Revision Total Knee Replacement surgery

What is revision knee replacement? 

A vast majority of people who undergo a total knee replacement, end up enjoying more active and fulfilling lifestyles without having to endure chronic knee pain. 

However, knee implants do not last more than 20 years. That means if you have had a total knee replacement at a young age, you would need to undergo another procedure to refix the implants. 

The procedure is known as revisions total knee replacement. In a knee revision, your surgeon removes the original prosthesis and replaces it with a new one. 

In certain procedures, your surgeon will only need to replace one implant but in other instances, all the prostheses require being replaced with new implants. This is called a revision total knee replacement.

Why would a knee replacement implant fail?

The main reasons why you might need a knee replacement are:

Infection

The risk of infection after a total knee replacement is significantly reduced by the use of antibiotics and up-to-date surgical techniques.

However, there is still a small chance of an infection happening and when it does, it has devastating effects.

In the case of a total knee replacement biofilm formation might contribute to infection. This happens because the plastic and metal implants form an environment that is conducive to the growth of bacteria.

It is hard for antibiotics to access these bacteria on account of their location.

While bacterial infection does not affect the fixation of implants, you would still require revision surgery to prevent the swelling and pain.

Revision knee replacement after an infection can take one of two forms based on the level of damage an infection.

Your surgeon may decide to wash the knee while retaining the original prosthetic.

The surgeon can decide to completely replace the infected implants with new prosthetics.

Loosening and wear

Proper fixation of implants to the bone greatly determines how an implant will function. To achieve the desired fixation, some surgeon cements the implant onto the bone.

Other surgeons opt for biologic fixation instead. In this kind of fixation, there is no need to place cement between the bone and the implant.

Even the most firmly fixed implants become loosened over time. While the actual cause of loose implants remains unclear, some of the contributing factors include a worn-out polyethylene component and excessive body weight.

The implant surfaces could also wear out over time, due to the friction of rubbing against each other. Tiny particles will form around the joint.

The bone-implant bond loosens in what is known as aseptic loosening. The body tries to digest the worn-out particles and in the process destroys the bone.

Aseptic loosening can also lead to osteolysis which involves digestion of healthy bone. The result is a fractured or weakened bone.

Loose prostheses cause instability, pain, or change in alignment.

Stiffness

At times, you may not attain the range of motion required to undertake your daily activities even after a total knee replacement.

One of the main causes of this could be excessive buildup of scar tissues around your knee. This hinders full joint movement.

To fix this problem, you would require knee manipulation. The procedure is administered under anesthesia.

Your surgeon will flex and straighten your knee using his hands. The goal is to regain the lost flexibility.

In case of significant impairment of motion due to excessive buildup of scar tissue, and when knee manipulation fails, your surgeon will recommend revision surgery.

This procedure allows you to regain the lost motion and go about your daily activities with minimal fuss.

Instability

Instability comes about when the soft tissue structures around your knee can no longer offer the stability needed to function properly while walking or standing.

Such instability could be caused by improper alignment of the prosthesis or loosened tissue.

Stretching of soft tissues post-surgery means your knee no longer gets the support it needs.

Your surgeon might recommend physical therapy or bracing to correct such symptoms. If that fails, you will need revision surgery.

Leg fractures

You may experience a broken bone around one or more of the components of total knee replacement.

This is known as a periprosthetic fracture. When this happens, you may need revision surgery.

Before recommending revision surgery, your surgeon will take into account various factors, such as the location and type of fracture, the quality of remaining bone, and if the implant is loose.

Types of revision knee replacement surgeries 

We have various forms of knee replacement revision procedures, based on the implant components being replaced: 

Total revision replacement

This involves replacing the tibial, patellar, and femoral components. 

Your surgeon will remove the injured components and replace them with new prosthetics. 

A total revision replacement also involves rebuilding the bone that surrounds the knee joint using another bone graft or prosthetic. 

Partial revision replacement

Here, your surgeon will only replace a part of the knee co-implant. 

