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Forum Name: Joint surgery

Question: severe trauma-induced osteo arthritis in knee - need options


 jkartm - Thu Jan 08, 2009 2:53 am

I am a 31 yo female with severe trauma-induced OA in my RK. In 2003 I was involved in an MVC which resulted in the knee injury. In 2004 my ortho did athroscopy to attempt to reduce pain and better evaluate the OA, he told me it was grade 3-grade 4 at that time. In 2006 he did a bone graft and a tuberosal elevation to relieve pressure on the patella. Both surgeries provided a small amount of relief for a very short period of time. Over-all though, the pain in my knee has been getting worse and worse. The pain is very sharp and "hot", it used to be only in the joint itself, but now it radiates up my femur to about mid-shaft. My right foot often goes numb or has "pins and needles" while the mid-lower leg is swollen (as is the knee joint and from about mid thigh down) and sore. My knee regularily grinds, pops, cracks and makes other such noises (kinda sounds like a bowl of rice crispies). The knee often "locks" or "collapses" without warning, this has even happened while I was carrying my 3 yo daughter. I have often fallen, stumbled and collapsed in pain. I was told that I am not a good candidate for a TKR as I am still young and they don't last long (Alberta Healthcare only covers 1 in a lifetime) and my doctor is unsure my bone would accept the TKR (don't know why). I have lost my career (former paramedic) due to this and am in constant pain. I can rarely walk more than a block or two, pain killers have not helped at all (nor has PT or bracing) and I have been slipping into a depression. I used to be very active and athletic and am now unable. I have gained weight as it is very difficult to excersise (I am being careful about my eating habits though) and I cannot keep up with my children. Are there any treatment options for me? Other than a wheelchair? I moved last year and cannot get into a new ortho for about a year more, but I don't know if I can continue to wait. I'm really sick and tired of the pain.
 Dr. mnermis - Sun Jan 11, 2009 5:36 pm

Osteoarthritis (OA) of the knee is not a rare condition for old people. It is very difficult living with pain, it decrease social life quality, and patients admitted to antiinflamatuar drugs. but knee arthroplasty is agood choise for them. Arthroplasty relieves pain, increase range of motion. but it has got some disadvantages; infection and revision. for elder patients without infection postoperatively, they do not need to much revision surgeries. because their sedentary life style do not hurt, wear prosthesis. and they live with one prothesis to end of their life.

But for young people we try to follow this algorithm;
[*]Nonsteroidal aniinflamatuar medication
[*]Arthroscopic debridment, rehabilitation
[*]Viscosuplementation and rehabilitation
[*]Osteotomies, if there is an malalignment of extremity
[*]Unicondylar knee arthroplasty
[*]Total knee arthroplasty

And also there have been some new techniques like moziplasty and chondral transplantation.

Degeneration size in the effected knee and its grades are important factors. And we choose one treatment option according to patient complaints, range of motion, x-ray, MRI or arthroscopy if necessary.

You are 31 years old. Your doctor performed an arthroscopy and said that your degeneration was grade 3-4. You suffer pain that stops you walking not more than one block as i understand.

[*]Are you using NSAİ and protective drugs for your stomach?
[*]Did your doctor recommend you any viscosuplementation therapy?
[*]At the trauma were there any bone fractured (femur or tibia)?
[*]Your grade 3-4 chondral lesion was at the medial side, lateral side or both of them?
[*]Have you ever get any rehabilitation program? (muscle atrophy increase pain at the groin and thight)

If you give answers for these questions, i will be more helpful.
 Tom Plamondon PA-C - Mon Jan 12, 2009 11:59 am

User avatar Hello,

It may be helpful for sake of exercise to find a pool for aerobic fitness. The buoyancy of the pool will take weight off the knee. Besides regular lap swimming for general fitness, you may find benefit to resistive leg exercise probably keeping the knee locked in extension during leg movement.

The symptom of pins and needles in the foot is of concern. I would be suspicious of a lumbar vertebrae source of this symptom.

Regarding the knee itself, I agree that a viscosupplement may be of benefit.

Your family physician can help evaluate your back and if trained, do the viscosupplement injections.

