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Author Topic: Desparately need advice on a loose knee replacement  (Read 6242 times)

Offline bfs

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Desparately need advice on a loose knee replacement
« on: October 11, 2008, 04:38:58 AM »
I have been diagnosed with a knee replacement that has loosened where the screws go into the lower leg. I am 57 years old and my knee replacement is only 2 years old. It has been loose for over 18 months. I have not spoken to anyone who has had a revision. My NEW doctor has been watching it for 5 months- I have been given Actenol and an electronic bone stimulator, and told to stay off of it. I have not been able to really stay off of it. I go Monday to see him and make a decision as to what to do. Has anyone had this problem and it get better without further surgery? My original doctor said if he had to do a new replacement, he would have to remove my knee, fill it with cement for 6 weeks and then do another knee replacement. I have not even asked my new doctor what is involved. We are in the middle of becoming new parents of a 17 year old girl from Belarus, and I can't even think about going through this now.
PLEASE, I need to hear from anyone who has any knowledge about loose knee replacements! Thanks !! :-\ :'(

Offline Janet

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Re: Desparately need advice on a loose knee replacement
« Reply #1 on: October 14, 2008, 03:09:38 PM »
I have not had that complication, but others here have. I'm surprised no one has answered you.

Here are a couple of questions you should be asking:
Do they know why your prosthesis came loose? Infection? Wrong size? (It sounds like they suspect an infection if they are going to remove your prosthesis and not do the revision right away).
Why can't you do the revision during the same surgery?
What will they do to make sure the revision doesn't come loose, too?
How will my recovery/rehab from this revision differ from my original surgery?

I know there are several others here who have had revisions and done well. Make sure you ask all the questions you can think of...and get another opinion or two if you don't like the answers. I'd be especially concerned about having the two-step revision.

Good luck,
Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline digginit

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Re: Desparately need advice on a loose knee replacement
« Reply #2 on: October 15, 2008, 12:01:20 AM »
Ditto what janet said, but I'm gonna add, WHY THE HECK HAVE YOU NOT STAYED OFF OF IT!!!!?  You have jeopardized your knee in a major way.  People laugh about not doing what their docs say.  This one was important, and it sounds like you blew it.  Your orthopaedist isn't talking to hear his head rattle. 

~dig

Offline Plumb

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Re: Desparately need advice on a loose knee replacement
« Reply #3 on: October 15, 2008, 01:37:35 AM »
http://www.totaljoints.info/LOOSE_TOTAL_KNEE.htm


Sorry to hear your having a hard time.  I hope this link helps you. 

LOOSENING  OF   THE  TOTAL  KNEE

 

What is a failed loose total knee replacement?

        A painful total knee which restricts the patientís daily activities severely is a failed total knee joint.  A failed total knee involves also severe psychical burden for the patient.

        The majority of loose failed total knee joints have distinct changes apparent on the conventional X-ray pictures.

How will I know the failed loose total knee?

    The surest sign of a loose total knee  is increasing and lasting pain and stuffiness  in the total knee. The patient will usually notice increasing pain in and around the artificial knee joint, difficulty to put weight on the knee joint, and diminished motion in the joint. The discomfort and pain usually develop slowly, years after the successful operation.

    In the minority of patients, however, the total knee joint was never functioning well, and the pain and other discomfort only increased steadily since the operation.

    Patients with a loose total knee joint limp.

    The pain is usually felt in the whole knee area. The pain is often accompanied by increasing stiffness and effusion in the knee joint.

    The patients with failed kneecap prosthesis feel the pain mainly in the front of the knee

        On X-ray pictures of a loose knee joint there are one or more radiolucent lines around the contours of the artificial knee joint.  The surgeon usually takes repeated X-ray pictures to assess the development of the radiolucent lines.

        If the radiolucent lines increase in width on successive X-ray pictures the diagnosis of aseptic loosening is confirmed. Sometimes, the total knee prosthesis changes its position on successive X-ray pictures, which is another sign that the prosthesis has lost its fixation to the skeleton.

        There is a special X-ray method called X-ray stereofotogrammetry that can measure the changes in the position of the total knee joint relative to the skeleton very accurately. This method can discover incipient loosening very early. Unfortunately, this method is difficult to implement, needs a special equipment  and is used only on special clinics for research purposes.

        Other methods to verify loosening of the total knee, such as  bone scan, are less precise.

         

        LOOSE_TOTAL KNEE

        PICTURE  :  Loose total knee

        Click on the icon for a full size picture.

        In this picture the left side shows a firmly seated total knee. The total knee prosthesis is in direct contact with the skeleton. The X-ray picture shows direct contact of the white shadows of the knee prosthesis with the white shadow of the skeleton.

        The prosthesis on the right side is loose, both components lost their contact with the surrounding skeleton. The components are surrounded by loose connective  tissue.

        Lower row:   The connective tissue is pervious for X-rays, so that on the (negative) X-ray pictures  the white shadows of the prosthesis are surrounded by a dark area of the loose connective tissues, by "lucent lines".

