a Revision Knee Replacement

Revision Knee Replacement

Total knee replacement (TKR), also known as total knee arthroplasty, stands as one of the remarkable success stories in the field of orthopedic medicine. The reason behind its success lies in the remarkable pain relief and the restoration of function that patients often experience post-surgery. Thanks to advancements in implant designs and refined surgical techniques, the majority of TKR patients can anticipate enjoying well-functioning knee joints for a considerable period, typically spanning 15 to 20 years, encompassing more than 85% to 90% of individuals.

However, it's essential to acknowledge that like any medical procedure or implanted device, there may be instances where TKR procedures or implants face challenges and may not endure indefinitely. In such cases, patients may find themselves at a juncture where knee revision surgery becomes a necessary consideration.

What causes a knee replacement implant to fail?

The predominant factors contributing to knee implant complications are wear and instability, infection, loosening, leg fractures, or restricted mobility.

Wear and loosening

The effectiveness of implants relies on their secure attachment to the bone, typically achieved through cementing or biologic fixation, which eliminates the need for cement. Despite initial stability, implants can gradually loosen over time. The causes of loosening may vary, including high-impact activities, excessive body weight, and wear on the polyethylene component. As the implant surfaces wear away due to friction, tiny particles accumulate around the joint, resulting in aseptic (non-infected) loosening. This process can also lead to the digestion of healthy bone (osteolysis), potentially causing bone weakening or fractures. When the prosthesis becomes loose, patients may experience pain, changes in alignment, or instability.

  • Total Knee Replacement, involving the replacement of the entire joint with artificial surfaces.
  • Partial Knee Replacement, which replaces only the damaged compartment of the knee.
  • Infection

    In the realm of medical progress, the risk of infection following a total knee replacement has been significantly minimized to less than 1% thanks to modern surgical techniques and meticulous antibiotic regimens. However, in the unfortunate event that an infection does occur, it can be a serious complication with far-reaching consequences.

    During a total knee replacement, the large metal and plastic implants can potentially become a breeding ground for bacteria to form biofilms. These biofilms create a protective layer that shields the bacteria from antibiotics, making them challenging to eradicate. If an infection takes hold, it can manifest as pain, swelling, and drainage, necessitating revision surgery to address the issue.

    Revision surgery for an infected knee can take various forms, with the surgeon's choice depending on the extent of infection and damage:

  • Simple Washout:In some cases, a straightforward washout of the knee can be performed while retaining the original prosthetic components.
  • Complete Implant Exchange:Alternatively, a full knee revision operation may be required, involving the complete replacement of the implants with new ones.
  • A comprehensive revision for infection can be carried out in one of two ways:a single-stage or two-stage operation, contingent on the severity of the infection and the aggressiveness of the bacteria.
  • Single-Stage Operation:During a single-stage operation, the infected components are removed as part of a thorough debridement, the knee is meticulously cleansed, and new revision components are inserted – all within a single surgical session.
  • Two-Stage Operation:In contrast, a two-stage operation is performed in two separate surgeries spaced several weeks apart. The initial operation involves the removal of the old prosthesis and the placement of an antibiotic-impregnated cement spacer. The second surgery is carried out to remove the spacer and install a new prosthesis. Intravenous antibiotics are typically administered throughout both stages to effectively combat the infection.

  • While infection remains a potential complication, advancements in surgical techniques and infection prevention protocols have significantly reduced the odds of this occurring, ensuring a smoother recovery for most total knee replacement patients.


    Instability in the context of knee joint function can be quite challenging, often stemming from issues with the soft-tissue structures surrounding the knee. This instability occurs when these soft tissues, including the ligaments, cannot deliver the crucial stability required for normal activities like standing and walking.

    Several factors can contribute to knee instability. One common cause is the loosening or laxity of soft tissues around the knee, which may develop over time. Additionally, improper positioning or alignment of the prosthetic knee joint can also lead to instability issues. walking.

    When knee instability becomes a problem, it can manifest as pain and a disconcerting sensation of the knee "giving away" during movement. These symptoms can significantly hinder knee function and overall quality of life.