Let us know how it goes.
 jkartm - Mon Jan 12, 2009 2:10 pm

My back has been checked many times and there is no concern. My surgeon feels he may have "caught a nerve" during my last surgery (I forgot to mention he also did a lateral release). The degeneration is "the whole" knee according to my ortho, he said I am equally affected both medialy and laterally. I was also told the distal head of my femur is "in pretty rough shape". I have not been able to get much clarification on this. To the best of my knowledge nothing was fractured in my knee at the time of initial injury, although no radiographs were done untill three months later (I was in an MVC and they were more concerned about my wrist and spine than my knee, altyhough it was my knee that caused the greatest discomfort from the beginning - it was trapped by the dash wrapped around it). Lately the pain has changed, it is no longer the dull, constant, throbby ache it was before. Now it is sharp, hot and searing. It radiates up my femur (sorry, but it really doesn't feel like muscle pain, it feels like bone pain) and the heat and swelling in my knee and thigh are getting insane. I wear a lose-leg jean so that my OA brace will fit underneath, but the sweeling has been so bad that I cannot get my brace on at all the past two weeks and the leg of my jeans is tight. The swelling is fairly localized, from about mid-thigh down to mid-shin/calf. The knee joint itself is somewhat red and the top of the joint (around the distal end of the femur) is very hot. The pain has been so bad that I break out into a cold sweat and am very nauseas. My doctor has never suggested any sort of injections. I once asked him about cortisone as I had heard it can make a big difference in OA, but he said he didn't feel I would garner any benefit from it. He said it would be better for me if I still had more cartilage left, but I hardly have any (according to our meeting) and he also told me that the constant crepitus I feel and hear in my knee is a sign that I am continuing to lose what is left. I am at the end of my rope and am begining to think I will be in a wheelchair before I'm 33 at this rate. I have had two years of weekly PT and have not been able to increase my ROM more than 3 degrees in that time. My therapist said there is nothing more he can do and sent me back to my doctor. My doctor had no further suggestions for me and now I am 6 hrs away from him with a 2 year wait to see a new one. I don't think I will be able to walk in a year, never mind two years if something isn't done soon, which is why I'm on here instead of waiting.
 Tom Plamondon PA-C - Mon Jan 12, 2009 7:40 pm

User avatar Hello,
Thank you for further describing your condition. As tough as it is, do not give up hope.

Consider the possibility of a bone infection in the knee or femur. Signs and symptoms including pain, swelling, redness, loss of motion. Although not specific these signs and symptoms with your history would lead me to at least consider some labs (CBC, CRP, sed rate) and bone biopsy (gold standard for osteomyelitis) or other testing - bone scan or MRI.

Nevertheless, a visit to the physician for evaluation of possible bone infection would be prudent.

Keep us posted.
 jkartm - Mon Jan 12, 2009 8:18 pm

Thanks, I'll try again, though I think my doctor thinks I'm nuts, lol.
 jkartm - Mon Mar 02, 2009 1:35 pm

I just got out of hospital after several weeks (I was in from Jan. 24 until Feb. 26). My new surgeon said that my arthritis has progressed to Septic Arthritis (I had both a joint infection and a bone infection in the femur). I had two scopes to wash out the joint (the second due to a recurrence of the infection) and have been told to expect more infections now that they have started. I am on IV Ancef, oral Flagyl and oral Cipro until March 18 as well as oral Dilaudid (4mg) for pain and Stematil (sp?) for the nausea caused by the antibiotics. Needless to say, I'm not having much fun, lol. Over the past five years (since the MVC that caused the original injury to my knee) I have been unable to do all the things I enjoy most such as snowboarding, hiking, bike riding, rollerblading/ice skating, skiing, I can't even walk more than a block. I feel that my quality of life has greatly diminished and depression has set in. I have done alot of thinking over the past two to three years in particular and now comes my new question...how do I convince my new surgeon to amputate? Before you think I'm crazy hear me out! I can't do any of the things I used to do all the time with my three older kids (eldest is 12) and can't keep up with my youngest (3 1/2), I can't even walk her to the park to play with her as I can't walk more than a block, shopping takes hours as I have to keep sitting down, I am in constant pain, etc. With a prosthetic I would be able to regain most of my mobility (not dumb enough to think it would happen overnight) and take control of my life again. I truly believe it would be in the best interests of both me and my children. Any suggestions how I can get my ortho to see it through my eyes???
 Tom Plamondon PA-C - Mon Mar 09, 2009 11:34 am

User avatar Hello,
Before you consider doing an amputation - it would be an above the knee amputation - give the antibiotics some time to heal the bone. I would suggest waiting 6 months before making this decision. Obviously, once an amputaion is done ...it's done.
I have seen another young man who was involved in a MVA and shattered his lower leg and been suffering for two years and now battling osteomylelitis. I have thought too that amputation would have been a better option for him but he continues to battle. It is a personal decision and in some cases walking with a prosthesis is better than with a chronically infected and inflamed bone and joint.
But give this some more time and certainly discuss this with the orthopedist now so he knows what you are thinking.
Take care and keep in contact.
 jkartm - Thu Apr 30, 2009 8:31 pm