        The white shadows of the skeleton around the prosthesis have been "eaten up" by the dark shadows of the connective tissue = osteolysis.  Both components  changed position.

         

 

When is a revision operation for a loose total knee necessary?

    Reasons for a revision operation of a failed loose total knee are

        unbearable pain

        loss of function

        progress of osteolysis

    The first two reasons for revision operation are much like the reasons for the primary total knee replacement. The third reason, progress of osteolysis, is, however, of overriding importance for your decision. The progress of the osteolysis, the dissolving bone disease that caused the failure of the total knee, is namely unpredictable. There is always  a risk that osteolysis will destruct large areas of the skeleton around the total knee joint if you will wait too long.

     

            There is  a small group of patients where the osteolysis can proceed without pain. In these patients the osteolysis has been discovered by chance on the X-ray pictures only. These osteolytic changes may lead to a fracture if they are extensive. Such extensive osteolysis that may cause bone fracture around the prosthesis  should  be treated with a revision operation, although the patient does not have pain.

         

        Risk of fracture

        In patients with skeletons weakened by osteolysis around the failed total  knee joint, there is always the risk that the weak skeleton may succumb to a fracture. Fracture through the skeleton which is already weak adds another challenge to the already difficult revision operation. Donít take the risks.

        Patients with grave medical condition that precludes a new operation of the loose total knee joint are left without a revision operation. Usually, the grave medical condition restricts the mobility of these patients substantially so that the risk of the skeleton fracture is lower in these patients.

 

Treatment of aseptic loosening .

        Not every total knee joint with "lucent lines" on an X-ray picture evokes pain and stiffness.

        Many patients live happily with their well functioning total knee joints while the X-rays  of their artificial joints show the lucent lines. Remember that the X-ray picture of your artificial joint and your personal comfort might not be correlated.

        Loosening of a total knee prosthesis with little changes in the skeleton, with no  progress of lucent lines, and with mild symptoms may be treated by "watchful observance".  That means reduced weight bearing and repeated controls including X-ray pictures, while you and the surgeon wait with the decision to operate on your total knee.

        If the patients experience increasing pain from their artificial joint and the X-ray pictures show  signs of incipient aseptic loosening, the first step usually ordered by the surgeon is a restricted weight bearing regime. Often this may by all that is needed. The loose knee prosthesis may find a new stable position, the discomfort and pain disappears, and the radiolucent lines seen on the X-rays do not progress.

        If the radiolucent lines on X-ray pictures widen and if the pain and other discomfort from the artificial knee joint increases then a revision operation becomes necessary. At this revision operation the surgeon will remove the loose prosthesis, remove carefully all loose tissue, and put in a new revision prosthesis. See more on these revision knee prostheses in the chapters Linked total knee prostheses .

How long can you wait with  the revision operation?

        There is always a risk that the loosening process will destruct too large parts of the skeleton if you wait too long. The revision operation may then be more difficult. So if you will wait, you should have a careful monitoring of the progress of the skeletal changes around your total joint.

        There is  a small group of patients where the osteolysis can proceed without pain. In these patients the osteolysis has been discovered by chance on the X-ray pictures only.

        The surgeons are discussing whether regular controls with X-ray pictures of the total joint are necessary for all patients  to discover these rare cases of "silent" osteolysis.

     

How is the revision operation done?

    The surgeon opens the total knee joint and assess the stability of the total knee joint prosthesis and takes samples for bacteriological cultures.

    If there is no suspicion of postoperative infection, the surgeon then removes the total knee component that is unstable. Usually, there is loose connective tissue around the unstable component. The surgeon must remove all loose connective tissue.

    There are  three components in every total knee joint ( femoral, tibial, and patellar component) and only one of them  may be loose. There is still a debate whether it suffices to exchange only the loose component and let the stable component stay in place or whether all three components should be always exchanged.

    The surgeon then  places a new total knee prosthesis in the clean bony bed.   Because the old total knee joint was exchanged with a new, this surgery is also called an exchange operation.

    The main problem of the exchange operation is the management of the bone cavities caused by the osteolysis (bone dissolving disease). Cement cannot be used to fill these defects.

    A new technique, called impaction grafting, uses small bone chips to fill large defects caused by osteolysis. The surgeon may take small bone chips from the patients own skeleton (from pelvic bones, e.g.) or use bone chips provided by the bone bank.

    The  bone chips are impacted into the defect and   make a stable ground for a new total knee prosthesis. The surgeons may use bone cement to fix the new total knee joint in the bed of impacted small bone grafts. Usually the surgeon uses total knee prostheses with long shafts. These shafts will anchor the total knee prosthesis in the marrow cavities of the thigh-  and shinbone. These long shafts will add stability to the new total knee prosthesis.

    TOTKNEE_cementless

    Picture: Revision total knee prosthesis.

    (Click on the icon for a full size image)

    Note  the long shafts that anchor the prosthesis in the marrow cavities of the femur and tibia.

