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Total Knee Joint Replacement Revision Surgery

Original Editor - Lucinda hampton Top Contributors - Lucinda hampton, Kim Jackson, Mariam Hashem, Lauren Lopez, Kirenga Bamurange Liliane and Rishab Mishra

Clinically Relevant Anatomy

Total Knee Joint Replacement (TKR) revision surgery is an orthopedic procedure involving the removal of prosthetic components from a previous TKR and the implantation of new prosthetic pieces within the knee joint. The components involved include the femoral condyle, tibial plateau, polyethylene spacer, and patella. Depending on the underlying reason for the revision, some or all of these components may need to be replaced.

Outcomes

Revisional TKR surgery is a more complicated operation requiring longer time in theater and rehabilitation is slower and takes a more cautious approach.[1] Surgery is more challenging due to such issues as stiffness, adhesion of tissues, and an unstable joint due to ligamentous laxity and poor bone stock.[2]
A 2023 systematic review highlights that patients undergoing revision Total Knee Replacement (TKR) often have high expectations for improved outcomes. However, in reality, revision surgery can significantly impact patients negatively. Outcomes are frequently worse compared to primary TKR, with approximately 50% of patients experiencing severe chronic post-operative pain and 40% facing limited mobility. Additionally, there is an increased fear of falling, further affecting patients' quality of life after revision surgery.[3]

Indications

Many reasons exist for the failure of a TKR. A meta analysis in 2011 found that TKA for OA has a revision rate of < 5% within 10 years.[4] The reason for this failure can be classified into long or short term reasons.[1]

Short term pathological process or injury include

  • Infection. This is a significant risk and is the reason antibiotics are given pre and post surgery.[5]A 2011 meta analysis reported that infection happened more regularly in obese recipients [6]. Smokers also have a higher rate of infection (due to the decreased blood flow effect nicotine and cigarette chemicals cause).[5] Poor nutrition also has an adverse affect on healing time and increased risk of infection.[5]
  • Mechanical failure
  • Implant loosening from failed procedure

Long term pathological process or injury include

  • Loosening due to wearing of the TKR ( life span of a replacement varies from approximately 10 to 20 years).
  • Stiffness. A possible indicator that the prosthesis has become loose or has an infection.[7]
  • Mechanical failure over time through eg. biologic reactions.Biological reactions can occur due to generation of wear particles ( both polyethylene and metal ions) that cause a chronic inflammation causing systemic and local effects to the immune system. This is thought to play major role in osteolysis around the implant and hence loosening of prosthesis.[8] This is often termed as loosening due to wear ( life span of a replacement varies from approximately 10 to 20 years).
  • Pain. May be an indication of loosening of the prosthesis or infection is present.[7]
  • Dislocation from a fall or direct blow.
  • Periprosthetic fracture. This is a fracture that occurs around the prosthetic piece(s).[7] Often from a fall or direct blow.
  • Leg length discrepancy or angular deformity[9]
  • Instability or a feeling that knee will give way. This occurs with ligament damage or loosening. eg from rheumatoid arthritis or poor muscle strength.[7]

[10]

Clinical Presentation

Pain is the most common presenting sign. The cause of the pain could be for many reasons: infection; mechanical failure; loosening of the prosthetic implant; metallosis; disclocation or peri prosthetic fracture. See also Total Knee Arthroplasty Neuropathic Pain

[11]

Diagnostic Procedures

May include:

  • X-rays, MRI, CT for closer visualization of anatomy
  • Joint aspiration to analyse joint fluid for infection
  • Blood tests to check no infection present
  • Nuclear Bone scans to look for any loosening

Outcome Measures

The below is a great Physiopedia page that has a efficient way to read set of outcome measures with each stage of rehabilitation awarded it's own set of measures.

Total Joint Arthroplasty and Outcome Measures (TJAOM) Toolkit

Physiotherapy Management

The pre and post op physiotherapy protocols follow the along the same lines as for the primary TKR. See the comprehensive guidelines in physiopedia TKR.