With a partial revision replacement, there is it is not necessary to have an extensive bone reconstruction. 

In the case of a revision replacement procedure, you will need to replace detailed bone reconstruction to repair or replace the damaged bone and surrounding tissues. 

You may also require specialized implants that are thicker and longer meaning they offer the much-needed support. 

Preparing for revision knee replacement

Before a revision knee replacement, you will undergo the following steps:

Medical evaluation

Your primary healthcare provider will administer a scheduled complete physical examination a few weeks before revision surgery.

Such a medical assessment will confirm to your primary care doctor that you are healthy enough to undergo the procedure successfully.

If you have chronic health conditions such as type 2 diabetes or heart disease, you will need to see a specialist before surgery.

Tests

Your primary healthcare provider will order the following imaging tests:

X-rays

These tests give your doctor clear images of the bone and the associated structures.

Through X-rays, your surgeon will also see if there has been a change or loosening of components or their positions.

Computerized tomography (CT) and magnetic resonance imaging (MRI) scans

A CT scan and MRI scan will assist your surgeon to establish the cause of a failed knee.

The scans further give detailed information regarding the condition of the bone.

Laboratory tests

Your surgeon may order blood work to establish if you have an infection.

During surgery 

Your surgeon will discuss with you beforehand whether you will be admitted a day before the revision knee replacement. 

You will have a meeting with the anesthesia team to discuss the type of anesthesia that is most appropriate for you. 

The main types of anesthesia available for this kind of surgery are general anesthesia and regional anesthesia. 

With general anesthesia, you will be asleep for the entire duration of the surgery. 

In the case of regional or spinal anesthesia, this kind of anesthesia numbs you from the waist down. You are also awake during the entire procedure. 

Revision knee replacement takes longer compared to total knee replacement. It is a far more complex procedure as well. 

Your surgeon starts by following the incision line made when you had the primary total knee replacement. 

The doctor might need to make a longer incision compared with the original. This permits the ease of removal of the old components. 

Next, the surgeon removes the kneecap and tendons to have a better view of the knee joints. 

The surgeon assesses the knee and associated soft tissues to rule out any infections. 

The surgeon also examines the plastic/metal parts of the old prosthetics to identify the loose or worn-out parts. It also helps the surgeon determine if the parts are out of position. 

Where necessary, the surgeon removes the original implants making sure there is maximum bone retention. 

The doctor will remove cement if it has been used in the primary total knee replacement. It is a tedious job to remove such cement which is why your surgeon will take longer to perform revision knee replacement. 

Once the original implant has been successfully removed, your surgeon proceeds to prepare the bone surface in readiness for a revision implant. 

In case there has been considerable bone loss around the affected knee, your surgeon may need to add platform blocks and metal augments as a supplement to the bony deficits. 

If bone graft material is needed for the knee buildup exercise, this will be obtained either from a donor or your own bone. 

It is very rare that your surgeon will need bone graft material. 

The surgeon inserts the revision implant in place. In case the adjacent soft tissues are damaged, the surgeon will repair them as well. 

The doctors will also test the knee joint movement. 

Your surgeon can insert a drain in your knee to collect any remaining blood or fluid following the procedure. 

After a successful revision knee replacement, the surgical team will move you to a recovery room. 

Your vitals and anesthesia are closely monitored during your stay in the recovery room. 

You may need to be moved to a hospital room for your continued recovery. 

You will receive the same level of care that you did while having a total knee replacement. However, the recovery process after revision total knee replacement is slower. 

Your surgeon will recommend the following as part of your recovery plan: 

Pain management

Feeling pain is a normal part of healing after surgery. You will be given local anesthetics opioids or nonsteroidal anti-inflammatory drugs (NSAIDs) to help you manage pain. 

Preventing infection

This can be a serious complication. While only a handful of patients present with infection, when it does occur, it could hinder or prolong full recovery. 

You are at a higher risk of infection following revision surgery than is the case after primary total knee replacement. 

Your surgeon will prescribe antibiotics before revision surgery and post-surgery to avoid this. 