    If the osteolysis is confined to a smaller area and the whole total joint is still stable, the surgeon can open the area of osteolysis only,   remove the loose tissue, and pack the cavity with healthy bone chips. The total joint, which is stable, will stay in place.

    If you wish more details about total knee loosening

References:

Archibeck, J Bone Joint Surg-Am, 2000, 81-A, 1485

www.nih.gov



 
« Last Edit: October 15, 2008, 03:17:51 AM by Plumb »

Offline Teresa_S

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Re: Desparately need advice on a loose knee replacement
« Reply #4 on: October 15, 2008, 02:56:55 AM »
Hi, I had the poly spacer lose the screws, they backed out into the knee joint, before 9 months after my first knee replacement. When they went in to replace the spacer, it had worn away exactly as my knee had and one side was about 1/5 as thick as the other. Then one year later, (before the knee was two years old, ) the implant came loose. On xray , and after bone scan, and several labs, they came up with the fact that it had loosened prematurely. When he was going to do the replacement, he wasn't sure whether or not he would do both the tibial and femoral, (the femoral was loose they thought). When he opened the knee the femoral implant came loose easily. He had warned me that if it were not loose, that one commoner complication is that they break the bone trying to loosen the component, and remove. Unfortunatly , the top was loose, but the OS who did the original implant had taken so much bone, that the new OS had to go with a stemmed implant, and hammered the femoral component about 6 inches into my femur, then the tibial wouldn't line up equally, so they had to use an offset stemmed component. it is about 4-5 inches into the femur. I have never been pain free, nor have I been without extreme swelling. Now (almost two years later) the tibia is extremely painful, when I try to move it, when I have been lying down, I have to grit my teeth and just try not to scream. If I stand on it very long, and then lift it and remove weight from it the same thing happens.† The OS will not fill the knee joint with cement. The only reason to take out the joint and not immediately replace it is if they expect infection, and then they fill the space with antibiotics. There is antibiotic mixed cement, that my OS used, as it helps prevent infection, when putting in the new joint. He could NOT fill it with cement, as the joint would fuse, as the cement hardened.I would ask if he expects infection, as if so, he should be treating it , not waiting to decide, and IV antibiotics will be used for 6 weeks or more. (BEEN TRHOUGH THAT TOO)There would be no other reason not to take out and put in the new joint at the same time. If it is infection, he should be doing a ESR and and C reactive protein.The ESR, or sed rate is the rate at which erythrocytes settle out of unclotted blood in one hour. This is based on the fact that inflammatory and necrotic processes cause an alteration in blood proteins, that results in the red cells becoming heavier and more likely to fall faster when in a vertical test tube. (there fore, the higher the sed rate, the more chance of iinflammation and infection.)This is now being used for acute MI, or likelihood to have mi in future. The C reactive proteinis a protein that appears in the blood as a result of infection or tissue destruction.HEalthy people don't have the protein in their blood. Any injury or condition that brings about injury or destruction of skin, tissue, etc, elevates the crp level. Like MI or myocardial infarction, rheumatoid arthritis, burns, etc. even malignancies. IT usually takes 18-24 hours to show up in the blood after injury. There are also complements you can measure.† Talk to the dr, and ask him why he expects the joint to be loosened, and WHY he would not do it all in one procedure. REMEMBER if HE EXPECTS infection, treatment should not wait. Hope this helps.I am a nurse, and tried not to be technical. Teresa
« Last Edit: October 15, 2008, 03:01:49 AM by Teresa_S »
On going instrumentation failure, chronic infection,
Arthroscopes Left 11 Right 2, MRSA, L TKR† ,† Revision, LR x5, Medial and lateral meniscus repair, Broken prosthesis
Osteochondral Fracture,untreated 6 mths. Revision new tkr 01-07 awaiting new hip and right knee
R TKR pending

Offline humpty dumpty

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Re: Desparately need advice on a loose knee replacement
« Reply #5 on: October 16, 2008, 02:26:33 AM »
Hi...

My Left  TKR from 98....got loose in 2005...it was the worst knee pain i ever felt, i had to walk with my leg sideways, and that did a number on my back..I had 7 very good years with it,

I was told some ppl can not have a lot of pain with a loose one, but pain is the indicator...

It was a longer surgery, 3 hours, i had a revision specialist....and he had to get the old cement out...in the replacement of that one, no glue was used..  I have seveere RA for 14 years, and also am told, i can get a flare in a TKR!...but thst revision is fine  n now


Today i got a bone scan of the TKR of the right leg, done in 2002.....Started getting some pain, on the inside  of the knee, last week, when walking...Last years annual xray by ortho, and this years, show bubbles on the film..So, ortho wants to monitor the situation..

I have the copies of the film, and will get the report Monday, when i see the doctor.....Whatever it is, it is just starting.....I have started the process to get a power wheelchair, so i will be able to go the malls etc.....but i can walk ok in the house..

will let you know what the report says next week

pain/free one to you

 















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