    In many cases, attempts to address these issues nonsurgically may be made first, such as the use of bracing or engaging in physical therapy to strengthen the supporting muscles and tissues. However, if these conservative treatments fail to provide the necessary relief and stability, revision surgery may become the recommended course of action.

    Revision surgery aims to correct the underlying causes of instability, whether it's addressing soft-tissue laxity, realigning the prosthetic components, or making other necessary adjustments to restore optimal knee function and alleviate the distressing symptoms of instability.

    Leg fractures

    The decision to undergo revision surgery after a knee implant may depend on the type and severity of the fracture involved. Specifically, fractures occurring in the vicinity of the knee implants, known as periprosthetic fractures, can pose significant challenges and may necessitate revision surgery.

    These fractures can adversely affect the fixation and stability of the implant, potentially compromising the overall function and comfort of the knee joint. In such cases, revision surgery becomes a crucial consideration to address the fracture and restore the integrity of the implant.

    The approach to revision surgery will be tailored to the specific nature of the fracture, its location, and its impact on the knee implant. Revision procedures are designed to not only repair the fracture but also to ensure that the implant remains securely in place, facilitating the best possible outcomes for the patient.


    In certain situations, individuals who have undergone a total knee replacement may find that they are unable to achieve the necessary range of motion required for their daily activities. This limitation can occur when excessive scar tissue accumulates around the knee, hindering its full range of motion. When this situation arises, some patients may find relief through a procedure known as knee manipulation under anesthesia.

    During this procedure, the patient returns to the operating room, where the surgeon utilizes manual manipulation to flex and extend the knee, assisting it in regaining flexibility. Although knee manipulation can help some patients overcome motion limitations caused by excessive scar tissue, others may require further intervention.

    For those individuals who have experienced significant impairment in knee motion due to substantial scar tissue build-up and have not achieved satisfactory results through manipulation, revision surgery may be considered. Revision surgery aims to address the underlying issues and provide patients with the opportunity to regain the motion necessary to resume their daily activities with greater ease and comfort.

    What are the risk factors for a failed knee replacement?

    The success of a knee implant can be influenced by various factors, including age, activity level, surgical history, and an individual's weight. These factors can contribute to the risk of implant failure, with certain demographics facing a higher likelihood of experiencing issues.

  • Age:Age plays a crucial role in implant longevity. Younger patients, especially those who are more physically active, tend to place increased stress on their knee prosthesis over an extended period. Consequently, they may have a higher rate of revision surgeries compared to older, less active individuals.
  • Activity Level:The level of physical activity can impact implant performance. Highly active patients, regardless of age, may exert more strain on their prosthetic knee joint, potentially accelerating wear and tear over time.
  • Weight:Obesity can significantly affect implant durability. Heavier individuals experience greater force due to their weight, which can lead to increased wear and loosening of the implant components. Additionally, obese patients are at a higher risk of infections, partly due to challenges in wound healing.
  • Surgical History:Patients with a history of previous knee surgeries face an elevated risk of complications, including infections and implant failure. Prior surgeries can create a more complex surgical environment, making revisions more challenging.

  • Understanding these factors and their potential impact on knee implant longevity is essential for both patients and knee replacement doctors. Tailoring the treatment plan to individual circumstances can help improve outcomes and minimize the risk of implant-related issues.

    What are the signs of knee replacement failure?

    When a knee implant encounters issues, several common symptoms and signs can emerge, indicating a potential problem with the prosthesis. These include:

  • Persistent Pain:Patients may experience ongoing pain in the knee joint, which can be localized to a specific area or more generalized throughout the knee. This discomfort may vary in intensity but typically persists.
  • Reduced Joint Function: A noticeable decline in knee function can become evident, leading to difficulties in performing everyday activities. Patients may develop a limp, stiffness, or instability in the affected knee.
  • Knee Instability:Instability in the knee joint can manifest as a feeling that the knee is giving way or lacks proper support during movement.
  • Swelling and Stiffness:Swelling and stiffness in the knee are common indicators of implant-related problems. These symptoms may contribute to discomfort and limited mobility.

