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Author Topic: intractible pain post TKR  (Read 1117 times)

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Offline sarahriley

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intractible pain post TKR
« on: August 31, 2006, 02:53:12 AM »
Please help if possible.  I am an RN.  My friend R. had a total knee replacement about 1 and 1/2 yrs ago.  Still having intractible pain, level varies from 4 to 8.  On MSO4 (decreasing doses since surgery but still on it).  All X-rays and a CT are not showing any reason for this problem.  He's very depressed re:  the pain.  Had a 2nd opinion in Tampa, FL - nothing remarkable found.  Would Synvisc injection possibly help him?  I know that the articulating parts are now metal, but his pain is directly in the knee joint so SOME nerves must be playing a part.  R. is 64 y/o, formerly very active, MS Education, retired, now can't walk a block without severe pain.  He isn't the type to be malingering or drug-seeking.  Any suggestions would be very welcome.

Offline emphatic

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Re: intractible pain post TKR
« Reply #1 on: August 31, 2006, 03:32:54 AM »
Wow... 1 1/2 years is a long haul to be in that much pain. I'm sorry your friend is having to deal with that.

Here's some ideas:

There is some research about pain and neural pathways. The short of it is that if a person has had a lot of pain from a bone or nerve problem (it doesn't seem to be as prevelant with soft-tissue problems), it seems that the body can "learn" the particular neural responses of that pain, and even when the source of the pain is alleviated, the neural pathways that the pain once used are still firing merrily away -- kinda like getting stuck in the "on" position.

A good pain medicine specialist would be able to help with that. I'm not sure if the latest thinking is to treat it solely from a neurological point of view, or if a combination of medical/neuro approaches are used. In the long run, it doesn't really matter... he just needs someone willing to figure out what works.

Another possibility is that he really does have a remaining structural or implant problem. At this point, I'd be wondering why no one has offered an exploratory scope, if only responding purely to clinical observations seeing as tests haven't shown anything. It's that old saying -- if the patient looks sick and the tests don't show it, isn't he still sick? Are we treating/believing the patient or the tests? If he's consistently demonstrating the clinical finding of pain, it's up to the doctor to keep looking for the cause. If his doctor is stopping at plain films and a CT (which given the metal aren't such great studies anymore, anyway), and throwing up his hands and giving up, it's time to find a new doc. This is the hard part -- it might not be the 2nd, 3rd, or even 4th opinion. It might be the 11th. Some points to look for would be a pocket of infection (yes, there are people who don't show signs of infection systemically, but have their joints opened up for other reasons and the pus comes pouring out once the pocket is broken), or some kind of problem with the implant (size, placement, etc.) I've even read about a tiny bit of cement being left behind and causing horrendous pain. That won't be distinguishable in the shadow artifact of the metal in any radiologic study (at least to my knowledge). I've only known that to be found during a scope.

While he's continuing to look for the reason for his pain, there's no reason that he has to remain in pain. A good pain specialist should be able to find whatever combination of meds it takes to keep him comfortable while a more definitive treatment is being discovered. A doctor I respect greatly said to me something pithy, but that I'm not likely to forget -- "remember, there's no extra points given out for suffering." If he's not responding to the MS anymore, there's a ton of other possibilities out there. The really cool thing is that a good pain specialist can get a patient to the point of being fairly comfortable and quite functional. The other benefit of a good pain specialist (and this alone is worth it for many patients), is that this doctor believes totally that you are in pain and he's going to work his butt off to relieve it for you.

I don't believe any of the visco-supplementation drugs are going to help him. Their mechanism of action is poorly understood, but it's believed to be some kind of interaction with the articular surfaces that fools the joint into feeling more lubricated. The fluid itself is absorbed within hours, and there is no overall increase or change in the synovial fluid. That sort of explains why people have widely varying results from it, but the best results seem to be in people with damage on the lower end of the scale. With the articular surfaces now consisting of metal and plastic, it doesn't seem that they're gonna much care about the synovial fluid in the joint.

