Total Knee Replacement Surgery in India is one of the most popular & successful procedures in the entire medical field. Vast majority of these cases enable people across the world live richer & more active lives free of any chronic knee pain. However, over a period of time, replaced knees of patients having undergone this procedure can become swollen & painful. The replaced knee may also feel stiff or unstable & thereby make it difficult for these patients to perform everyday activities.
Read: Knee Replacement Surgery In India
Revision Total Knee Replacement Surgery
When knee replacement fails in people, doctors usually recommend that they undergo a second surgery which is known as revision total knee replacement surgery. During this procedure surgeons will remove some or all parts of the original prosthesis & replace them with newer ones. Although both these procedures have the same goal, as to relieve pain & improve function, revision knee replacement procedure is different from primary total knee replacement surgery. Revision surgery is a longer & more complex surgical intervention which requires extensive planning & specialized implants 7 tools in order to achieve good results.
What Happens During Revision Total Knee Replacement Surgery?
Natural knee joint is replaced with prosthesis or an implant during primary total knee replacement surgery. This artificial joint is typically made of plastic & metal components. Even though most total knee replacement surgeries are quite successful, some problems like implant wear & tear & loosening may occur over time & require a revision procedure so as to replace original components. There are many different types of revision surgery which are performed. Only one implant or component of prosthesis is required to be revised in some cases, while all three components including tibial, femoral & patellar components need to be replaced or removed, along with bone around the knee which requires to be built with augments involving metal pieces substituting missing bone, or with bone grafts. Damage to bone may often make it difficult for doctors to use standard total knee implants for the purpose of revision knee replacement surgery. However, in most cases surgeons would use specialized implants with thicker & longer stem fitting deeper inside bones for extra support.
When to Recommend Revision Total Knee Replacement Surgery?
Revision knee replacement surgery is recommended in the following cases.
Implant Loosening & Wear – An implant must firmly remain attached to the bone for total knee replacement to function properly. During the initial phase of surgery it is either cemented into position or bone is expected to grow into surface of implant. The implant was firmly fixed in place in either case. However, over time implants may loosen from under bone & cause knees to become painful. Actual cause of loosening may not always be clear, but high-impact activities, wear of plastic spacer between two metal components of implant & excessive body weight are factors which may often contribute. Moreover, it is quite natural for patients who are young while undergoing initial knee replacement surgery to ‘outlive’ life expectancy of the artificial knee. Therefore, there is a higher long-term risk for these patients of requiring revision surgery due to loosening of implant or wear & tear. In quite a few cases, tiny particles which wear off the plastic spacer accumulate around the knee joint & are subsequently attacked by the immune system of the body. This natural immune response also attacks healthy bones located around the implant & which leads to a condition known as osteolysis. As a result of osteolysis, bone around the implant deteriorates & makes implants loose or unstable.
Read: Reasons to Undergo Total Knee Replacement Surgery in India
Infection – This is a potential complication in all types of surgical interventions, including revision total knee replacement surgery. Infections can occur while patients are still in hospital or after they have gone back home. In some cases it may even occur years later after the operation. In case artificial joints become infected, it may become painful & stiff. Subsequently, the implant may begin to lose its attachment to bone. Even in case implant remains properly fixed to bone, swelling pain & drainage from infection site may make revision knee replacement surgery absolutely necessary. Revision replacement surgery for knee infection can be done in any one of the following two ways depending upon how long infection has been present, type of bacteria, degree of infection & the preference by the patient. Debridement – Bacteria can be washed out, plastic spacers can be exchanged, while metal implants can be left in place for some cases requiring revision knee replacement surgery.
Staged Surgery – However, the knee joint implant must be completely removed in some other cases of infection requiring revision knee replacement surgery. In case implants are removed to treat infections, doctors would prefer to perform the revision operation in two separate stages. In the first stage, surgeons will remove the implant & place a temporary cement spacer within the patient’s knee. Treated with antibiotics so as to fight infection, this spacer will remain within knee for several weeks. Patients will also receive intravenous antibiotic injections during this time. Orthopedic surgeons will then perform a second surgery for removal of antibiotic spacer & insertion of new prosthesis when the infection has cleared. Removal of implant leads to a higher chance of curing infection in general, but is however associated with a prolonged time for recovery.
Instability – When ligaments around knee become improperly balanced or damaged, patient’s knee may as a result become unstable. Since most knee implants are designed to work together with the patient’s existing ligaments, any type of change in these ligaments can prevent proper working of the implant. Patients may therefore experience recurrent swelling along with a sense that the knee is ‘giving way’. When knee instability cannot be effectively treated through nonsurgical methods like physical therapy & bracing, revision knee replacement surgery may be the only option left to treat this condition.
