Sports Medicine

Revision Knee Replacement

Introduction

Revision Knee Replacement means that part or all of your previous knee replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone. The typical knee replacement replaces the ends of the femur (thigh bone) and tibia (shin bone) with plastic inserted between them and usually the patella (knee cap).

Why Does a Knee Replacement Need to be Revised?

Pain is the primary reason for revision. Usually, the cause is clear but not always. Knees without an obvious cause for pain in general do not do as well after surgery.

Plastic (polyethylene) wear – This is one of the easier revisions where only the plastic insert is changed.

Instability – This means the knee is not stable and may be giving way or not feel safe when you walk.

Loosening of either the femoral, tibial or patella component – This usually presents as pain but may be asymptomatic. It is for this reason why you must have your joint followed up for life as there can be changes on X-ray that indicate that the knee should be revised despite having no symptoms.

Infection- usually presents as pain but may present as swelling or an acute fever.

Osteolysis (bone loss)- This can occur due to particles being released into the knee joint that result in bone being destroyed.

Stiffness- This is difficult to improve with revision but can help in the right indications.

Pre-Operation

  • Your surgeon will send you for routine blood tests and any other tests required prior to surgery.
  • You will be asked to undertake a general medical check-up with your primary care doctor.
  • You should have any other medical, surgical or dental problems attended to prior to your surgery.
  • You should make arrangements with your family and friends for help around the house after surgery.
  • You must stop taking aspirin and anti-inflammatory medications 7 days prior to surgery as they can cause bleeding.
  • You must stop taking any naturopathic or herbal medications 10 days before surgery.
  • You should quit smoking or stop smoking as long as possible prior to surgery.

Day of Surgery

  • You will be admitted to the hospital usually on the day of your surgery.
  • Further tests may be required on admission.
  • You will meet the nurses and answer some questions for the hospital records.
  • You will meet your anesthetist who will ask you a few questions about your medical history.
  • You will be given hospital clothes to change into and have a shower prior to surgery.
  • The operation site will be shaved, cleaned, and marked for surgery.
  • Approximately 30 minutes prior to surgery, you will be transferred to the operating room.

Surgical Procedure

Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss sometimes extra pieces of metal or bone are added.

Surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. You will be on your back and a tourniquet is applied to your upper thigh to reduce blood loss. Surgery takes approximately two hours.

The patient is positioned on the operating table and the leg is prepped and draped.

A tourniquet is applied to the upper thigh and the leg is prepared for the surgery with a sterilizing solution.

An incision around 7cm is made to expose the knee joint.

The bone ends of the femur and tibia are prepared using a saw or a burr.

Trial components are then inserted to make sure they fit properly.

The real components (femoral and tibial) are then put into place with or without cement.

The knee is then carefully closed with sutures and staples, a drain is usually inserted, and the knee is then dressed and bandaged.

Post-operation Course

When you wake, you will be in the recovery room with intravenous drips in your arm and a number of other monitors to check your vital observations. You will be given pain medications as needed to help control your pain. To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.

Once stable, you will be taken to the ward. The post-op protocol is surgeon dependent, but in general your drain will come out at 24 hours. You will be allowed to bear weight on your knee as tolerated after surgery and you may sit in a chair and walk around your room as tolerated. The surgical dressing will be changed on the 2nd post-op day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist. Your medications and overall health will be managed by a hospitalist.

Your surgeon will use one or more measures to prevent blood clots in you legs. These include aspirin, blood-thinning medications, inflatable leg coverings, and compression stockings.

Usually, you will be in hospital for 2-3 days and then you will either go home or to a rehabilitation facility depending on your needs. You will be discharged from the hospital being able to bear weight on your knee as tolerated. You may use a walker or cane if needed.

When you go home, you need to take special precautions around the house to make sure it is safe. You may need rails in your bathroom or to modify your sleeping arrangements, especially if they are up a lot of stairs.

You will receive home physical therapy for your knee for two weeks following surgery.

Many of the long-term results of knee replacements depend on how much work you put into your rehabilitation following your surgery. Patients who work hard in physical therapy following surgery tend to get better faster.

You will follow up with your surgeon two weeks after surgery. The surgical staples are removed at this visit. You will then be referred for outpatient physical therapy.

Bending your knee is variable, but by 2 weeks it should bend to at least 90 degrees. The goal is to get 120-130 degrees of movement and be able to fully straighten your knee.

Once the wound is healed, you may shower. You can drive at about 6 weeks once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks. More physical activities, such as exercise and leisure sports, may take 3 months to be able to do comfortably.

You will usually have a 6 week check-up and a 12-week check-up with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray.

You are always at risk of infections, especially with any dental work or other surgical procedures where germs (bacteria) can get into the blood stream and find their way to your knee.

If you ever have any unexplained pain, swelling, redness, or if you feel unwell, you should see your doctor as soon as possible.

Risks and Complications

    As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

    It is important that you are informed of these risks before the surgery takes place.

    Complications can be medical (general) or local complications specific to the knee.

Medical Complications

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reactions to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attacks, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems that can lead to ongoing health concerns, prolonged hospitalization, or, rarely, death

Local Complications

Infection

Infection can occur with any operation. In the knee, this can be superficial or deep. Infection rates are approximately 1%. If infection occurs, it can be treated with antibiotics but may require further surgery. Very rarely, your knee prostheses may need to be removed to eradicate infection.

Blood Clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (pulmonary embolism). These can occasionally be serious and even life-threatening. If you get calf pain or shortness of breath at any stage, you should notify your surgeon.

Fractures or Breaks in the Bone

These can occur during surgery or afterwards if you fall. To repair these, you may require surgery.

Stiffness in the knee

Ideally, your knee should bend beyond 120 degrees but, on occasion, the knee may not bend as well as expected. Sometimes a manipulation is required, which means going to the operating room where the knee is bent for you under anesthesia.

Wear

The plastic liner eventually wears out over time (usually 15 to 25 years) and may need to be changed.

Wound Irritation or Breakdown

Surgery will always cut some skin nerves, so you will inevitably have some numbness around the wound. This does not affect the function of your joint. You can also get some aching around the scar. Vitamin E cream and massaging can help reduce this.

Occasionally, you can get reactions to the sutures or a wound breakdown that may require antibiotics or, rarely, further surgery.

Cosmetic Appearance

The knee may look different than it was because it is put into the correct alignment to allow proper function.

Leg length inequality

This is also due to the fact that a corrected knee is more straight and is unavoidable.

Dislocation

An extremely rare condition where the ends of the knee joint lose contact with each other or the plastic insert can lose contact with the tibia (shinbone) or the femur (thigh bone).

Patella Problems

The patella (knee cap) can dislocate. This means that it moves out of place and it can break or loosen.

Ligament Injuries

There are a number of ligaments surrounding the knee. These ligaments can be torn during surgery or they can tear or stretch out any time afterwards. Surgery may be required to correct this problem.

Damage to Nerves and Blood Vessels

Rarely, these can be damaged at the time of surgery. If recognized, they are repaired but a second operation may be required. Nerve damage can cause a loss of feeling or movement below the knee and can be permanent.

Summary

Surgery is not a pleasant prospect for anyone but, for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan. It may help restore function to your damaged joints as well as relieve pain.

Surgery is only offered once non-operative treatment has failed. It is an important decision to make and, ultimately, it is an informed decision between you, your surgeon, your family, and your primary care doctor.

Although most people are extremely happy with their new knee, complications can occur and you must be aware of these prior to making a decision. Be sure to discuss your concerns thoroughly with your surgeon prior to surgery. If you are undecided, it is best to wait until you are sure this is the procedure for you.

^ Back to Top