- Why does a knee replacement need to be revised?
- Day of your surgery
- Surgical procedure
- Post-operation course
- Risks and complications
Revision Knee Replacement means that part or all of your previous knee replacement needs to be revised. This operation varies from 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).
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 results in bone being destroyed.
Stiffness- This is difficult to improve with revision but can help in the right indications.
- Your surgeon will send you for routine blood tests and any other
- Investigations required prior to your surgery
- You will be asked to undertake a general medical check-up with a physician
- You should have any other medical, surgical or dental problems attended to prior to your surgery
- Make arrangements for help around the house prior to surgery
- Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
- Cease any naturopathic or herbal medications 10 days before surgery
- Stop smoking as long as possible prior to 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
- Anesthetist will ask you a few questions
- Attendant will give you hospital clothes to change into and have a shower prior to surgery
- The operation site will be shaved and cleaned
- Approximately 30 minutes prior to surgery, you will be transferred to the operating room
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.
In any surgical operation, you will be under sterile conditions, spinal or general anesthesia. You will be on your back and a tourniquet applied to your upper thigh to reduce blood loss. Surgery takes approximately two hours.
Your leg’s position is prepped and draped on the operating table.
Your leg is prepared for the surgery with a sterilizing solution with a tourniquet to the upper thigh.
It will expose your knee joint by 7cm incision.
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 & Tibial) are then put into place with or without cement.
The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged.
When you wake, you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder and a number of other monitors to check your vital observations. You will usually have a button to press for pain medication through a machine called PCA machine (Patient Controlled Analgesia).
Your surgeon will take you to the ward when you get stabled.The post-op protocol is surgeon dependent, but in general, your drain will come out at 24 hours and you will sit out of bed and start moving your knee and walking on it within a day or two of surgery. Movement gets easier on the 2nd post-op day as dressing reduces a bit. Your physical therapist will supervise your rehabilitation and mobilization process.
To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.
To minimize blood clots in your legs, you can use one or more measures such as inflatable leg coverings, stockings, and injections into your abdomen to thin the blood clots or DVT’s, which will be discussed in detail in the complications section.
A lot of the long-term results of knee replacements depend on how much work you put into it following your operation.
Usually, you will be in a hospital for 3-5 days and then either go home or to a rehabilitation facility depending on your needs. You will need physical therapy for your knee following surgery.
Your surgeon will discharge you on a walker or crutches and usually progress to a cane at six weeks.
Remove sutures at approximately 10 days if it doesn’t dissolve naturally.
Bending your knee is variable, but by 6 weeks it should bend to 90 degrees. The goal is to get 110-115 degrees of movement.
Take a bath when wound dries up. 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 sports previously discussed may take 3 months to be able to do comfortably.
When you go home you need to take special precautions around the house to make sure it is safe. You can install rails in your bathroom or modify your sleeping arrangements especially if they are up a lot of stairs.
Usually, you need to have a 6-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.
You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the bloodstream 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.
- Major surgery involves risk but it outweighs the potential disadvantages
- Inform yourself of these risks before the surgery takes place.
Complications can be medical (general) or local complications specific to the Knee
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 can lead to ongoing health concerns, prolonged hospitalization or rarely death
Infection can occur with any operation. In the hip, this can be superficial or deep. Infection rates are approximately 1%. Antibiotics can treat it but may require further surgery. Hip removal eradicates the 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
Can occur during surgery or afterward if you fall. To repair these, you may require surgery.
Stiffness in the knee
Ideally, your knee should bend beyond 100 degrees but on occasion, the knee may not bend as well as expected. Sometimes manipulations require you to take it while going to the operating room.
You don’t need to change the plastic liner as it eventually wears out over time, usually 10 to 15 years.
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.
Surgery puts your knee into the correct alignment to allow proper function so it may look different than it was.
Leg length inequality
This is also due to the fact that a corrected knee is more straight and is unavoidable.
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).
The Patella (knee cap) can dislocate. This means it moves out of place and it can break or loosen.
There are a number of ligaments surrounding the knee. Surgery corrects torn ligaments, broken out or injured.
Damage to nerves and Blood Vessels
Damages on nerve and vessels require a second operation. Nerve damage can cause a loss of feeling or movement below the knee and can be permanent.
Discuss your concerns thoroughly with your Orthopaedic Surgeon prior to surgery.
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 restores function to your damaged joints as well as relieve pain. You may regard it as part of your treatment plan.
Doctors offer surgery only once non-operative treatment has failed. It is an important decision to make and ultimately it is an informed decision for you, your surgeon, family, and medical practitioner.
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. Wait until you are sure this is the best procedure for you.
What are the types of knee replacement surgery?
Knee replacement surgery entails removing the diseased part of the damaged knee joint and capping it with an artificial part. The knee joint has three compartments called medial (inside of the knee), lateral (outside of the knee) and patellofemoral (underneath the knee cap) compartments. Total knee replacement is the most common type of knee replacement that involves replacing the all three compartments.
Partial knee replacement involves replacing only part of the joint-the medial, lateral or patellofemoral joint. It is imperative to be selective in choosing which knees are good candidates for partial replacements because poor selection is responsible for early failures. If there is an excessive deformity or if there is significant arthritis in other compartments, partial knee replacement does not result in good pain relief and may necessitate revision to a full knee replacement.
What conditions require knee replacement?
Knee replacement is the last option for treating pain from arthritis. Arthritis means that the cartilage (the glistening tissue at the end of the bone) has worn out and the bone is rubbing on bone. There are numerous conditions that can cause this and there are more than a hundred types of arthritis. The most common types are osteoarthritis and rheumatoid arthritis. Orthopedic surgeons typically try a variety of injections in the joint and physical therapy before knee replacement surgery.
How to prepare for knee replacement?