Preventing blood clots

You are at risk of increased leg swelling and formation of blood clots after revision total knee replacement. 

To prevent this, your doctor may recommend blood compression stockings and blood thinners. 

You will also be encouraged to make foot and ankle movements as soon as you have had revision surgery. This improves the flow of blood in your leg muscles and reduces blood clots and leg swelling.

Home recovery 

You will be discharged from the hospital once your surgeon has confirmed you are stable and that there were no complications from the procedure. 

Most patients take several days or weeks to recuperate at home from the time of discharge. 

If you leave alone, make plans to have a family member or friend stay with you during the recovery period. 

You will require crutches or a walker during the first few weeks as you regain the strength to walk unaided. 

You will be guided on how to take care of the wound while recovering at home, including while bathing. 

Do not soak the wound in water unless it has completely dried and sealed. 

Your surgeon will schedule a post-surgery appointment to remove the staples or stitches. 

Your physical therapist will guide you on the kind of exercises or movements you will need to make at home, to enhance mobility and strength. 

Make sure you have adhered to the instructions issued by your surgeon to minimize the risk of infection, blood clots, and other complications during the recovery phase. 

Your surgeon may recommend antibiotics and blood-thinning medication to reduce the risk of complications. 

Benefits of revision knee replacement

Revision knee replacement aims to :

• Improve the patient’s quality of life

• Increase mobility

• Reduce pain

• Prevent infections

• Risks of revision knee replacement

• Like all other surgical procedures, there are certain risks that come with revision knee replacement

Some of those risks include:

• Infection in the implant or on the wound

• Blood clots – This can either lead to pulmonary embolus or deep vein thrombosis

• Reaction adverse reaction to spinal or general anesthetic

• Fractures

• Kidney problems

• Stroke

• Heart attacks

• Bone fracture

• If you have a pre-existing health condition, revision knee replacement surgery can cause complications

Cost of revision knee replacement in India

The cost of knee replacement surgery in India starts from Rs. 2,50,000 but could go all the way to Rs. 5,00,000.

The cost of knee replacement surgery in India is relatively low compared to what Western countries charge.

Some of the contributing factors to this difference in the cost of  revision knee replacement surgery in India are:

• Type of revision knee replacement – A total revision knee replacement surgery costs more than a partial revision knee replacement procedure

• Location of the clinic/hospital – If the hospital or clinic is located in a metro city like Mumbai, New Delhi, Pune, or Bangalore, you will pay more for a revision knee replacement procedure than would be the case with a hospital located outside of the metro cities

• Type of implants – The kinds of implants used will also affect the overall cost of revision knee replacement surgery

• Surgeon’s experience – Highly skilled surgeons who have performed hundreds of revision knee replacement surgeries are more competent and will therefore charge more for this surgery

• The type of hospitals – Public hospitals in India charge less for revision knee replacement surgery than private hospitals

• Examination or lab tests – Your doctor will order ECG, X-rays, and other tests to determine the extent of damage to your knee. This will add to the overall cost of surgery

• Age of the patient – As you age, a revision knee replacement procedure becomes more complicated to administer and affects the overall cost of the procedure

• Post-surgical complications – If the revision knee replacement surgery was accompanied by complications such as bleeding or infection, this calls for further treatment using antibiotics and other medication to control such complications. This increases the cost of the procedure

• Admission room chosen – If you choose a deluxe room for your recovery while at the hospital, you will end up paying more than another patient who is sharing a room

• Doctor’s consultation fee – The consultation fee that your surgeon charges to administer a revision knee replacement is determined by the location of the clinic /hospital and the surgeon’s reputation and experience

• Physical therapy – Your surgeon may recommend physical therapy before revision knee replacement. This enhances the range of motion. It also strengthens your muscles

The cost of the number of physical therapy sessions and associated costs will depend on the quality of the therapy center and its location.

The sessions are also charged per hour. The more hours that you spend in physical therapy, the more you end up paying for the overall revision knee replacement.

References

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