Revision Knee Joint Replacement

What to Expect Pre & Post Surgery- Revision Total Knee Replacement

Prior to the surgery itself, Nigel may or will ask you to see:

Physiotherapist

  • This is to give you exercises to do before the operation.
  • To optimise the muscles around your knee, the knee itself, 
your core strength
  • To get an idea of what help you may need when you leave hospital.
  • To give you an idea of what is expected of you when you leave hospital.
  • For follow-up after you leave hospital.

Anaesthetist

  • To make sure that the anaesthetic planned for you is safe.
  • That all your medical conditions if you have any are being well managed.
  • To discuss with you risks of anaesthesia and minimise your risk of any complication following surgery.

Physician

  • Not everyone will need to see a physician.
  • If you do it is to make sure that you are on the correct medication.
  • That your medical condition/s are optimised for surgery.
  • That the surgery can be carried out at the appropriate hospital.
  • To minimise any risk to you.

Nigel may require you to have:

  • Up-to-date x-rays of your knee (if more than 3 months)
  • A MRI scan, CT scan, or a Bone Scan
  • Blood tests

Nigel will also ask for your consent to get your original operation report as this will help with planning and preparation for revision surgery.

Medications

Before the operation it is important to tell Nigel, the Anaesthetist, and if you have seen a physician what medications you are taking. If you are taking a medication particularly one that affects blood clotting such as:

  • Aspirin

  • Warfarin

  • Clopidogrel

Aspirin does not need to be stopped but Warfarin and Clopidogrel do need to be.

If you have a history of blood clots the medical team needs to know as we will have to take important steps to make sure that your blood is thinned enough to stop clots from occurring.

All other medications need to be mentioned even natural remedies as they can interfere with medication being given to you in hospital, such as antibiotics, painkillers and anti-inflammatories.

Length of Stay Revision Total Knee Replacement 


You will be in hospital for up to 7 days generally. This is only a guide. There is no race. You have to be safe before you are sent home. To be safe you need to be independent with:

  • Mobilisation (this will be with crutches or on a frame)
  • Dressing
  • Toileting / Showering / Bathing
  • Getting into and out of a bed and chair
  • Able to stand for periods of time


The Physiotherapists are the most important people in the immediate post-surgery 
phase to get your knee moving and your leg working.

What to Expect - Day of Surgery

  • Do not have anything to eat or drink within 6 hours of your operation. If you do there is a good chance your operation will not be performed on that day and will have to be rescheduled.
  • The nursing staff will make sure that all x-rays, blood tests, and medications are present. That all pre-surgery protocols are followed. The area being operated on will be shaved, washed and prepped.
  • You will be asked many times what operation you are having done. This is so that no mistake is made.
  • Nigel will meet with you, will mark the operation site, make sure the consent form is signed, ask you if you have any questions, will check to see that next of kin details are correct so he can call after the operation is performed.
  • It is completely normal to be nervous, and anxious, but if you feel that things are getting on top of you, please inform a staff member, because we will be able to give you a medication to help calm you. 


What to expect - Immediately after the operation

  • Your knee may be painful even with the anaesthetic given and also the injection of local anaesthetic around your knee.
  • Your knee will be wrapped up in a big bandage.
  • There will be a drain coming out of your knee.
  • You may have a catheter in your bladder so you do not require a bed-pan or urine bottle.
  • You will have a line going into one of your veins.
  • You will have compression stockings on both legs with mechanical pumps helping blood flow in your calf muscles.
  • You will spend a period of time in recovery before being transferred back to 
the High Dependency Unit (HDU).

What to expect - On the ward (day 0)

A nurse will be looking after you:

  • Your observations will be monitored including:
  • Heart / Pulse rate
  • Blood pressure
  • Breathing rate
  • Pain score
  • Warmth / colour / sensation of the operated limb
  • Fluid input and output

You will be offered pain relief.
You will be given:

  • Antibiotics
  • Blood thinning medication
  • Pain relief if you request it
  • ICE for your knee

A Physiotherapist will come and see you and if your observations have been good, will get you to stand and maybe take a couple of steps.

Nigel will come to see you at the end of his operating list and tell you how the operation went.

What to expect - Day 1

  • In the morning Nigel will see you.
  • The nursing staff will continue to monitor you.
  • Blood tests will be done.
  • X-rays will be done.
  • The drain will be removed.
  • The catheter will be removed if you are male (females day 2 or 3).
  • Antibiotics may stop.
  • Blood thinning medication will continue.
  • ICE treatment will continue on your knee.
  • The physiotherapist will start moving you, and your knee.
  • If one of the blood tests comes back low (haemoglobin) you may need to have a blood transfusion.

What to expect - Day 2 – Discharge

  • The expectation is that each day you will do a bit more every day.
  • There are going to be times where you feel fantastic and may do too much.
  • There are going to be times when you feel sore, sick, or lethargic and do not do enough.
  • Your pain will develop day 2 but hopefully will be controlled with oral pain-killers (it is still going to be sore though).
  • Your movement will increase both from a knee perspective but also you moving around your room and the ward.
  • You will progress from a frame to crutches (not everybody though).
  • You will become more independent. 


What to expect - Day of discharge

  • You will need to be able to get yourself toileted, showered, dressed and in-out of bed.
  • You will be given an appointment card to see Nigel at the 6-week mark.
  • You can get in contact with Nigel’s rooms at any stage if you have any 
concerns or issues. Please do not hesitate to do so.
  • You will be asked to see the practice nurse at your local GP 10-14 days post 
surgery to have any clips, along with a wound check.
  • The physiotherapist will ask you to make contact with your physiotherapist to 
continue rehabilitation.
  • Some people will instead of going home go to a rehabilitation facility for further convalescence. 


