What problems can occur with a total knee replacement?
Sometimes a total knee replacement can become problematic earlier than expected and may require revision surgery. Alternatively, you may be one of the many patients out there who has had a well-performed total knee replacement which has now failed or become problematic with the passage of time.
A problematic total knee replacement is often just that and the symptoms are often difficult to pin down and can be quite vague. Pain may or may not be present all the time – it may be slightly hot, warm or swollen. Your surgeon will examine you in the office and this often yields vital clues as to what the underlying diagnosis or cause could be.
What causes these problems?
The causes of a troublesome total knee replacement can be broadly divided into those intrinsic to the knee replacement or extrinsic to the knee replacement. Extrinsic hip or spine pathology can masquerade as knee pain. Therefore the treating surgeon needs to have a high index of suspicion before focussing on the knee replacement itself. Further, other systemic conditions such as metabolic bone disease/rheumatoid arthritis can all present with pain in the knee.
Causes intrinsic to the knee replacement: loosening, wear, mal-alignment, instability, stiffness (inability to fully bend or flex the knee), flexion contracture (inability to fully extend the knee), periprosthetic fracture, periprosthetic infection.
What investigations may be required?
The routine bloods, including ESR and CRP, weight-bearing long leg films are taken in both AP and lateral dimensions.
If an infection is suspected, then often a full infective workup is performed which comprises, in addition to the ESR and CRP, an aspiration and a bone scan +/- bone implant interface biopsies.
Can the problem get worse?
A long-standing problematic total knee replacement is unlikely to spontaneously get better.
It should be borne in mind that complications may result from a condition with or without surgery. Complications of non-operative treatment include worsening pain, increased stiffness, increasing deformity, adjacent joint disease, pain elsewhere, for example in the ankle, hip or lower back (due to abnormal gait and compensatory mechanisms). Complications can occur with any type of surgery.
Potential general complications: risks and complications of anaesthesia, bleeding, infection, blood clots, the need for further surgery, persistent pain, complex regional pain syndrome and wound healing problems, genito-urinary complications and cardiovascular complications.
Potential complications which are specific to the surgery mentioned above include nerve damage/foot drop, intraoperative fracture, stiffness, instability, loosening, wear, the need for revision surgery and non-resolution of symptoms, partial resolution of symptoms, leg length discrepancy.
These can be activity modification, painkillers and physiotherapy. Revision joint replacement surgery is a lengthy, technically demanding procedure and therefore should be performed by joint replacement specialists.
Patient fitness and physiological status should be rigorously assessed prior to committing to such a procedure. Your surgeon will sit down with you at the time and go through all the complications.
Due to recent significant biotechnological advances, there are a number of implants available each with their own biomechanical and fixation philosophies. It is important to select a reconstructive option which best suits the unique personality of your knee.
As mentioned this is lengthy, challenging and technically demanding surgery and there is now, due to biotechnological advances, a significant number of reconstructive options available. The variety of options and implant choice specific to your individual needs and reconstructive personality, will all form part of a shared decision-making process in the office.
Click here for more information on revision knee replacement surgery.
Postoperative period and recovery
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
After your operation, a routine enhanced programme of recovery will commence. The main parallel work streams of this programme are as follows:
Stop using a stick once you feel comfortable to do so. Do not worry if this takes a bit longer since we all recover at different rates. Your surgeon will advise you at your follow up appointment.