Read: Knee Joint Replacement Surgery Cost In India
Stiffness – At times total knee replacement does not help patients achieve the required range of motion which is required to perform everyday functions. This is usually found to happen when excessive scar tissue has built up around the knee joint. In case this occurs, surgeons would initially attempt what is called ‘manipulation under anesthesia’. During this procedure, patients are given anesthesia so that they do not feel any pain. Surgeons then aggressively bend the patient’s knee in an attempt to break down scar tissue. In most cases however, this procedure is quite successful in largely improving the range of motion. However, sometimes it does not help & the knee still remains stiff in case extensive scar tissue or position of components within the patient’s knee is limiting the range of motion. In such scenarios, revision knee replacement surgery may be necessary.
Fractures – Periprosthetic fractures are broken bones which occur around components of total knee replacement. Some of these fractures are most often resulting from falls & usually require revision knee replacement surgery. Orthopedic surgeons will consider several factors for determining the extent of revision required, including quality of remaining bone, type & location of fracture & whether the prosthetic implant is loose. In case bone is weakened or shattered from osteoporosis, damaged sections of the bone will also be required to be completely replaced with larger revision components.
Preparing for Revision Knee Replacement Surgery
Following points must be duly considered while patients are preparing for revision knee replacement surgery.
- Medical Evaluation – Revision knee replacement surgery patients will be asked to schedule a complete physical examination with doctors for several weeks before undergoing revision surgery. This is essentially required so as to make sure that they are healthy enough to undergo surgery & complete the process of recovery. However, patients with chronic medical conditions like heart disease are also evaluated by specialists, including a cardiologist prior to undergoing surgery.
- Imaging Tests – Orthopedic surgeons will usually order revision surgery patients to undergo imaging tests in order to learn more about the condition of the patient’s knee.
- X-Rays – This test provides images of dense structures like bone. Doctors will recommend patients to take X-rays around the area of the knee joint in order to look for loosening or change in position of components of the knee joint.
- Other Imaging Tests – Nuclear medicine bone scan can effectively help determine in case the patient’s prosthesis has loosened from the attached bone. Moreover, in some cases, MRI or magnetic resonance imaging scans or CT – computed tomography scans will help determine as to why the patient’s knee has failed along with the condition of bone which is involved in the joint.
- Laboratory Tests – Doctors may often revision knee replacement surgery patients to undergo blood tests which can help them determine if there is any infection. They will also aspirate the patient’s knee through which joint fluid is removed with help of a needle & syringe & subsequently analyzed within a laboratory so as to determine if any infection is present.
- Home Planning – As mobility of patients will be limited immediately after surgery during recovery, they will require help for several weeks with tasks like bathing, shopping, cooking & doing laundry in case they are living alone. A social worker or discharge planner at hospital can also help patients make advance arrangements for someone to assist patients at home. Patients may often need to stay at a rehabilitation center or nursing facility for some time depending upon their condition after leaving hospital. Healthcare team can help arrange short stays for patients in extended care facility during recovery if required.
Risks & Complications of Revision Knee Replacement Surgery
As it is with any type of surgical intervention, there are risks which are associated with revision total knee replacement surgery. Since this procedure is longer & more complex than primary knee replacement procedure, it poses greater risk of complications. Surgeons usually discuss all of these risks with patients before surgery & take a variety of specific measures in order to help avoid potential complications. Some possible risks & complications associated with revision knee replacement surgery include the following.
- Bleeding
- Poor healing of wound
- Infection in wound or in new prosthesis
- Stiffness or reduced range of motion in knee
- Blood clots
- Damage to blood vessels or nerves during surgery
- Bone fracture during surgery
- Pulmonary Embolism – blood clot in lungs
- Medical problems like heart attack, stroke or lung complications
Revision Total Knee Replacement Surgery Procedure
Patients undergoing revision knee replacement procedure are most likely to be admitted to the hospital on the day of surgery.
Administration of Anesthesia – Patients will be evaluated by a member of anesthesia team after being admitted for surgery. Most common types of anesthesia which are administered for revision knee replacement surgery include epidural, spinal or regional nerve block anesthesia which will keep the patient awake but will stay numb from waist down. General anesthesia which will put patients to sleep during the procedure is also another option which doctors may consider depending upon the individual case. The anesthetic team in consultation with the patient will determine which type of anesthesia will be most ideal in each case.
Surgical Procedure – Revision total knee replacement surgery is more complex than the preceding primary knee replacement surgery. It also takes longer to perform than the primary procedure. Normal time taken for the revision surgery procedure is about 2 – 3 hours in most cases. Orthopedic surgeons will usually follow the line of incision which was made during the primary total knee replacement surgery. Incisions may however be longer than the original ones in order to allow old prosthetic components to be removed. After the incision is made, surgeons will move tendons & the kneecap to a side in order to reveal the knee joint. The surgeon will then examine soft tissues in the knee so as to make sure they are free from any kind of infection. After this they will assess all metal and/or plastic components of prosthesis in order to determine which part has worn out or shifted out of the right position.
