Arthroscopic knee surgery gone bad

[applevalley]

I had arthroscopic knee surgery to repair a torn meniscus (sp?) on July 11th, with the whole regimen/protocol of Lovenox bridging. About 36 hours after the surgery, I made my husband take me to the ER in the middle of the night because I had excruciating pain in the knee. The ER doc drained blood from my knee to relieve the pressure which helped somewhat.

The upshot of this is that 9 weeks later, I still have blood (kind of like blood sludge as my family physician calls it) in my knee, the knee is still painful with limited range of motion after 6 weeks of physical therapy, and I'm still limping around with a crutch.

Has anyone else had this kind of experience with relatively simple routine surgery? If so, how long does it take for this blood to reabsorb? Two weeks ago my orthopedic surgeon was surprised at how poorly the knee was doing....he tried to drain it somemore to no avail, but gave me a cortisone shot which seemed to help somewhat. He wants to see me again after 6 weeks and told me it's just a matter of waiting for the blood to disperse/reabsorb.

At this point, I'm seeking a second opinion from an older more experienced orthopedic surgeon, because my knee is 2000 times worse than it was before I had the surgery!!!! I will see him in two weeks.

Both the original orthopedic surgeon and my family doctor mentioned that the procedure may need to be repeated to clean out the knee.....not what I wanted to hear!

Anyway, if anyone out there has insight into this, I would appreciate and welcome your input. Ain't Coumadin fun!!!!!!!

 

[KristyW]

Applevalley,

I suspect that the culprit in your post operative bleeding is the Lovenox. I had major issues after a hysterectomy that necessitated that the surgeon open me back up 1 week after the 1st surgery. My surgeon was blaming my INR of 1.6 as causing the post op bleeding...hogwash! Those not on coumadin/warfarin have INRs of 0.9 to 1.3, so a 1.6 is not an increased bleeding issue. I told my Dr. that I would NOT under any circumstances take another Lovenox shot post op until the bleeding stopped. Because of the intervention of my surgeon, I was given vitamin K more than once. It took 5 weeks to get my INR to therapeutic levels. If they'd have listened to me I believe it would not have taken that long. In my limited experience, the Lovenox pre-surgery is good, but it should be held up until the post operative bleeding risk has passed.

JMHO

 

[Protimenow]

I'm really sorry to hear about your bleeding problem post-op. Yes, you spelled meniscus correctly.

Do you know what your INR was before surgery? Kristy may be right about the Lovenox and bleeding in the knee.

From what I know, the body CAN usually reabsorb the blood -- it kind of forms a jelly -- but being located where it is, the process might take quite a while. I'm not an M.D., but arthroscopic removal of the jelled blood may be a good thing to do and may speed recovery. (Of course, there's always fear of clotting, but I wonder if just cleaning out old blood and not messing with active vessels, may not be all that risky).

From what I remember about PT after my major knee surgery, a year before I got my valve, ultrasound can help break down the clots or loosen up the tissues. (I was in a cast for six weeks, so there was a lot of fusing to undo).

Good luck with your recovery. I'm certainly interested in learning how it goes.

 

[njean]

Oh boy, did your thread bring back nightmarish flashbacks or what!!!!

I had to have knee surgery back in 2004 for a torn MCL and I was told that I'd only be in the hospital overnight! Yeah, right!!! Overnight turned out to be seven long, horrible, painful days in the hospital! In fact, the surgery was suppose to be arthroscopic but it turned out to be open knee with a cut about 6.5 inches long. The first night in ICU, I woke up covered in sweat and feeling like I had wet myself. When I stuck my hand underneath the blankets and pulled it back out, it was covered in blood! I had bled through bandages, sheets, covers, etc.! And the stupid nurses had not even noticed it....in ICU mind you! Luckily for me, a very fine doctor happen to appear in my room, which to this day I tell him, "he was my guardian angel", and he immediately jumped into action to stop further bleeding! That doctor is now our family doctor!

I too had to go in twice to have my knee drained and I stopped going to the knee doctor altogether because I was never happy with the results of the surgery! One time, the doctor mentioned he wanted to put me back in the hospital and forcibly "re-break" the knee, while I was under of course, in an effort to break the scar tissue which he said was hindering full mobility! I told him he was crazy and I never went back to him!!!

I hope you get better and if you are not happy with what's going on, definitely seek another opinion!

 

[applevalley]

Kristy, njean and protimenow, THANKS! I feel like I'm not alone in this and i'm not crazy!

I'm really interested , Kristy in your theory about the Lovenox being the problem....my surgery was on a Monday afternoon and I wasn't done with the Lovenox shots until
Saturday morning. Hmmmm.....maybe that caused all the bleeding.