  • These signs and symptoms may raise concerns about the performance of the knee implant and the need for further evaluation and treatment. When a knee implant fails, it typically requires a second surgical intervention, known as Revision Knee Replacement or knee revision surgery.

    Revision surgery involves addressing the issues with the original knee implant, which may include replacing the prosthetic components, addressing any infections, and restoring proper joint function. It aims to provide patients with improved pain relief, joint stability, and overall knee function.

    It's crucial for individuals experiencing these symptoms to consult with their knee replacement doctor for thorough evaluation and appropriate treatment recommendations. Early intervention can lead to more successful outcomes in addressing failed knee implants.

    What is Revision Knee Replacement?

    Revision Knee Replacement, often referred to as a "second knee replacement," is a sophisticated surgical procedure designed to address the issues associated with a failed total knee prosthesis. This complex surgery involves replacing the existing knee replacement components with a new prosthesis. To shed light on this intricate process, it's important to understand the following key aspects:

  • Advanced Preoperative Planning: Successful Revision Knee Replacement begins with meticulous preoperative planning. Surgeons must thoroughly assess the patient's condition, including the reasons for implant failure, extent of damage, and overall health, to develop a comprehensive surgical strategy.
  • Specialized Implants and Tools:Due to the complexity of revision surgery, specialized implants and surgical instruments are often required. These advanced tools are designed to accommodate the unique challenges posed by revising a knee replacement and achieving optimal results.
  • Extended Operating Times:Revision total knee replacement typically involves longer operating times compared to initial knee replacement procedures. This extended duration allows surgeons to carefully remove the existing implant, address any complications, and precisely position the new prosthesis.
  • Expert Surgical Techniques:Performing revision knee replacement demands a high level of surgical expertise and proficiency. Surgeons must navigate challenging anatomical considerations, manage scar tissue and bone loss, and ensure proper alignment and stability of the new implant.
  • Achieving a Positive Outcome:The ultimate goal of Revision Knee Replacement is to provide patients with improved joint function, pain relief, and mobility. This procedure aims to address the issues that led to implant failure and enhance the patient's overall quality of life.

  • It's important to recognize that revision knee replacement is a specialized and intricate surgical intervention that requires a skilled and experienced surgical team. Patients undergoing this procedure can expect thorough evaluation, advanced techniques, and personalized care to optimize the chances of a successful outcome.

    What does the doctor do prior to revision surgery?

    When the decision to proceed with revision knee replacement is reached, the surgeon initiates a comprehensive evaluation process to ensure the best possible outcome. Here are the essential steps in this evaluation

  • Clinical Examination:The surgeon conducts a thorough clinical examination of the patient's knee, assessing various factors such as pain, range of motion, stability, and overall joint function. This examination helps guide the decision-making process.
  • Diagnostic Imaging:To gain a comprehensive understanding of the condition and potential issues, diagnostic imaging is crucial. X-rays play a fundamental role in visualizing the prosthetic components and identifying abnormalities. In some cases, additional imaging modalities such as bone scans, CT scans, or Magnetic Resonance Imaging (MRI) may be recommended to provide a more detailed assessment.
  • Laboratory Tests:Laboratory tests, including blood work and joint fluid analysis, are conducted to detect signs of infection or other underlying conditions. If infection is suspected, the aspiration of joint fluid from the knee may be necessary to identify the specific type of infection.
  • Identification of Bone Loss:In cases where bone loss is suspected or confirmed, advanced imaging and assessments are used to determine the location, extent, and cause of bone loss. This critical information guides the surgical planning process, enabling the surgeon to address bone deficits effectively.
  • Surgical Planning:Armed with a comprehensive understanding of the patient's condition, the surgeon develops a meticulous surgical plan tailored to the individual's unique needs. This plan includes the selection of appropriate implants, surgical techniques, and strategies to address any identified issues.
  • Infection Assessment:If infection is a concern, additional steps are taken to evaluate its presence, type, and severity. Aspiration of joint fluid is performed, and the aspirated fluid is sent to a laboratory for detailed analysis.
  • Decision-Making:Based on the gathered information and evaluation results, the surgeon collaborates with the patient to make informed decisions about the revision knee replacement procedure. This includes discussing the surgical approach, potential risks, and expected outcomes.

