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Is corrective surgery the only solution for a weak/fractured thigh bone post TKR ?

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Orthopaedic Surgeon
Practicing since : 2000
Answered : 170 Questions
My mother(now aged 74 yrs) underwent knee replacement surgery 5 yrs ago for both knees at a hospital in Kerala, India. One of the knees was bent sideways at the time of surgery. After surgery, though this was corrected, again within 5 yrs, the knee has started bending and she experiences intense pain on standing for a long time and is forced to use the walker always. Initially as per the orthopeadic surgeon's advise, a knee brace was used regularly for almost a year, as this was not effective, though we consulted the same doctor again, he has reluctantly advised for a corrective surgery which he has not attempted before. The doctor's assessment based on X rays is that the upper portion (thigh bone) has become weak/fractured and hence the artificial joint got displaced(gap is seen between the lower and upper contact surfaces). He has stated that the knee joint has to be opened first to assess exactly the replacement/correction required and then only the old joint can be removed and new suitable one put in place. The procedure will require minm 6-8 weeks hospitalisation. As we are not confident of the outcome, is there any alternative to surgery by which pain and discomfort can be reduced/avoided and she can resume near normal activity? Thanks
Posted Wed, 18 Apr 2012 in Bones, Muscles and Joints
Answered by Dr. Atul Wankhede 26 hours later
Hello Jairamchandran,

Thanks for asking the question.

Its unfortunate that your mother is having a trouble with a replaced knee. Nevertheless it is imperative for us to find out the cause of this persistent pain.

From what I gather she had a 'Varus' deformity. Or as you said, a side-bending of her knee before the operation. This deformity is to be, and in your case, has been corrected. Since a year
now she is developing it again.

This could be either due to loosening of the implant or a fracture above the implant level in Femur (thigh bone).

This complication is not an uncommon one, and the options open to us are limited. If it is loosening then we have to first make sure that there is no infection at that site. Suppose there is infection then we have to remove the implant, clean the operative site thoroughly in first stage.

Then after 3-6 months, when the knee is certified infection free, we go for second stage fresh implantation.

If it is a fracture, then it needs to be fixed in correct position to prevent any further deformity and subsequent pain.

I'm afraid these procedures require a minimum 2 weeks hospitalization but certainly not 6-8 weeks.

It would be more appropriate if I can have a look at the soft copies of her latest and old X-rays.

You have a feature to upload the reports / image by yourself at the right side of the query page, please utilize that so that I can answer your queries better.

We shall at all time try to find a solution that does not lead to surgery, but many a times its a necessity.

Kindly refrain her from using pain killers for a long time.

I would also like to know the following details:

1. Were both knees operated in single sitting?

2. Is she having an associated fever?

3. Does her knee have swelling/ redness/ local warmth/ opening-gaping
oozing fluid?

4. Can she completely straighten both knees?

5. How much can she bend her knees in degrees with straight knee as 0
degree(kindly comment on each knee separately)?

6. How long can she walk before she gets pain/exhaustion?

Hope I have answered your query. Feel free to ask more queries.

Above answer was peer-reviewed by
Follow-up: Is corrective surgery the only solution for a weak/fractured thigh bone post TKR ? 12 days later
Dear Dr.Wankhade,

I have uploaded Xrays of the affected left knee joint- the day before opertion and two recent ones. She is currently taking the following medicines:

Becozinc- every night
Shelcal 500- alt days morning
Retroz(Painkiller)- once in 3 days

I would now answer your queries in seriatim:
1. No. The left knee was done first and the right one after 2 months
3. There is no such swelling/redness/local warmth/opening/oozing fluid etc- however a lump is noticeable on one side which pains when touched
4. Yes
5.She can bend both knees while sitting, but crouching is difficult- cannot use Indian style water closet. She feels there is something loose inside left knee while bending.
6. Can walk for about 10 min. using walker after which it starts paining. After sitting for 20 min or more, she finds it difficult to stand up or walk.

Please let me know the right solution preferably non-surgical one

Answered by Dr. Atul Wankhede 6 hours later
Dear Jairamchandran,

Thanks for replying with prompt answers.

