. As Celle often says, there are no prizes for giving them up early. They are a tool to help you walk better and to help prevent a fall.

 

[Josephine]

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?

 

[eaglemom]

I'm thinking you need to put the brakes on everything - focus on the knee - resting & elevating. Your doing far too much. Your body is telling you its tired, listen to it. (Sorry if that sounds harsh)

We are all hard on ourselves, but in reality what is best is rest. Goodness your not even a month into two major surgeries. Yes recovery is a slow process but over doing only extends that process. Lots of naps, reading, Netflix - you get the idea. Hang in there it will get better - over time.

 

[BridgetJ]

Had my one month check up with tests and appointments with the vascular surgeon and orthopedic surgeon. All 3 incisions are healing nicely, iron level is back near “normal,” blood is circulating at the same levels as the non surgical leg. Overall everything is good.

Two big concerns are quad is not engaging and leg is only bending to about 70 degrees. If I don’t get to 90 in 2 weeks (6 weeks post-op) then MAU. I had 2 MUA on this leg when the first knee was put in in May 2018 - I am NOT doing it again! They were more painful recoveries than the actual surgery. I will do everything in my power to get to 90 degrees in 2 weeks.

My husband said I should maintain an open mind and that if I don’t get there the MUA may be the best option. I am so frustrated - my swelling is still significant and I think that is what is inhibiting my flexion. I ice and elevate frequently, wear the TED hose during the day and have cut back in my walking. Not sure what else I should do?

 

[BridgetJ]

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?

I just saw your post. Yes, I am happy to answer any questions.

 

[Jockette]

I will do everything in my power to get to 90 degrees in 2 weeks

First of all, you cannot make your leg acheive a certain number by a certain date. Your swelling doesn’t work that way.

Doing everything in your power should consist of lots of rest, ice and elevation, especially the resting! Activity makes the leg swell.

Don’t think of it as doing nothing, think of it as giving your leg/knee the best opportunity in which to heal.

I am so frustrated - my swelling is still significant and I think that is what is inhibiting my flexion.

Yes, swelling is inhibiting your bend. You’re only 4 weeks post op and your knee is very upset from the surgery and has barely had a chance to start healing. Complete healing takes an average of 52 weeks.

Your are entitled to decline the MUA if that’s what you want. Your surgeon can’t do it without your consent. It’s way too early to even consider it anyway, but surgeons are impatient and want recovery to happen right away. Our knees don’t agree with that, and our knees are in charge.

 

[sistersinhim]

If I don’t get to 90 in 2 weeks (6 weeks post-op) then MAU. I had 2 MAU on this leg when the first knee was put in in May 2018 - I AM NOT DOING IT AGAIN!

It's your knee and no one can make you do anything to it that you don't want to do. Jockette is right, it's way too early in your recovery to even think about a MUA. Your knee has to heal. A MUA will set that recovery back because it will tear away all those soft tissues that are trying to knit back together. Just look at what's done inside your knee:
https://bonesmart.org/forum/threads/closing-surgical-wounds-how-is-it-done.4286/#post-90691

my swelling is still significant and I think that is what is inhibiting my flexion.

You are correct. When that swelling goes down the bend will increase and not before. You can't work to increase your bend, but you can rest and get rid of that fluid to increase that bend!

 

[Josephine]

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?

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.

 

[BridgetJ]

1. Pain level is 3 when laying down. Level 5 when bending or in motion. Feels like calf (between knee incision and incision from bypass is in a vice...constant tight pressure).

2. 2 tablets XL TYLENOL every 6 hours dueling the day. Night time Tramadol.

3. Swelling moderate during the day but huge at end of day if I have done too much.

4. Flexion before PT (no assistance) is 70. After 45 minutes of gentle PT I can get to 80 on my own. Extension varies 1-4.

5. During the day Icing every 3 hours for 30 minutes. At night I ice when I go to bed for 30-40 minutes and then again not until I wake up and take a shower.

6. Elevating several times a day for at least 45 minutes - depending on the day about every 3 hours.

7. Average activity - light housework (pickup, make bed, laundry, unload dishwasher) and I show property for about 2 hours a day the last 2 weeks (I am a realtor). Husband does shopping, cooks dinner, walks dog.

8. Exercises
Heel slides - 3x day / 15 reps
quad sets - 3x day / 10 reps
straight leg raises - 2 x day / 10 reps
lay on stomach with leg hanging off bed - 2x day for 10 minutes
Same position as above - bend knee - 2x day / 10 reps
Sit down/stand up trying to place equal weight on both feet - 10 times a day
Walking - approximately 5,000 steps spread throughout the day

 

[Josephine]

XL TYLENOL every 6 hours dueling the day. Night time Tramadol.

1. I can't find XL TYLENOL anywhere but there is a Toprol-XL - or do you mean ES (extra strength) Tylenol (500mgs)?

2. What do you mean by 'dueling'? To me it means

3. As for the Tramadol, you've not said what dose you take

 

[BridgetJ]

So sorry....I was tired.
1. XS Tylenol is what I meant.