The treating orthopedic surgeon coordinates care in preparation for knee replacement surgery. There are established protocols before any joint replacement surgery that involve medical clearance, dental clearance, nasal cultures, cardiac, urine and blood tests etc. It is very important to select a surgeon who specializes in joints and a hospital that does a large number of joints. Literature has shown that larger volume a surgeon and hospital performs, better are the outcomes.
How long does the surgery last?
Surgery lasts about an hour to one and half hour depending on the complexity of the case. There are many steps involved in the operating room before surgery like anesthesia, prepping and draping the knee etc. Therefore by the time the patient is wheeled into the operating room to the time patient comes out of the post-operative care unit, the time maybe more than two hours.
Most patients walk full weight bearing on the same day of surgery with a walker. Most patient with partial knee replacements go home the same day. Majority of total knee replacement surgery patients go home the next day. Fewer patients are going to inpatient rehabilitation facilities.
How much pain is involved after? And how can that be managed?
We have made major advances in pain management in the post-operative period. We stay ahead of the pain by giving pain medication on a scheduled basis. Pain medication is even given before the patient is wheeled into the operating room. We use a combination of narcotic and anti-inflammatory medications orally, intramuscularly and intravenously. Additionally, we inject the joint and the tissues around it intraoperatively with anesthetic with lasts for about two days.
How long is the recovery?
The total rehabilitation after total knee replacement is about three months. Recovery after a hip replacement is very different where patients are pain free within days. After total knee replacement surgery, patients see light at the end of the tunnel at 4 to 6 weeks and at 3 months they are significantly better. Improvements continue for several months afterwards but the range of motion that exists at 3 months is what remains for life which is why rehabilitation and physical therapy is extremely important after total knee replacement surgery.
What restrictions on activities are there at each stage of recovery?
Patient can walk with full weight immediately after knee replacement surgery. They should range their knee in the post-operative period and do physical therapy to decrease the possibility of stiffness. In the long term, it’s advisable not to do any impact type of activities. Artificial joints have no ability to heal themselves and impact increases the possibility of loosening.
What does the recovery involve?
After having full knee replacement surgery, most patients go home the next day. A visiting nurse and physical therapist that visits them at home. Patients then do outpatient physical therapy three times a week for next several weeks. Most patients are pain free in 3 months after the surgery.
How much physical therapy is involved after?
Physical therapy start immediately after surgery and is required for about three months after surgery. Physical therapy starts in the hospital, then at home and then in an outpatient facility. It helps in improving range of motion, improving strength, decreasing inflammation and pain.
What are the best case scenario results?
Knee replacement surgery is done for pain and most patients are completely pain free after the surgery. Along with hip replacement surgery, it is one of the most satisfying surgeries in orthopedics. Some patients have trouble swatting and kneeling. Occasionally they may have clicking in the joint but their quality of like has improved substantially after surgery.
When and why do some knee replacements fail?
More than 90% of knee replacements last for more than 20 years. Most early failures are due to infection that may happen within few months of the surgery. Most late failures are due to loosening that happens over several years. Intermediate failures may happen because of suboptimal alignment and patient factors that include impact activities to the joint.
How long does it take to know if your knee replacement was successful?
The arthritis pain is gone immediately after the surgery. Patients immediately notice this when they place weight over the operated extremity. The surgical pain gets better with time. Most pain is gone in three months. Infection or other adverse events manifest as increasing pain, redness, swelling etc. A knee is not improving after surgery warrants further evaluation by a joint replacement surgeon.
Are follow-up surgeries (that aren't a total re-do) ever needed (say, for scar tissue), and why?
The idea of knee replacement surgery is to give the patient one operation that will last a lifetime. Follow up surgery after knee replacement will only be needed if there is a complication. Occasionally, if the knee is not progressing for range of motion with physical therapy, the knee may need to be manipulated under anesthesia to break the scar tissue. If there is an infection surgery maybe need to clean up the joint.
How long does a knee replacement last?
More than 90% of full knee replacements last for more than 20 years. Partial knee replacements may not last long if the indications are not accurate. There is growing literature to show that if the selection is correct for doing partial knee replacements and if the surgery is done in an accurate manner to insure correct alignment, the long term results may be similar to a full knee replacement.
How best to take care of one's knee following knee replacement?
Patients have an active pain free life after knee replacement. They can play golf, swim, do horseback riding, ski etc. Its prudent to avoid constant impact type of activity. Some of the worst long term outcomes are in active males who abuse their joints. Additionally, it’s imperative to take antibiotics when patients visit the dentist because bacteria can travel from the mouth to the knee through the blood and cause infection in the knee joint.
How to AVOID knee replacement.?
Arthritis leading to knee replacing is a combination of genetic and environmental factors. Modifiable factors include maintaining body weight and musculature around the joint. Patients suffering from rheumatological disorders should be diligent in taking medication. We are going significantly less joint replacement surgery for rheumatoid arthritis because of better drugs that have come out in the past few decades. Surgery can be done for deformities of the knee like bow leggedness to dramatically decrease the need for knee replacement surgery in the future.
Revision Knee Replacement Case Studies
- Limb Salvage Surgery Case Study 1
- Loose Total Knee Replacement Case Study 2
- Left Total Knee Replacement Case Study 3
Why choose Dr. Kakare?
As a top joint replacement specialist in New York City, Dr. Karkare has extensive experience in revision knee replacements, ensuring patients have the broadest array of safe and effective treatment options to relieve pain and other symptoms.
Doctor Karkare performs an in-depth evaluation of each patient to determine if an anterior approach would be a good choice or if another approach might be preferred before any procedure is performed.
This enables every patient to make an informed, educated decision so they can feel confident in their care every step of the way.
To schedule your evaluation, call (212)951-0182 or use our online contact form to learn more.