Due to technical problems I'm unable to view the copies of Xrays so I would request you to kindly resend them at earliest.

Meanwhile, its clear from the information provided that she's certainly not having an infection at the operated site. The lump she notices needs further evaluation, clinically and radiologically. I also infer that the movements of knee seem to be restricted but not to a disabling level. Crouching or squating should be forbidden. The medication seem fine, a supplement of Vit. C may be added to promote early healing of tissues. Also consult your physician regarding oral Bisphosphonates. Normally calcium from diet and supplements is carried till bones, but in old age its again reabsorbed from bones and thrown out. Bisphosphonates like Alendronate, Residronate prevents calcium from being reabsorbed from bones. You also might consider doing a little physiotherapy for her muscle strengthening.

A persistent deformity and pain is a sign of a failing implant. I wish we had more information regarding what implant was used.

I shall at this stage guard the prognosis and await the soft copies of Xrays.
Above answer was peer-reviewed by
Answered by Dr. Atul Wankhede 3 days later
Dear Mr. Jairamchandran,
Thanks for the follow up.

Looking at the Xrays, I wish to say that the implant has failed. The femoral component has shifted over a period of time, and still progressing. The loosening could be due to a misfit, infection or faulty operative technique.

The medial part of her joint before operation shows severe arthritis and varus deformity. Unfortunately that deformity has not been completely corrected (on both femoral and tibial front).

With a heavy heart I see no other option other that a re-implantation. I understand the disappointment you feel but let bygone be bygone and help your mother achieve the best of her knees once again. Physiotherapy and exercises, even walking will make the matter worsen further.

Think about this at length and take another opinion from a joint replacement surgeon near you if you wish without further delay.

Wising you good health.

Good luck.

Above answer was peer-reviewed by
Follow-up: Is corrective surgery the only solution for a weak/fractured thigh bone post TKR ? 5 days later
Dear Dr.Wankhede,
Thank you for the valuable advice. Sorry for the delay in raising this follow up queation, but I had to collect some details regarding the implant etc which took time.

I have a few doubts based on your previous replies which you may please reply, if possible:
•     In the light of your latest reply, will adding a Vitamin C supplement help in alleviating pain/delaying the deterioration? Esp. since the tablet Shelcal OS she is taking is having Calcium with Alfacalcidol. Or as an alternative, will taking Calcium and Vitamin C supplements marketed by Amway(Nutrilite) help improve the condition/lessen pain or will it have any reaction/side effects when taken alongwith other medicines/BP tablets(Alphadopa- 2 daily, Lorvas -1 daily) she is taking
•     The type of implant provided now is of “ Zimmer USA” make consisting of stemmed Tibial component, articular surface for use with femoral CD & femoral component, “ALL POLY PATELA”- of “Nexgen – complete knee solution”, bone cement-“Sulcem”. Does the type of implant affect its life? What is the type of implant you would recommend for a revision surgery and what would be the apprx.hospitalisation duration and cost?
•     Would you recommend any doctor/hospital in or close to Trivandrum(place of mother’s stay) where this surgery can be done?

Answered by Dr. Atul Wankhede 9 hours later
Dear Mr. Jairamchandran.
Thanks for furnishing the necessary details.

Vit C does not help in pain alleviation per se. But it does help in tissue healing and regeneration. So what ever structural damage she has sustained would have help healing. Amway products are nice but should not be used as a substitute for your physicians medicines.

Zimmer nexgen is a good implant and carries a successful track record. They have a special gender knee designed for women.

I'm unaware of specialist in and around Trivandrum, but I might help you if Hyderabad, Bangalore or Chennai is close to you. The prices of entire procedure shall vary from place to place.

I personally feel your mother needs a two stage reimplantation with a dynamic antibiotic antifungal impregnated cement spacer. Make sure you spell these exact words where ever you decide to do the surgery. Reimplantation can be with the same company if you afford, or you may go for XXXXXXX n Nephew, XXXXXXX n XXXXXXX depending upon your budget.

Hope you find this helpful and I shall gladly help you understand any query you have further.
Good luck.
Above answer was peer-reviewed by
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