Total Knee Revision

Despite it being a serious procedure, a total knee replacement is one of the most successful in all of medicine. Almost always, this procedure is one that drastically improves a patient’s quality of life and often eliminates any chronic knee pain. After some time, some folks experience a failure of their knee replacement; something that can happen for a number of different reasons. If this happens, pain and swelling may return to your knee. This can make the knee stiff and ultimately make walking and other daily activities difficult, if not impossible.

If your knee replacement does fail, your doctor may suggest that you have a second surgery known as a revision total knee replacement. Simply, this procedure involves your surgeon removing the necessary amount of the original prosthesis and replacing those parts with new ones.

Even though revision total knee replacement has the exact same goal as your original knee replacement, the revision surgery is a bit different because it is longer and more complex. This procedure involves a lot of pre-planning and uses specialized instruments to achieve a positive end result. 

Description

During a total knee replacement, the knee joint is totally replaced by an implant, known as a prosthesis, that is made of metal and plastic parts. Even though most total knee replacements are totally successful, problems and complications can occur over time that wear and loosen components. This is when a revision procedure is needed to replace the original components.

There are a few different types of revision surgery. Sometimes, only one portion of the prosthesis needs to be revised, while other times all three components—femoral, tibial, and patellar—need to be taken out and replaced. The bone surrounding the knee may also need to be rebuilt with augments (metal pieces that replace missing bone) or bone grafts.

If the bone has been damaged due to loose or broken components, this may make it difficult for the doctor to use standard total knee implants during revision surgery. Most often, your doctor will use customized implants that have longer, thicker stems that will fit deeper into bone for additional support.

Your Surgery

Anesthesia

Once you have been admitted, a member of the anesthesia team will meet with and evaluate you. The most commonly used types of anesthesia include general anesthesia (when you are put to sleep) or spinal, epidural, or regional nerve block anesthesia (you are awake, but your body will be numb from the waist down). Along with your input and their expertise, the anesthesia team will determine which option is best for you.

Procedure

As we have mentioned, revision total knee replacement is more involved and takes longer to complete than the original total knee replacement.

During the initial stages, your doctor will follow the line of the incision that was made during your total knee replacement. Though the incision may end up being longer than the original, this is to allow old components to be removed and new, potentially larger components, to be inserted. After the incision has been made, your kneecap and tendons will be moved to the side to fully reveal your knee joint.

First, the soft tissues of the knee will be carefully examined to confirm that there are no infections present. Then, all of the components inserted during the total knee replacement will be examined in order to determine which parts have become worn, loose, or have shifted out of position.

The doctor will remove the original implant with extreme caution such that as much bone as possible is preserved. If cement was used during the initial total knee replacement, this is also removed. The cement removal is one of the most time-consuming aspects of the process.

Once the original implant has been removed, your doctor will prepare the surfaces of the bone for the revision implant. Sometimes, there will be a good bit of bone loss around the knee. If this is the case, metal augments and platform blocks can be added to the main components in order to make up for this bone loss.

In rare instances, bone graft material can be used to help physically rebuild the knee. If the graft comes from your own bones, it is known as an autograft, while grafts from donors are known as allografts.

During the final stages of the procedure, your doctor will insert a specialized revision implant and will repair any soft tissues around the knee that might have been damaged. Range of motion will also be tested at this time. A drain will be used in order to collect fluid and blood that may still be there once the surgery has been completed.

After your surgery, you will be moved to the recovery room where you will remain for a few hours so that your recovery from anesthesia can be closely monitored. Once you are fully awake, you will then be transported to your hospital room.

Your Recovery at Home

Once you are sent home, you will need help at home for several days and even weeks after surgery. Before your surgery occurs, it is recommended that you make plans for a friend, family member, or caregiver to help you at home. Walkers and/or canes may also be used for the days and weeks following surgery, until you are able to walk without any assistance

Wound Care

There will be stitches or staples along your wound. A few weeks after surgery, the stitches or staples will be removed.

You will be advised to avoid soaking your wound in water until it has healed thoroughly such that it is both sealed and dry. The wound will need to be bandaged continuously to prevent clothing or any support stockings from irritating it.  

Diet

It is common for patients who have undergone a knee revision to experience a loss of appetite for a few weeks following the surgery. A balanced diet, sometimes supported with an iron supplement, is important in assisting your wound’s healing process and restoring muscular strength.

Activity

When you are home, there is a lot of emphasis placed on moving and exercising your knee. Your physical therapist will give you exercises to increase strength and mobility and improve your ability to complete daily activities. You will also perform work with your therapists so that he or she can ensure that you are able to straighten your leg and subsequently bend your knee to at least 90 degrees of flexion.

Your at-home activity schedule should include the following:

• A walking program that will increase your mobility over time. First inside, then outside.
• Slowly and carefully resuming normal household activities such as sitting, standing, and climbing stairs.
• Specific exercises that are to be performed several times a day to restore movement and strengthen your knee. Most can perform these exercises with little to no help, however some people may need the assistance of a physical therapist for a few weeks.

When it comes to driving a car, this is something that will be permitted only so long as your knee bends enough that you can enter into and sit comfortably within your car. What’s more, your muscles must be in good enough shape so that you can both brake and use the gas pedal without any strain. You must also be done using strong pain medications that can alter your judgement and reaction time. It usually takes about a month to six weeks before people can begin driving.

Outcomes

The overwhelming majority of patients who have revision surgery experience long-term outcomes that are favorable, including pain relief, increased stability, and increased function. Complete and total pain relief, as well as complete restoration of function is not always feasible, and some patients may still experience pain and stiffness following revision surgery. Most times, the pain and stiffness pales in comparison to what was experienced before the procedure took place.