ArcaMax

DEAR DR. ROACH: My husband had left knee replacement surgery three weeks ago. He has had continuous unrelenting pain since. He was initially on hydrocodone with acetaminophen alternating with tramadol. This barely touched the pain. We were referred to a pain specialist who prescribed hydrocodone, but our insurance wouldn't allow it. He is also on gabapentin and baclofen. The doctor took an X-ray, and said all looked normal.

My husband spiked a fever of 103 five days after surgery but nothing since. The swelling has been reduced, but his knee is still fairly swollen. He is unable to straighten his knee or walk without heavy dependence on a walker. He has been using the prescribed splint but cannot tolerate it for very long.

I keep thinking this is not normal. The doctor has warned him if he doesn't get his leg straight soon, he might never. In-home PT has been working with him to no avail. He starts outpatient PT this week.

We have been married 44 years, and this is the first time I have seen him sob uncontrollably for a half hour from the pain, exhaustion and depression. I am so worried but don't know what to do.

Have you heard of a patient having so much pain after three weeks? Should we get a second opinion? I worry about the long-term use of opioids although he has cut back to one every night when the pain spikes and Tylenol as needed. Still, he cannot drive until he stops the pain meds completely. He was a very healthy and active 73-year-old until August. -- M.

ANSWER: This is NOT normal. This needs intervention. Sobbing in pain is not an acceptable outcome.

People with severe pain after knee replacement may have several different reasons for it. One is an infection, and the fever spike is concerning. However, a single fever spike is not a good indication of infection, and what sounds like a normal X-ray also argues against infection. Still, your husband's surgeon might consider blood tests to look for evidence of infection and inflammation, and might even perform removal of fluid from the knee to look for infection.

Loosening and instability of the joint is a common cause of pain. An X-ray is often the first study done, but his surgeon might do an MRI (many modern prostheses are MRI-safe).

I had one patient who had a severe metal allergy and who unfortunately had placement of a prosthetic knee with that metal, which never did well and had to be removed. Metal hypersensitivity typically does not show up so quickly or so dramatically.

He needs to go back and see his surgeon. He needs a more complete evaluation to determine the cause of his pain and limitations of movement. While you can certainly consider a second opinion, I would go back to the surgeon, who does not seem to me to understand the severity of your husband's symptoms.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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