Total knee joint replacement - revision

The results of a total knee joint replacement are often excellent. Most artificial knee joints last 10 to 15 years. Some last as long as 20 years before they loosen and need to be replaced again. Revision of knee joint replacement may either require replacement of the whole prosthesis or some of its parts.

You will not feel any pain during the surgery. You will have one of these two types of anesthesia:

• General anesthesia -- This means you will be asleep and unable to feel pain.
• Regional (spinal or epidural) anesthesia -- Medicine is put into your back to make you numb below your waist. You will also get medicine to make you sleepy. And you may get medicine that will make you forget about the procedure, even though you are not fully asleep.

After you receive anesthesia, your surgeon will:

• Make an incision following the same line used for the primary (initial) knee replacement surgery.
• Assess the soft tissues for any infection.
• Examine all the metal and plastic parts of the prosthesis to check if any part is worn, loose, or dislocated.
• Remove the existing implant, if required.
• Remove cement, if it was used in the primary surgery.
• Reconstruct damaged bone around the knee, if there is significant bone loss. For reconstruction, metal parts or blocks (augments) are used or a bone graft is done to give strength to the bone.
• Insert specialized implants instead of standard knee implants. They are designed to make up for the damage to the soft tissue and bone around the prosthesis. They can be placed deeper in the bone for greater support.
• Place a temporary drain to collect extra blood or fluid to prevent extreme swelling.

Total knee joint replacement revision takes longer to perform than primary total knee joint replacement. The surgery usually lasts 2 to 3 hours. In complex cases, it may take even longer.

The two most common reasons revision surgery may be needed are infection and instability of the joint.

Infection can occur:

• Right after surgery
• Days or weeks after you go home
• Years later, in some cases

Instability of the joint may be caused by:

• Injury to the ligaments around the knee
• Fracture in the bones around the joint, often due to a fall or arthritis
• Wearing down of the implant itself

Other factors leading to revision surgery include loosening of the implant and stiffness and swelling.

Loosening of the implant may be due to:

• High-impact activities
• Trauma
• Excess body weight
• Bone degeneration around the implant (osteolysis), which happens less often than in the past

Stiffness and swelling can be caused by a build-up of scar tissue (arthrofibrosis) in the knee.

People at a higher risk of needing revision surgery include:

• Younger, more active people. They may put extra stress on the artificial knee and cause it to wear out early and not last as long.
• People who have had an artificial knee joint for 10 years or longer. Most artificial knee joints last 10 to 15 years. Some last as long as 20 years before they loosen and need to be replaced again.

You will have a complete physical examination several weeks before the revision surgery. This is to check if you are healthy enough for the surgery. If you have diabetes, heart disease, or other medical conditions, your surgeon may ask you to see the health care provider who treats you for these conditions to see if it is safe for you to have the surgery.

You will have imaging tests to check the condition of your knee and the extent of bone loss around the implant:

• X-rays
• CT scan
• MRI

Imaging tests help to determine if there is loosening or other mechanical problems of the prosthesis or its parts.

Your surgeon may order blood tests to determine if you have an infection. Aspiration of knee joint fluid may be done to check for infection.

You may need to make some changes before the surgery.

• Tell your surgeon or nurse if you are taking any medicines, including any drugs, supplements, or herbs you bought without a prescription.
• Tell your surgeon if you have been drinking a lot of alcohol, more than 1 or 2 drinks per day.

If you smoke, you need to stop. Ask your providers for help. Smoking will slow down wound and bone healing. Your recovery may not be as good if you keep smoking.

During the week before your surgery:

• Prepare your home ahead of time.
• You may be asked to temporarily stop taking medicines that keep your blood from clotting. These medicines are called blood thinners. This includes over-the-counter medicines and supplements such as aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and vitamin E. Many prescription medicines are also blood thinners.
• You may also need to stop taking medicines that can make your body more likely to get an infection. These include methotrexate, etanercept (Enbrel), or other medicines that suppress your immune system. Make sure you ask your surgeon when it is safe to resume taking these medicines.
• Ask your surgeon which medicines you should still take on the day of your surgery.
• Always let your surgeon know about any cold, flu, fever, herpes breakout, or other illness you have before your surgery.
• You may want to visit a physical therapist to learn some exercises to do before surgery.
• Ask your provider whether you need to go to a nursing home or rehabilitation facility after surgery. If you do, you should check out these places ahead of time and note your preference.

Practice using a cane, walker, crutches, or a wheelchair correctly to:

• Get in and out of the shower
• Go up and down stairs
• Sit down to use the toilet and stand up after using the toilet
• Use the shower chair

On the day of your surgery:

• Follow instructions about when to stop eating and drinking.
• Take the medicines your surgeon told you to take with a small sip of water.
• Arrive at the hospital on time.

After your revision surgery, you will stay in the hospital for several days. The type of care you will receive will be similar to the care you received after your primary knee replacement surgery.

Physical therapy will be started as soon as the first day after surgery and will continue for up to 3 months. You will require a walker or crutches during the recovery phase. As your condition improves, you may use a cane or walk without any aid.

Recovery after revision surgery takes longer than recovery after primary knee replacement surgery. Complete recovery will take 3 months to a year.

Some people need a short stay in a rehabilitation center after they leave the hospital and before they go home. At a rehab center, you will learn how to safely do your daily activities on your own.

Total knee joint replacement revision is a complex surgery. Certain complications are more common after revision surgery than the primary surgery, such as:

• Fractures
• Infection
• Loosening and instability of the prosthesis
• Damage to nerves or blood vessels

Revision surgery will help relieve your pain and improve your knee stability and function. However, because it is the second replacement, you may still have some pain or instability following revision surgery.

Revision knee arthroplasty; Total knee implant revision; Total knee replacement revision; TKA - knee replacement revision

Ellen MI, Forbush DR, Groomes TE. Total knee arthroplasty. In: Frontera, WR, Silver JK, Rizzo TD Jr, eds. Essentials of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, PA: Elsevier; 2019:chap 80.

Mihalko WM. Arthroplasty of the knee. In: Azar FM, Beaty JH, eds. Campbell's Operative Orthopaedics.14th ed. Philadelphia, PA: Elsevier; 2021:chap 7.

Updated by: C. Benjamin Ma, MD, Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery, San Francisco, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.