  • In summary, the evaluation process for revision knee replacement is a comprehensive and multidisciplinary approach aimed at ensuring the most effective and personalized treatment plan. It involves clinical assessments, advanced imaging, laboratory tests, and thorough planning to address the specific challenges associated with revising a knee prosthesis.

    What happens during knee revision surgery?

    In revision knee replacement surgery, the process involves several key steps to ensure the successful placement of the new prosthesis.

  • Removal of Old Implant: The first and crucial step is the removal of the existing knee implant. This involves careful extraction of the old prosthesis to make way for the new one. This step can be more complex if there has been significant wear, loosening, or bone loss around the implant.
  • Bone Grafts:In cases where bone deterioration has occurred, bone grafts may be necessary to fill voids and restore bone integrity. Bone grafts can be sourced from the patient's own body (autograft) or from another donor (allograft) obtained from a bone bank. These grafts help reinforce the bone structure and provide a stable foundation for the new prosthesis.
  • Reinforcement Techniques:To address extensive bone loss or instability, specialized techniques may be employed. This can include the use of metal wedges, wires, or screws to strengthen the bone and create a more secure environment for the revision knee implant.
  • Placement of Revision Implants:After addressing any bone-related issues, the surgeon proceeds to insert the specialized revision knee implants. These implants are carefully selected to match the patient's unique anatomical requirements and provide the best possible function and stability.
  • Temporary Drains:Temporary drains may be positioned in the surgical site to assist in preventing excessive swelling of the knee. These drains help manage post-operative fluid accumulation and are typically removed a few days after the surgery.
  • Negative Pressure Incisional Dressings:To enhance wound healing and minimize post-operative complications, specialized negative pressure incisional dressings are often applied. These dressings maintain a controlled environment around the surgical incision, promoting healing and reducing the risk of infection. They are typically connected to a portable pump that remains in place for approximately a week to ensure the wound remains protected and dry.

  • The entire process of revision knee replacement surgery is meticulously executed to address the specific challenges posed by the patient's condition. It involves removing the old implant, restoring bone integrity with grafts, reinforcing the bone structure if necessary, and carefully placing the revision implants to restore function and stability. Additionally, measures such as drains and specialized dressings are employed to optimize post-operative recovery and minimize complications.

    What happens after knee revision surgery?

    After undergoing knee revision surgery, postoperative care is a critical aspect of ensuring a successful recovery, and it shares many similarities with the care provided after a primary knee replacement. Here are the key components of postoperative care for knee revision surgery:

  • Physical Therapy:Rehabilitation and physical therapy play a central role in the recovery process. Physical therapy is typically initiated within the first 24 hours following the surgery and continues for an extended period, often up to three months. The focus is on improving joint mobility, strength, and function.
  • Blood Management:Like in primary knee replacement, blood management strategies may be employed to address potential blood loss during surgery. This may include measures to minimize bleeding and, in some cases, the use of blood transfusions.
  • Pain Management:Pain management is tailored to the individual patient's needs. Pain medication is administered as necessary to ensure the patient's comfort during the recovery period.
  • Antibiotics:Prophylactic antibiotics are commonly administered to reduce the risk of infection following surgery. Infection prevention is a critical aspect of postoperative care.
  • Blood Clot Prevention:Measures to prevent blood clots, such as deep vein thrombosis (DVT), are taken. This may involve the use of blood-thinning medications or mechanical devices to encourage blood circulation.
  • Bracing or Splinting: Depending on the specific circumstances of the surgery and the patient's condition, a brace or splint may be utilized to protect the knee joint immediately after the procedure.
  • Recovery Timeline: The recovery timeline can vary from patient to patient, but most individuals can expect to engage in physical therapy for up to three months following knee revision surgery. While some patients may recover more quickly, others may require a longer rehabilitation period.
  • Weight-Bearing and Range of Motion: To promote appropriate healing, some patients may initially need to limit weight-bearing on the operated knee or restrict the joint's range of motion. These precautions are determined based on the individual's condition and surgical approach.
  • Assistive Devices: Early in the recovery process, assistive devices such as walkers or crutches may be necessary to support mobility. As the patient's condition improves, they can transition to using a cane or walking without assistance.