A recent study advocated in addition to usual physiotherapy a small skateboard be placed under the operated lower limb when able to comfortably sit out of bed and perform gentle ROM. [2]

Patients typically begin using an exercise bike on the second day postoperatively. Knee flexion of approximately 105° is required for bike riding, though this may vary based on seat height and leg length. Before discharge, patients must demonstrate the ability to safely mobilize on stairs. Discharge is approved once patients are deemed safe, mobile, and comfortable.

Go to:

It is important to note that a more cautious approach is often necessary due to the complex nature of revision TKR surgery. The procedure typically takes longer, with more extensive release of the quadriceps or patellar tendon. Advanced techniques, such as bone grafting, bone substitution, long-stem implants, screws, and metal augments, are commonly employed to address bone loss. These factors contribute to a longer recovery period compared to primary TKR.[9]

A 2004 report found that primary Total Knee Replacement (TKR) led to significant improvements in proprioception, balance, and kinesthesia. These findings could reasonably be extrapolated to revision TKR as well. The improvements are believed to result from the pretensioned capsuloligamentous structures, along with reduced pain and inflammation following the procedure.[12]

The goal is to have a pain free, functional and stable knee joint, however knee outcomes are not as predictable as in a primary TKR and despite the best intentions the research finds that 10% of patients have a poor outcome.[9]


"I did 30 minutes at physiotherapy on the bike today....tomorrow I plan to use the pedals!"

References

  1. ↑ 1.0 1.1 Healthline. What is Knee Replacement Revision Surgery. Available from: https://www.healthline.com/health/total-knee-replacement-surgery/revision#1 (last accessed 4.3.2019)
  2. ↑ 2.0 2.1 Quinn J, Jones P, Randle R. A reliable surgical approach to revision total knee arthroplasty. Clinics in Orthopedic Surgery. 2022 Jun;14(2):213.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9152900/ (accessed 30.3.2023)
  3. ↑ Omar, I., Kunutsor, S.K., Bertram, W. et al. Rehabilitation for revision total knee replacement: survey of current service provision and systematic review. BMC Musculoskelet Disord 24, 91 (2023). https://doi.org/10.1186/s12891-023-06196-1. Available: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-023-06196-1#citeas ( (accessed 28.3.2023)
  4. ↑ Lützner J, Hübel U, Kirschner S, Günther KP, Krummenauer F. Long-term results in total knee arthroplasty. A meta-analysis of revision rates and functional outcome. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21258774 (last accessed 4.3.2019)
  5. ↑ 5.0 5.1 5.2 Premier Health. Revision Total knee Replacement: getting the facts.Available from: https://www.premierhealth.com/Your-Wellness/Live-Well-Stay-Well/Managing-a-Health-Condition/Spine-and-Joint/Revision-Total-Knee-Replacement-FAQ/ (last accessed 5.3.2019)
  6. ↑ Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. The Journal of bone and joint surgery. American volume. 2012 Oct 17;94(20):1839. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3489068/ (last accessed 5.3.2019)
  7. ↑ 7.0 7.1 7.2 7.3 Orthoinfo. Revision Total Knee replacement. Available from: https://orthoinfo.aaos.org/en/treatment/revision-total-knee-replacement (last accessed 5.3.2019)
  8. ↑ Kretzer JP, Reinders J, Sonntag R, Hagmann S, Streit M, Jeager S, Moradi B. Wear in total knee arthroplasty—just a question of polyethylene?. International orthopaedics. 2014 Feb 1;38(2):335-40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923952/ (last accessed 5.3.2019)
  9. ↑ 9.0 9.1 9.2 The Gold Coast centre for bone and joint surgery. Revision knee replacement. Available from: http://www.gccbjs.com.au/revision-knee-replacement/ (last accessed 6.4.2019)
  10. ↑ Joseph Gondusky,M.D. Revisional Knee Replacement. Available from: https://www.youtube.com/watch?v=ayYTyUdRjrs (last accessed 4.3.2019)
  11. ↑ UMPC. Knee instability and complex revision surgery. Available from: https://www.youtube.com/watch?v=e9An0IzLypQ (last accessed 5.3.2019)
  12. ↑ Swanik CB, Lephart SM, Rubash HE. Proprioception, kinesthesia, and balance after total knee arthroplasty with cruciate-retaining and posterior stabilized prostheses. JBJS. 2004 Feb 1;86(2):328-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14960678 (last accessed 7.3.2019)
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