My orthotosist is fully supportive (he is an amputee as well - left foot) and he agrees that amputation may very well be in my best interests. My orthopedic surgeon, however, disagrees. I have now been in hospital three times since January (Jan. 24 - 2.5 wks, Feb. 19 - 2 wks, and April 19, 1.5 wks). The infection has not gone away, or even improved, even after me being on IV Ancef, Cipro and Flagyl since Jan 24. The antibiotics make me sick to my stomache, exhausted, etc and now my hair is falling out by the handful. I still cannot weightbear at all and my ortho says he doesn't think I will ever walk independantly on this leg again. They are now talking about more bracing, one that will include foot through hip to take ALL weight off my knee...why are we bothering? I was told that with this special brace I will be able to walk, but not without crutches or a walker. I am only 31 years old and am a single mum to four young children and am really feeling the need to regain mobility so that I don't miss out on any more of my children's childhoods. I am at a loss, everyone says I won't walk on this leg again without crutches and the meds the pain specialist wants me to take make getting out of bed a challenge, nevermind caring for my children. I feel like my life is spinning out of control and I am not permitted any say in my care. I don't know what to do. This last time I was in hospital they did yet another surgery and sent samples of my tibia, patella, and femur to the lab, all three bone samples grew cultures (three different bugs, all three bugs in each sample). The latest MRI and bone scan show the infection has spread further up my femur and also invaded the previously clean tibia. Any suggestions are welcome at this point. My ortho will not even consider amputation as he says an above-knee amputation makes walking REALLY difficult and he says I'm "too young to even think about that". I need something to change fast, as it is I have missed out on going back to school in the fall and my doctors (the whole team) have referred me to AISH (Assured Income for the Severely Handicapped), a government program that helps provide financial support (like wealfare). I really don't want the future they are steering me towards and I feel that no one is taking me seriously, they all think I am depressed and are sending me to a psychiatrist. PLEASE HELP ME, I am at the end of my rope and WILL go crazy soon if we can't figure SOMETHING out!!!!
 Tom Plamondon PA-C - Mon May 04, 2009 6:50 am

User avatar Hello,

Osteomyelitis which is worsening is concerning.

You may consider a second opinion regarding your orthopedic options.

AKA is more difficult than BKA however but depends on how high up the amputation. The closer to the knee the better. If amputation is a definite option and with the infection working up proximally, it is important for your team to seriously discuss your options.

Your may consult a physiatrist who specializes in rehab medicine and include him in the discussions.

Take care.
 jkartm - Mon May 04, 2009 10:42 pm

I have asked for a second opinion, but I am required to wait my turn on a new doctor's wait list, this is running 2-4 years right now. I don't think I have that long to wait for options. I don't know how else to fight the infection, one would think that four months of IV antibiotics would help, but it's not. A referral has been made to a psychiatrist, I am willing to talk to them if and when I ever get the appointment, but I think that the referral was made more because my ortho thinks I'm nuts. I'm not nuts, I'm desperate to get better, not worse. The antibiotics make me so sick and so exhausted that I am useless right now and they aren't even working...any suggestions? I really wish I would have healthcare coverage in the US, I would look at seeing someone down there asap to try and figure this out. I need answers, it can't possibly be good for my physical health to be this sick for this long. Did I mention that my hair is falling out by the handful??
 jkartm - Tue Aug 04, 2009 12:46 am

I just got out of hospital for the fourth time since January (another debridement, etc. for the infection) and now have a new ortho. The new doctor has recommended AKA and plans on doing it this fall once I have recovered from this last surgery. All the doctors have agreed that my knee and lower leg are beyond repair and the combination of bone and nerve damage caused by the initial injury and the infection have rendered it useless. Now I am searching for as much information as possible as to what I should expect with an AKA. Please tell me everything you can. My new surgeon has told me quite a bit, but I wish to hear from as many people as possible so as to garner as much insight as possible.
 Tom Plamondon PA-C - Mon Aug 10, 2009 10:11 pm

User avatar Hello,
There is much to learn about living with an amputated leg and I applaud you for being so proactive about it.
The whole process of going through the amputation and rehabilitation will be a team effort including nurses, doctors, therapists, friends and family.
Include as many people as possible for support.

Just some general things: after surgery, make sure to maintain good knee extension and good stump shape. This will make wearing the prosthesis and learning to walk with it a lot easier.
Do not give up on the prosthesis. It will take quite some time and effort to get the stump in good shape for routine walking with a prosthesis but well worth the effort.
Lastly, talk to other amputees.

Take care.

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