Revision Knee Joint Replacement

Because of the many different reasons for which a revision joint replacement may be done, surgery decisions are made on an individual basis. Not all revision joint replacements require the replacement of all parts of the implanted joint. In some cases, parts of the original implant may still be in perfect condition while others may need to be replaced.

Reasons a revision joint replacement may be needed include worn-out implants, implants coming loose from the bone, infection of a replaced joint, and instability or misalignment of an implanted joint. Much of the information applicable to the original (or primary) joint replacement in terms of preoperative, intraoperative, and postoperative care is also true for a revision procedure. However, there are some differences of which you should be aware.

Hospital Stay

The hospital stay for a patient undergoing a revision total joint surgery may be slightly longer than for the original surgery. Hospital stays for the original (primary) total joint replacement average around three days. This compares to 5-7 days for a revision total joint replacement patient.

Blood Loss

As with the original joint replacement, revision total joint replacement is associated with some loss of blood during and immediately following the surgical procedure. The lost blood can be replaced with either: 1) blood that you have donated before the surgery or 2) blood that is donated at an authorized blood bank.

In general, we prefer that patients do not donate their own blood prior to surgery. The blood available through the blood bank is tested with sophisticated and sensitive tests to minimuze the risk of infection. You will be in better physical health if you have not donated blood prior to surgery and your overall risk of transfusion is reduced by not pre-donating blood.

Bone Graft

In revision total joint replacement, a bone graft procedure may be required. Grafting involves the reconstruction of the bone surrounding the implant with new bone. The new bone can either be taken from another location in your own body or from a donor patient.

The decision to use your own bone (called autograft) versus donor bone (called allograft) is usually based upon how much bone is needed. If only a small amount of bone is needed, bone can be obtained from either bone removed during the surgical procedure itself or bone taken from another site (such as the pelvis). For many revision total joint replacement cases, more bone is needed than can be obtained from another site from your own body. When this is the case, donor bone is used.

Similar to blood bank blood, donor bone comes from a certified tissue bank. Certification standards include screening of all donor samples for infectious agents (hepatitis, HIV, e.g.) and the assurance of proper processing so that bone grafts carry the smallest risk possible for use in patients.

Revisions for Infection

In the case of a revision due to infection, depending on the type and extent of infection, you may be told that you need to undergo a 2-stage revision. This involves two surgeries: 1) the removal of the prosthesis and the treatment of the bone to get rid of the infection, and 2) inserting a new prosthesis several weeks later after the infection has been eradicated.

There are a variety of non-surgical treatment options that should be considered before proceeding with a joint replacement.

Weight Loss

For both the hip and the knee, the forces acting across the joint are a combination of body weight pressing down on the joint and the muscles pulling up to stabilize the joint. As these values combine, the hip and knee experience 3-4 times the body weight in pressure with each step. Loosing excess weight reduces the pressure on damaged joints and can relieve pain.

Physical Therapy

By stretching, strengthening and re-balancing the muscle- forces across the joint, the movement and control of the joint can be improve. Pain can also be improved with therapy in addition to the mobility of the joint.

Acetaminophen

Acetaminophen (Tylenol) containing products can be very useful analgesics in arthritis. Given its low cost and good side effect profile, it is a good first-line drug for treating arthritis. It should be avoided in some patients with a history of liver disease and care should be taken not to exceed the total daily dose of 4gm per day. This is especially true when a patient takes multiple different medications that contain acetaminophen.

NSAIDs

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications that block the COX receptors on cells and reduce inflammation which can play a significant role in both osteoarthritis as well as other inflammatory arthridities such and rheumatoid arthritis and lupus. Different versions of this type of drug have different side-effect profiles, but, in general, NSAIDS, when taken for extended periods, can play a role in stomach irritation, ulcers, and bleeding and kidney problems with elevated blood pressure. While these can be very helpful medications, their prolonged use should be done under the guidance of a physician.

Steroid Injections

Steroid injection (often referred to as a “cortisone shot”) is generally performed with a depot version of a corticosteroid that remains within the joint. Once in the joint, the steroid blunts the inflammation within the joint and can reduce the pain of the arthritis. This effect can last from a few days to 6 months. There is a small risk of infection with an injection which can be very debilitating and destructive if it were to happen. The risk of infection is less than 1%. There is no agreed upon number as to how many times an injection can be repeated if the most recent injection had benefit for multiple months. Most agree that multiple injections can be offered, the whether a limit should exist or how high the limit may be is unknown.

Unloader Bracing

As arthritis progresses in the knee and joint space is lost, the leg becomes more bow-legged or knock-kneed. As this collapse occurs, increased load is applied to the already diseased and damaged section of the joint. By applying and unloader brace, the leg can be straightened and the load shifted back onto the more healthy area of cartilage remaining. This can reduce pain and suffering during activities such as walking, shopping and yard-work.

Viscosupplement Injection

Viscosupplement injections inject a purified, viscous fluid into the joint. The injection frequently includes components of normal healthy joint fluid known to be reduced in arthritis. While the exact mechanism of benefit is not known, many patients, especially with early arthritis, can benefit from these injections for a variable period of time.

Walking Aid

Many patients find the use of a cane, walking stick or walker to reduce their pain. By transferring weight to the walking aid, the effected joint can be off-loaded reducing the pain experienced and improving the distance that a patient can walk.

When can I resume driving after hip or knee replacement surgery?
It may take up to 3 months before you can return to driving. Your surgeon will assess your situation and advise you when you may resume driving. If you are taking narcotic pain medications, you should not be driving.

What shouldn’t I do after my THA?
For the first 3 months following surgery, you may be advised by your surgeon to not flex your hip past 90 degrees and to not cross your legs during this time. Not all patients will require this restriction and the assessment for needing these limitations will be made by your surgeon during your operation. High impact activities such as jumping and running for exercise should also be avoided for the long term.

When can I resume bathing?
After the wound has healed, about 24 to 72 hours after the stitches or staples are removed you can resume bathing.

How long will the surgery take?
The time varies depending on the case. However, the majority are completed in 45 to 90 minutes.

How long will I be in the hospital?
1 – 3 days

What is the implant made of?
Most implants are a combination of several materials and can include metal (Cobalt Chromium and Titanium), plastic (polyethylene) and/or ceramics.

Will it set off metal detectors in airports?
Yes, it will probably set off metal detectors, especially if more than one joint is replaced. Patients should allow for extra time when clearing airport screening due to their implants and should be prepared for additional screening procedures.

What shouldn’t I do after my TKA?
We advise against high impact activities such as jumping and running. Kneeling may become more difficult.

When can I resume bathing?
After the wound has healed, about 24 to 72 hours after the stitches or staples are removed you can resume bathing.

How long will the surgery take?
The time varies depending on the case. However, the majority are completed in 45 to 90 minutes.

How long will I be in the hospital?
2 – 5 days

What is the implant made of?
Most implants are a combination of several materials and can include metal (Cobalt Chromium and Titanium), and plastic (polyethylene).