I' d love to hear more about the vitamin K too, Kristy. I don't have a clear grasp of the role of it in the post surgical treatment. Can you elaborate?

I'm willing to try anything at this point as I approach 10 weeks post-op. I had a knee massage in Wednesday and discovered that the massage therapist is also an LPN and used to manage a Coumadin clinic. She is a gem and a fountain of information.....she suggested some alternative treatments which I'm trying....arnica gel, slippery elm bark poultices, Epsom salt soaks , etc. At this point I'm not sure if any of this is doing any good but it' probably not hurting!

I really appreciate all your comments and suggestions....you have given me food for thought and lots of questions to ask when I go for a second opinion!


Susan

 

[Protimenow]

Susan:

Vitamin K contains factors that PROMOTE coagulation. It's kind of like an antidote to warfarin (though not exactly), but it's used to bring the INR closer to 1.0. If someone wound up with an INR of 4 or more (depending on doctor), they'd probably use an injection of Vitamin K to reverse the unwanted anticoagulation.

If your INR was suddenly a bit over the top of your range, you may want to eat more grens and other foods containing high levels of Vitamin K.

In your case, it may be possible that the Lovenox did TOO GOOD a job on your blood, which may have resulted in unwanted bleeding -- and the Vitamin K was used to reduce the effects.

This is not to say that Vitamin K is bad for you. It's actually beneficial when used at a consistent level, so that you can more easily get into a consistent dosage of warfarin and maintain your INR more easily. It also does other good things in addition to just the coagulation stuff.

I'm hoping that your massage therapist and physical therapists (and doctor) can resolve the issue with your knee and you'll be dancing around in no time.

 

[catwoman]

Susan:
Kristy and Protimenow are most likely correct in suspecting Lovenox as a or the culprit.
Lovenox is known to cause bleeding.

 

[KristyW]

Kristy, njean and protimenow, THANKS! I feel like I'm not alone in this and i'm not crazy!

I'm really interested , Kristy in your theory about the Lovenox being the problem....my surgery was on a Monday afternoon and I wasn't done with the Lovenox shots until
Saturday morning. Hmmmm.....maybe that caused all the bleeding.

I' d love to hear more about the vitamin K too, Kristy. I don't have a clear grasp of the role of it in the post surgical treatment. Can you elaborate?

I'm willing to try anything at this point as I approach 10 weeks post-op. I had a knee massage in Wednesday and discovered that the massage therapist is also an LPN and used to manage a Coumadin clinic. She is a gem and a fountain of information.....she suggested some alternative treatments which I'm trying....arnica gel, slippery elm bark poultices, Epsom salt soaks , etc. At this point I'm not sure if any of this is doing any good but it' probably not hurting!

I really appreciate all your comments and suggestions....you have given me food for thought and lots of questions to ask when I go for a second opinion!


Susan

You're not crazy Susan I don't have anything to help you as far as the knee goes. Are you still taking warfarin? If so, make sure you check interactions with the arnica & slippery elm bark poultice they may interact...I don't know.

My experience with the Lovenox was with the post operative injections they were giving me until my INR was back in range. My personal beliefs are that the Lovenox prior to surgery wasn't the issue as it is effective for only 12-15 hours per shot.

I was given Lovenox post operatively during my hospital stay and at discharge 2x per day until my INR reached therapeutic levels. I went home, gave myself the injections as directed and 1 week from the day of surgery I was back in the hospital in incredible pain. I had developed a LARGE hematoma in my pelvis from abdominal "oozing". I was kept in the hospital for observation for almost 1 full day until I stood up to go to the restroom and all hell broke loose. The doctors blamed my warfarin for the oozing/bleeding even though my INR was only 1.6 at that time. I received a subcutaneous shot of Vitamin K to counteract the warfarin. That didn't seem to help. The Drs. worked all night packing the area, trying to stop the bleeding. Nothing worked. The next morning, they decided that they had to go in and mop up (my INR was 1.4). In post op & recovery I was still bleeding/hemorrhaging. I was given another vitamin K shot (remember INR 1.4...normal person .9-1.3 & Lovenox does not show up in the INR number), 4 units of fresh frozen plasma, 2 units of packed red blood cells, and 4 cryopacks. It took 5 weeks for my INR to become therapeutic. My Drs. did the right thing as I was actively bleeding, but I had to undergo a 2nd surgery 1 week after the 1st.

I have no proof, but I truly believe that this was because the Lovenox was administered too soon. If I had to do it all again, I'd tell them that I'll take the Lovenox pre surgery, but not immediately post surgery. Nothing ever had a chance to start to clot with the fast acting Lovenox on board within 12 hours post surgery. I will gladly start taking the Lovenox 1 week after surgery, but not right away.