Surgeons will next very carefully remove the original implant in order to preserve as much bone as it is possible. In case cement was used in primary total knee replacement surgery, it will be removed as well. Removing cement from bone is a time-consuming process which adds to length & complexity of revision replacement surgery. Following removal of the original implant, surgeons will prepare bone surfaces for fixation of revision implant. There may also be significant amount of bone loss around knee in some cases. If this is the case, platform blocks & metal augments can be added to main components so as to make up for bone deficits. It is only in some rare cases that bone graft material is utilized to help rebuild the knee. This bone graft in most cases comes from the patient’s own bone (autograft) or from donor bones (allograft). Finally, the surgeon will insert specialized revision implant alongside repairing any surrounding soft tissues which are damaged. After this the surgeon will carefully test the range of motion of the joint. Drains may also be placed within the patient’s knee so as to collect fluid or blood which may accumulate or remain at the operation site following revision total knee replacement surgery. Patients will be moved to a recovery room following completion of the operation. They will remain closely monitored in the recovery room for several hours while they recover from anesthesia. Only after they have woken up will they be taken to their regular hospital rooms.
Aftercare Following Revision Total Knee Replacement Surgery in India
Revision knee replacement surgery patients are most likely to stay in hospital for several days following operation. Although recovery following revision surgery is normally slower than recovery after primary knee replacement surgery, the type of caring which patients receive is quite similar.
Pain Management – Revision knee replacement surgery patients will usually feel some pain following surgery. However, they will be given medications in order to make them feel as comfortable as possible. Management of pain is an important part of the patient’s recovery program. Though there can be exceptions, most patients will begin walking, bearing weight & knee movement functions soon after surgery.
Physical Therapy – Physical therapists usually give patients specific exercises in order to strengthen their leg & restore effective range of motion so that patients can begin walking & resume other everyday activities as soon as they can, following operation. In order to restore movement in knee & leg, doctors in some cases employ a CPM or Continuous Passive Motion Machine. This device essentially provides a knee support system which slowly moves the patient’s knee while he is in bed. Quite a few doctors believe that using CPM will help restore range of motion in a short time.
Preventing Blood Clots – Doctors often prescribe one or more than one measures for patients to prevent occurrence of blood clots & thereby decrease swelling in legs. These usually include blood thinners, special graded compression stockings & compression boots or inflatable leg coverings. Foot & ankle movements are also encouraged immediately after surgery so as to increase flow of blood within leg muscles in order to help prevent swelling of leg & formation of blood clots.
Prevention from Infection – This is one of the most serious complication facing patients who have undergone revision knee replacement surgery. Even though infection is found to occur only in a small percentage of patients, it can dramatically prolong or even limit chances of full recovery. In order to prevent infection, patients are given antibiotics, both before & after the surgical procedure. Moreover, risk of infection is also slightly higher after revision knee replacement surgery than it was after primary total knee replacement surgery.
Recovering at Home Following Revision Knee Replacement Surgery
Patients will require help at home from several days to several weeks after being discharged from the hospital. Prior to surgery, they must also arrange for someone to drive them back home & serve as caregiver. Revision knee replacement patients may need a cane, walker or crutches for the first few days or weeks until they feel comfortable enough to walk without any assistance.
Caring for the Wound – Patients will have staples or stitches running along the wound or suture beneath skin on front of the knee. Staples or stitches will be removed after several weeks following surgery. However, sutures beneath skin will not require removal. Patients must take care so as to avoid soaking the wound in water until it has completely sealed & dried. Patients can continue to bandage the wound so as to prevent irritation from support stockings or clothing.
Physical Therapy – It is important for revision total knee replacement patients to continue moving & exercising the knee when they are at home. Physical therapists will provide them with specific exercises which are designed to increase mobility & strength & to improve upon ability to perform everyday activities. Patients must also work with the therapist so as to ensure that they can straighten the leg & subsequently bend the knee to a level of 90 degrees of flexion at least.
Preventing Complications – Revision knee replacement surgery patients must follow doctor’s instructions in order to reduce risk of developing complications. These generally include infection & blood clots, especially during the first several weeks of the recovery period. Surgeons may also recommend that patients continue taking antibiotic & blood-thinning medications which they had started taking while they were at the hospital.
Revision Total Knee Replacement Surgery Long-Term Outcomes
Vast majority of patients who have undergone revision total knee replacement surgery experienced favorable long-term outcomes including relief from pain along with increased stability & function. Although, complete relief & restoration of full function is not always achievable, some patients are still found to experience pain & stiffness in knee following revision knee replacement surgery.
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