  • Overall, postoperative care following knee revision surgery focuses on optimizing the patient's recovery, managing pain, preventing complications, and gradually restoring function and mobility. It is a comprehensive approach that involves multiple components to ensure the best possible outcome for each patient.

    What are the risks and complications of revision knee replacement?

    Like any surgical procedure, knee revision surgery carries certain risks and potential complications due to its complex nature. It's essential for patients to be aware of these possibilities as they weigh the benefits of pain relief and improved function against the risks. Here are some of the potential complications associated with knee revision surgery.

  • Wound Drainage: Surgical wounds may have drainage, which is typically monitored and managed as part of the postoperative care.
  • Infection: Infections can occur following knee revision surgery. To mitigate this risk, preoperative and postoperative antibiotics are often administered, and strict sterile surgical techniques are employed.
  • Bleeding: While bleeding is a potential complication, it can be controlled during surgery and monitored in the postoperative period.
  • Nerve or Blood Vessel Damage: Due to the complexity of the surgery, there is a risk of damage to nerves or blood vessels. Surgeons take precautions to minimize this risk during the procedure.
  • Intra-operative Fractures: Fractures that occur during surgery are a known risk, but they are addressed and repaired as needed during the procedure.
  • Blood Clots (Deep Vein Thrombosis, DVT): Blood clot formation, particularly deep vein thrombosis, can be a concern. Measures to prevent clots, such as blood-thinning medications and early mobilization, are employed.
  • Pulmonary Embolism: In rare cases, a blood clot can travel to the lungs, causing a pulmonary embolism. Preventive measures are taken to reduce this risk.
  • Swelling: Postoperative swelling around the knee or ankle can persist for several months. It can be managed through techniques like leg elevation, ice application, and the use of compression stockings.
  • Exacerbation of Preexisting Medical Conditions: Some patients may experience exacerbation of preexisting medical conditions, such as heart or lung issues, following revision surgery.
  • Development of New Medical Conditions: In some instances, patients may develop new medical conditions after undergoing revision surgery.

  • It's important to emphasize that while these complications are potential risks, they do not occur in every case. The surgical team takes measures to minimize these risks, and postoperative care is designed to address and manage any complications that may arise. The decision to proceed with knee revision surgery is typically made when the expected benefits, including pain relief and improved function, outweigh the potential risks of complications. Patients are encouraged to discuss any concerns with their knee replacement docotor’s and fully understand the risks and benefits before undergoing the procedure.

    What should you expect after knee revision surgery?

    Patients undergoing revision knee surgery can generally anticipate positive outcomes, with a significant improvement in their quality of life. While expected results typically encompass pain relief, enhanced stability, and improved function, it's important to note that complete pain relief and the restoration of full function may not always be achievable. Here are some key points to consider:

  • Good to Excellent Results: The majority of patients who undergo revision knee surgery can look forward to good to excellent outcomes. These may include reduced pain, increased stability, and improved overall knee function.
  • Residual Pain: It's important to acknowledge that a portion of patients, up to approximately 20%, may still experience some level of pain even after undergoing revision knee surgery. This residual pain can persist for several years post-procedure.
  • Individual Variability: The extent and duration of pain relief and functional improvement can vary from patient to patient. Factors such as the patient's overall health, the condition of the knee prior to revision surgery, and the specific details of the procedure can influence outcomes.
  • Preexisting Knee State: The state and function of the knee before undergoing revision surgery play a significant role in the recovery process. Patients with more compromised knees may face a more challenging rehabilitation journey.
  • Realistic Expectations: It's important for patients to maintain realistic expectations regarding the outcomes of revision knee surgery. While substantial improvements are anticipated, complete pain relief and the restoration of full function may not be attainable in all cases.
  • Postoperative Rehabilitation: The success of the procedure is also closely linked to diligent postoperative rehabilitation. Following the guidance of doctors and engaging in physical therapy exercises can contribute to better outcomes.
  • Long-Term Benefits: Patients should consider the long-term benefits of revision knee surgery. While some residual pain may persist, the overall improvement in knee stability and function can enhance the quality of life for those who undergo the procedure.