2. Dueling was supposed to be "during"

3. Tramadol HCL 50 mcg

 

[Josephine]

1. XS Tylenol is what I meant.

I thought that might be the case.

2. Dueling was supposed to be "during"

Ah, predictive texting bites again, eh?

 

[Josephine]

5½ weeks

1. Pain level is 3 when laying down. Level 5 when bending or in motion.

3. Swelling moderate during the day but huge at end of day if I have done too much.

I hope you noted my footnote (in the questions) that swelling is a form of pain. Moderate swelling adds about 4 points to your pain score and huge swelling adds about 9!

2. 2 tablets XS Tylenol every 6 hours dueling the day. Night time Tramadol.

Why don't you add a Tramadol every time you take the Tylenol? They make a perfect companion pair. You might also consider taking 2 Tramadol (and Tylenol) at night because pain is always worse at night.

4. Flexion before PT (no assistance) is 70. After 45 minutes of gentle PT I can get to 80 on my own.
Extension varies 1-4.

Yes, I think your pain and excessive swelling is responsible for that. Quite common.

5. During the day icing every 3 hours for 30 minutes. At night I ice when I go to bed for 30-40 minutes and then again not until I wake up and take a shower.
6. Elevating several times a day for at least 45 minutes - depending on the day about every 3 hours.

You accomplish little or nothing in 30 minutes. Ice and elevate for at least 40-60mins and more than 4 times a day.

7. Average activity - light housework (pickup, make bed, laundry, unload dishwasher) and I show property for about 2 hours a day the last 2 weeks (I am a realtor). Husband does shopping, cooks dinner, walks dog.

Did you read the Recovery Guidelines in the second post of this thread? Specially this one Activity progression for TKRs
In that article, these are the recommendations for weeks 5 and after

Weeks 4 and 5 - add to all the previous
Increase walks to out in the garden or street; to 20mins or longer if you feel up to it bt don't forget that means 10mins there and 10mins back!

Additionally activity:
Gather a little bit of laundry OR put it in the machine OR take it out but not all of it
Now you can do a little dusting and tidying;
Do a little meal prep (for yourself not the entire family!)

Please note that does NOT allow for showing property! I suggest you read this article again.


Exercises 3x day - once a day would be plenty and none at all at the weekends
Heel slides x15 - contrary to popular opinion, heel slides do not improve flexion, quite the opposite in fact
quad sets x10 - these are also questionable and I recommend you stop doing them
straight leg raises x10 - once you can do these, you don't need to do them any more and in any case, 30 a day is far too much!
lay on stomach with leg hanging off bed 2x day for 10 minutes - popular though these might be with PTs, they actually do nothing to improve extension, quite the reverse, in fact. So stop doing them because they are contributing to your pain
Same position as above bend knee 2x day for 10 reps - same again here
Sit down/stand x10 - no need to do these specially as an 'exercise'. You do plenty in the normal course of your day anyway
Walking - approximately 5,000 steps spread throughout the day - So you seem to have a Fitbit then? That's okay, so do I. But don't become a slave to the numbers. Look at this Fitbit steps to miles, did you know that 5k steps is approx 2½ steps?

Summary
1. adjust your pain med schedule as suggested
2. adjust your pattern of icing and elevating
3. cut back on your activities. Showing property is contributing to your pain and swelling which is far greater than it should be at 5-6 weeks
4. read the Recovery Guidelines (again, if you already have!)
5. you will notice I have crossed out all your exercises because, basically, you just don't need them, even though you have had a revision.

There are many on this forum who went through their recovery doing absolutely no exercising/PT at all and we got excellent outcomes anyway (yes I was one of them!). I recommend you read my recovery thread to see how little exercising I did for either knee! Knee recoveries UK style Parts I & II (Josephine)

If you are concerned about refusing to do therapy, you need to read this Saying no to therapy - am I allowed to?

 

[BridgetJ]

Thank you for the thoughtful reply Josephine. I will definitely re-read the Recovery Guidelines. If you cannot tell I am a "Type A" personality and some of my behaviors are difficult to change.....believe it or not, I am much better than I used to be! The entire mentality where I live is very PT/exercise focused as my therapy is done where many Olympic athletes (ie US Ski Team, marathoners, etc) train and recover. I know it seems like I listed a lot of exercise but that is a fraction of what they want me to do so I feel like I have said "no" to quite a bit. I will read your recovery thread and carefully consider your advise. Thank you very much.

 

[Josephine]

If you cannot tell I am a "Type A" personality and some of my behaviors are difficult to change.....believe it or not, I am much better than I used to be!

Don't worry - most people on here are Type A!

I know it seems like I listed a lot of exercise but that is a fraction of what they want me to do so I feel like I have said "no" to quite a bit.

Well jolly good for you!