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Patella realignment after a reconstruction?

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Hey,
Im 19 now, but when i was 13 i had a full knee reconstruction with tendon transfer, for constant dislocations (my records 12 in a day) which did not go well. I got golden staf and spent 2 weeks in hospital, and managed to dislocate again within 6weeks while wearing a zimmer splint. Its been generally decided that the original surgery failed and i still dislocate my knee weekly. Im now looking at having a patella realignment, as im at uni and studying to be a vet, i want to work with farm animals. I have oestoarthritis and thinning of the meniscus. I have daily pain in my knee, and want the best outcome. Ive done so much physio and its just not working! Any advice on having this surgery? is it a good idea or do i need to keep going as i am?
thanks! :)

ps, i have a congenital disorder that affects muscle strength and tendon strength (Elhers-danlos) which makes it a bit more difficult!
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replied September 8th, 2012
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gracebunny,

Having Ehler-Danlos disease will make the surgery more difficult. This may actually be why your first surgery failed. It also depends upon the type and severity of your ED.

Yours is a very complex case. Not only do you have the ED, but you have a failed previous attempt to stabilize the patella. If a procedure can be done, it should probably be done by a specialist in complex patellar stabilizing procedures. This may require you to travel to a large facility.

You should ask your current orthopedic surgeon his/her advice. He/she may even be able to refer you to a large tertiary care center, which does this type of surgery. Do your research, before having anything done. This may be the last time you can try to have something done, and you want it to be done correctly and for it to last a while.

Good luck with your studies.
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replied September 8th, 2012
Thanks very much Gaelic,
was also wondering if in the future i will still be a candidate for knee replacements given the arthritis? Its hard to find anything on this in regards to elher-danlos. Just to add to the complications, i've also been diagnosed with osteopenia, particularly in my hips and lower spine.
Thanks again, this is all a lot to think about!
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replied September 9th, 2012
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gracebunny,

The following is an abstract of a paper on patients with ED who had a total knee replacement. It is out of the Mayo Clinic, which is a tertiary care center in the USA. Usually, patients with “special” circumstances should be taken care of at centers such as the Mayo. They are about the only one who get to see a significant amount of patients with any one particular disorder. As you can see from the abstract, even at the Mayo they only had ten patients to study.

As noted in the abstract, patients with ED can have total joints done, but the results may not be quite as good as a “normal” patient, which is to be expected.

Good luck with your studies and your knee.



J Arthroplasty. 2004 Feb;19(2):190-6.

Total knee arthroplasty in Ehlers-Danlos syndrome.

Rose PS, Johnson CA, Hungerford DS, McFarland EG.

Source
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Abstract
The Ehlers-Danlos syndromes (EDS) are a rare group of connective tissue disorders characterized by severe joint hypermobility and instability. Ten patients with 12 primary knee arthroplasties were identified. Average age at time of surgery was 43.3 years, with follow-up data acquired at an average of 65 months after surgery. Primary indications for surgery were tibiofemoral or patellar instability (n = Cool and arthritis (n = 4). Knee Society Functional scores averaged 29.6 before surgery and 51.3 at time of interview (P<.005). Knee Society Knee scores at time of follow-up evaluation averaged 70. Tibiofemoral and patella stability were significantly improved. Arthroplasty appears to be an effective option for knee arthritis and instability in EDS patients, although results and satisfaction are lower than that reported for conventional arthroplasty indications.
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replied September 15th, 2012
Hi Gaelic,
I really appreciate your help, I just have one more question!
After my original knee surgery, I had a staff infection that we think caused a joint bleed, the first bleed 2 days post op was 500ml of blood, the second, a further 2 days later was another 250ml. Both required surgical drainage, and then I had a drain put in for 2 weeks after that. My question is, is this likely to happen again? I saw my surgeon again during the week and got the feeling he was a bit scared about operating again. I had all the blood work done, and no factor deficiencies were found. He also said that if I have a bleed again, it is likely that this would be the last lot of surgery I could have? Why is this?
Thanks very much, I appreciate your help!
Just a note that I had the ehlers danios genetic tests done recently, and it was found that I did not have the bleeding type, just the hyper mobility type,
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replied September 16th, 2012
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gracebunny,

A hemarthrosis (blood in a joint) after a surgery is not due to an infection. It is due to lack of hemostasis, where bleeding continues and it collects within the joint.

If you had developed septic arthritis (Staph is the most common), the drainage from the knee would have been pus (thick, white to yellow, mayonnaise looking material).

Unfortunately, it sounds like during your surgery, the surgeon did not obtain complete hemostasis at the end of the surgery. So, there was most likely a little bleeding vessel somewhere around the joint, which just kept dripping and the blood collected in the joint. Usually, once the knee fills up with the fluid, the pressure will tamponade the vessel and stop the bleeding. Unfortunately, when the knee is drained, it releases the tamponade and the bleeding can start up again.

If the bleeding cannot be stopped by the body tamponading the vessel or from some external compression, sometimes the patient has to be returned to the OR to find the pesky little vessel and tie it off or cauterize it. Luckily, this is usually not necessary.


So, the chances of it happening again are probably pretty low. However, whoever does your next surgery should be made aware of the problem, so that the surgeon can make sure that the wounds are all dry (no bleeding) at the end of the surgery. Orthopedic surgery is usually done under tourniquet control, so that there is very little blood in the surgical field during the surgery. Thus, some surgeons do not release the tourniquet until after the dressing has been applied. So, if they happened to miss a small vessel when obtaining hemostasis (stopping all bleeding), they don't know about it. So, some surgeons will actually let the tourniquet down before closing the incision. That way they can make sure there are no little bleeders that have slipped by. Both of these methods are acceptable and mostly it depends upon the surgeon's training as to how he/she finishes up a surgery.


So, again, the chance of it happening again is probably small. But, it is always possible. Just make the surgeon aware of the fact that you had some problems with post-op bleeding in the past.


Good luck. Hope you get that knee fixed up.
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