  • In summary, revision knee surgery offers the potential for significant pain relief and functional improvement, which can greatly enhance a patient's overall well-being. However, individual experiences may vary, and complete pain relief may not always be achieved. Realistic expectations, along with thorough postoperative care and rehabilitation, are essential components of the revision knee surgery journey. Patients are encouraged to have open and honest discussions with their doctors to better understand what to expect based on their specific circumstances.

    What are the alternatives to revision surgery?

    While revision knee surgery is often the preferred course of action for addressing complex knee issues, there are alternative approaches available, although they are less commonly utilized due to their potential drawbacks. These alternatives are considered in cases where the severity of the knee problem warrants a different strategy.
  • Knee Arthrodesis (Fusion): Arthrodesis involves fusing the knee joint, which can provide pain relief but comes at the cost of permanently immobilizing the knee. This procedure is typically considered when other options have been exhausted, and the goal is to alleviate pain by eliminating joint movement. While it may offer relief from discomfort, it sacrifices the ability to bend or flex the knee joint.
  • Amputation: In extreme cases where the knee joint is severely infected and conventional treatments have proven ineffective, amputation may be considered. Amputation involves the surgical removal of the affected limb, which can be a last-resort measure to eliminate the source of infection and prevent its spread. While amputation is a drastic solution, it may be necessary to save the patient's life when faced with a severe, unmanageable infection.

  • It's essential to emphasize that these alternative approaches are typically reserved for unique and challenging situations, as they involve significant limitations or permanent consequences. Revision knee surgery remains the preferred choice for addressing most knee issues, as it aims to preserve joint function while addressing the underlying problem. Healthcare providers carefully evaluate each case to determine the most appropriate course of action based on the patient's specific condition, overall health, and treatment goals. Patients are encouraged to engage in thorough discussions with their medical team to explore the best options available for their individual circumstances.


    While total knee replacement is generally a highly effective procedure, there are instances where these implants may not perform as expected, leading to the need for revision knee surgery. Identifying signs and symptoms of potential implant failure is crucial in addressing these issues promptly. Several factors can contribute to the failure of knee implants, and understanding these can guide the appropriate course of action. Here are key points to consider:

  • Recognition of Implant Failure: Patients should remain vigilant for signs like increased pain or a noticeable decline in knee function, as these could indicate potential issues with the joint replacement.
  • Causes of Implant Failure: Knee implant failure can occur due to various reasons, including:
  • Infection: Infections can compromise the implant's stability and function.
  • Instability: When the knee's soft tissues are unable to provide adequate stability, instability can affect daily activities.
  • Stiffness: Excessive scar tissue can restrict joint motion, requiring intervention.
  • Wear and Loosening: Over time, wear and loosening of components can lead to instability and pain.
  • Leg Fractures: Fractures around the implant can disrupt its fixation and stability.
  • Revision Knee Surgery: Modern techniques and materials for revision knee surgery have significantly improved outcomes, offering substantial pain relief and enhanced function. However, it's important to note that achieving complete pain relief and restored function may not always be possible.
  • Complexity of Revision Surgery: Revision Knee Replacement is a complex procedure that necessitates the expertise of an experienced surgeon and thorough preoperative planning. Proper evaluation, careful consideration of the patient's unique circumstances, and the use of advanced techniques are crucial for successful outcomes.

  • Patients should maintain open communication with their doctors and report any concerning changes in pain or knee function. Early intervention can help address issues before they escalate and improve the chances of a successful revision knee surgery, ultimately enhancing the patient's quality of life.

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