There's actually a lot in the literature about all the fun things that can go wrong post-TKR. If he's the type to feel more in control when he knows more, maybe you can set him lose on the lit databases and he can educate himself toward feeling more in control of his situation? Just a thought.

I really feel for him... I hope he can find an answer.


Offline Teresa_S

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Re: intractible pain post TKR
« Reply #2 on: August 31, 2006, 06:15:36 AM »
HI, You will get many answers , probably, and many suggestions. I , too, am an RN, and had a tkr 3 years ago, that has never been right and never pain free. I have had  xrays, MRI, bone scans, ct, etc. The MRI is hard because of the shadows of the prosthesis. The bone scans show increased intake at the tibia, femur andpatella, and they can;'t rule out osteomyelitis. BUT recently, I went back through all my records, and discovered, what I think in the answer to my increasing and spreading pain. Most OS think the tkr fixes the knee, and will usually take an xray and say it looks fine. I did have screws come lose in my knee and lodge in the spacer and had a partial revision one year to the day of my tkr.  I am now traveling to see somebody, as I have lots and lots of scar tissue, in addition a history of MRSA, and a prosthesis that just does not fit me. The best you can do is to keep searching for another opinion. IF the OS is still providing pain meds, he has either given up and is calling it instrumentation failure, or finds it easier than dealing with the actual problem.  I think, that if he is like me, all he wants is a knee that functions, and is relatively pain free.

I wish you luck, but research, getting all the records, and getting a different opinion is a start. Teresa
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 Sandy_F

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Re: intractible pain post TKR
« Reply #3 on: August 31, 2006, 12:43:40 PM »
I had continued pain with my left TKR.  It started within about 3 weeks of the surgery.  I told the original OS and he just ignored me and when I pushed, he said patella tendonitist.  It was not.  I went about a year with pain escalating.  It would get so bad the muscles in my whole leg would contract and try to protect the knee.  I had a lateral release as they thought it was patella tracking.  Nothing showed up on xray.  Bone scan showed a higher uptake in the tibia and a little in the femur.  No one thought that had showed any problems.  I thought an allergy and found out that I am allergic to nickel.  No on thought that was a problem.  I started writing to some of the major clinics on the east coast.  Each on would not touch me but referred me to a doc in Baltimore.  I went.  I had surgery and had the spacer replaced as it was too small.  I think there was other stuff done but can't find out as the Baltimore doc is friends (and now partners) with the original OS and is protecting him from his mistakes.  I still had problems and ended up with a partial knee denervation.  That has helped trememdously.  I am not pain free but it is so much better now. 

Your friend needs to keep looking for answers.  Write to major hospitals or teaching hospitals.  Find out who is a revision specialist and see out their opinion.  Its hard and takes a lot of research and patience but keep looking for an answer.
Right knee - 14 surgeries including a fulkerson, patellectomy and finally a TKR.  Left knee - Lateral release, microfracture, TKR, then another LR, spacer replacement.

Offline Janet

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Re: intractible pain post TKR
« Reply #4 on: September 01, 2006, 01:36:59 AM »
I know someone who had a TKR and continued to complain to her OS about pain. He did tests and kept watching her and said nothing was wrong that he could see. She finally got another opinion and the new OS decided she needed a revision (I don't know all the details). Anyway, when he got 'in' the knee, he found that a ligament had been attached wrong during the original TKR. Imagine! All that time and complaining, nothing showing on any of the tests, and it was all caused by a surgical error!

The suggestion to find a good pain management doctor is the first step. Then, if nothing else, your friend should get a second (and even a third) opinion just to make sure his doctor's not missing something. I have found that when I continued with an OS and he wasn't listening to my complaints, it seemed that he was focused only on his preconceived notions of what was going on. I needed someone to start from the beginning and look at the whole picture. Each time I went to a new OS, they found something the old one had missed.

You're a good friend.One of the hardest things is when you are in pain and no one (including your doctor) believes you!  Keep being supportive.

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.