 

[Protimenow]

I'll have to refer back to the Duke protocols, but I seem to recall that they advise AGAINST the use of Lovenox before a 'procedure.' I'm concerned that people seem to overreact to a low INR and may be causing issues by jumping to bridging when it may be more dangerous than beneficial.

 

[Protimenow]

I just found this interesting tidbit at the following website: http://www.rxlist.com/lovenox-drug.htm. "What are the possible side effects of enoxaparin (Lovenox)?

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Tell your caregivers or call your doctor at once if you have any of these serious side effects:

bleeding that won't stop;
pale skin, easy bruising, unusual weakness;
swelling, bruising, or bleeding where an incision was made during a surgery or other medical procedure;
sudden numbness or weakness, headache, confusion, problems with..."

Although Lovenox has a 12 hour half-life (which doesn't mean that its effects completely go away in 12 hours), it sounds as if there is an increased risk of post-operative bleeding if you're on Lovenox.

 

[applevalley]

Protimenow,
Thanks for the reference on Lovenox. I suspect that what happened with my arthroscopic knee surgery was that when I went to the ER 36 hours after the surgery, the ER doc was pretty young, probably not very familiar with anticoagulation/Lovenox and didn't recognize that the Lovenox was causing my bleeding issues.
NOW I KNOW!!!!!

When I get my second opinion this week, if the surgeon recommends a re-do of the procedure, I will question the anticoagulation protocol every step of the way! Once bitten, twice shy!!!

Thanks to all on this forum for the input and encouragement. The Lovenox bridging isn't as simple as it seems, is it????!!!!

Susan

 

[Protimenow]

This will be a bit longer post -- and I'm thinking about starting a new thread on it.

It is probably quite likely that the Lovenox caused the extra bleeding. In reading further in the link I sent, I saw that there were test results relating to post-operative bleeding in knee surgery.

The Lovenox probably contributed to the bleeding. It happens in 1% of knee surgery patients post-op. However, without Lovenox, the risk of the same bleeding is higher -- 4%. You were just one of the people who was unlucky enough to fall into that 1% group. The surgeon and post-operative team followed protocol designed to reduce the risk of post-op bleeding -- your risks of bleeding were probably reduced by 3/4 because of the Lovenox.

Bottom Line -- it's easy to make conclusions about whether or not something should or should not have been done, after the fact. If I was having another knee surgery, I would probably play the odds and trust recent research (and get post-op Lovenox). A 1% risk by taking it beats a 4% risk by not taking it.

(Another issue that I've discussed before -- for INRs below 2.0 that will be below that value for just a few days, I still believe like recent research I've seen that there's no need for bridging in people with bi-leaflet valves who are more than 3 months post-op - unless they're having surgery or some other procedure done. It seems like demanding Lovenox anytime you have a 1.5 is a knee-jerk reaction that is usually unnecessary).

 

[applevalley]

Here's an update on my knee. I sought a second opinion last week and the orthopedic surgeon thinks that the blood in the knee has been reabsorbed. He felt that at this point the knee is in contracture and doubling the physical therapy for four to six weeks to try to regain my range of motion is the way to go. If PT four times a week versus twice a week doesn't work, then he recommends a manipulation......putting me under and bending the knee for me. Does anyone have any experience with this? Manipulation doesn't sound like much fun, so I'm going to really try hard with the PT! He said that even though a manipulation doesn't involve any incisions, etc. he would still recommend/require Lovenox bridging if it comes down to needing a manipulation. Apparently this is due to the chance of the manipulation causing internal bleeding......

I welcome any input or thoughts on this!

 

[Protimenow]

I tore the quadriceps off my knee one year BC (before coumadin -- before valve replacement). This was a different surgery from the one you had - but there was an arthroscopic look inside my knee to spot any damage, and nothing was done to my knee behind just poking some holes and inserting the arthroscope.

I was told (and it was true) that immobilizing the knee for the six weeks it took for me to heal would freeze the knee joint. It took quite a bit of physical therapy to restore flexibility and strength in the knee.

If I were you, I'd give PT a chance -- and do my homework, attempting to bend the knee as much as possible. You should be okay....but good luck.

 

[evelyn2]

Lovenox should be given prior to surgery but definately not immediately after surgery and you should DEMAND a drain be placed in the surgical area and be left in for a least a week. I had extensive bleeding into the joint after knee replacement surgery (my INR was 1.6) and had to have my knee drained twice. Two months later I had to have surgery again to clean up the mess inside my leg. With the second surgery, I refused Lovenox afterwards and a Jackson Pratt was placed to collect any bleeding. This was successful and I really believe the combination of no Lovenox after surgery and placement of drains is the answer.