What to expect - First 6 weeks

  • Pain will improve.
  • Movement will increase.
  • Independence will return.
  • Continue with ICING of the knee.
  • You will start to feel better about having had the knee replacement done.
  • You may find that you can walk without a crutch or both of them.
  • YOU CANNOT DRIVE FOR THE FIRST 6 WEEKS no negotiation if the RIGHT knee has been replaced.  If the LEFT knee has been replaced you may be able to drive an automatic at the 4 week mark. If you have any concerns, do not drive until seen by Nigel in clinic. If you are unsure, you can contact your motor vehicle insurer to see if you are covered or not.
  • Nigel will see you at the 6 week mark and at that stage will hopefully be able to give you indications regarding:
  • Driving
  • Work
  • Return to activities
  • Medication
  • Use of walking aids

What to expect - 6 weeks to 1 year

You need to be aware that your revision total knee joint replacement will result in slightly poorer function and there may be more pain than when you had your original total knee joint replacement. It will take a good 6 months for you to forget you have had a revision knee replacement. Minimal or no pain relief will be required. You should have returned to all your previous work, leisure, daily activities.

Nigel’s expectations 


I expect you with a revision total knee joint replacement to have a nearly completely pain free knee that moves at the same degree maybe slightly worse than what you had prior to the original operation. To have a knee replacement that allows you to do all your daily activities, and most low impact leisure activities, without feeling pain, giving you the freedom in your life, to recapture and enjoy your life, those around and close to you, without worrying about your knee.

Patients reactions 


It is difficult to know who will do well and who will not do well. It never fails to amaze me how when I think someone will do well and they do not and then when you are dreading the result of someone else that they do well. I believe in providing a well informed approach is the key to how well a patient does, giving them no illusions, being realistic, and providing plenty of encouragement to the patient from all members of the team. As many patients tell me, it is there knee, if they want to do well, they will. I also believe that it is important for you to discuss with your family, and your friends that you are having a revision total knee replacement and to ensure that you have the appropriate level of help and care on discharge. You will remember what it was like after the operation with your original total knee joint replacement.

How long will it last?

Revision total knee joint replacement does not last as long as total knee joint replacement. Like primary total knee joint replacement there are many different types of revision total knee joint replacement available. Giving specific percentages is difficult given the different combinations and different types of revision that are done, but a figure of approximately 80% are successful at 7 years according to the Australian Orthopaedic Association Joint Registry.

Complications

As with any surgical operation the benefits of the operation do far outweigh any risks, but there is always a potential for complications to arise, Orthopaedic or otherwise. These complications are increased further with any form of revision surgery. Nigel will discuss the Orthopaedic complications of your operation when he consents you outlining in detail what these are and when they are likely to occur. He will give a general complication rate but will also mention his complication rate for the procedure that you are having performed.

Infection

Perhaps the most devastating of all complications particularly so in revision total knee joint replacement.

Around 3-5% (including skin infection likely to be 6-7%).

Infection may include the skin or incision which can be treated with oral antibiotics.

Deep infection (that is infection in your new knee joint) although around 3-5% is the most devastating outcome for both the patient and Nigel. It has been estimated that each knee joint replacement infection in the USA costs $400,000 - $800,000 to treat.

Deep Vein Thrombosis (DVT)

  • Is a Blood clot in a vein of the leg or thigh.
  • 20-40% of all patients having a knee replacement - Seen on ultrasound scans 
of the thighs/leg veins.
  • Well over 90% of patients and staff are not aware that a DVT may 
have occurred.
  • Not all DVTs need to be treated with medication.
  • If a DVT occurs you will be put on a medication that helps to thin the blood
and break down the clot.

To prevent a DVT from occurring Nigel will assess your risk profile for DVT and grade you high, medium, or low risk according to the American Academy of Orthopaedic Surgeons guidelines on DVT prevention. Once this assessment is completed you will either be given aspirin, or a tablet or injection of an anti-coagulant (blood thinning) medication whilst in hospital and on discharge from hospital.

  • All patients who take aspirin are to keep taking their aspirin.
  • If you are on warfarin then you will need to stop 5 days prior to surgery.
  • If you are on Clopidogrel you will need to stop at least 5 days prior to surgery.

Nigel may need to discuss your medication use with your GP, cardiologist, or physician before deciding on the best approach at aiming to reduce the risk of a DVT developing.

Pulmonary Embolus (PE)

  • This is a blood clot in the lung.
  • This occurs in 1/500 patients having a knee replacement (0.2%).
  • Unfortunately in 1/1700 patients the PE will result in death (0.06%).
  • All PE’s are treated with an injection in the short term and with warfarin long 
term.

Aseptic loosening

  • This refers to the lifetime or potential survival of your prosthesis.
  • There are lots of reasons why your knee replacement may not last or fail.
  • As mentioned previously, generally speaking there is an 80% success rate at 7 
years for all types of revision total knee joint replacement.

Pain

  • All patients will have pain immediately following knee replacement.
  • More patients have pain after revision surgery than the initial knee replacement.
  • This pain may persist for a longer period of than the original replacement.
  • Nigel will detail in no uncertain terms that there may be an element of pain with your revision total knee joint replacement that could last for 12-18 months.

Stiffness / Lack of Movement

  • This is a problem in revision total knee joint replacement. If your revision is being done as a result of stiffness or lack of movement you will have more movement after revision surgery.
  • Nigel will outline to you what his expectations for movement are following your joint replacement.
  • If you lose movement, then a manipulation of your knee under a general anaesthetic will need to be performed to break down the scar tissue that has formed so as to give you that movement back.

Swelling

  • Following your joint replacement your thigh, leg, and foot will swell.
  • The swelling will persist for up to 6 months.
  • Your knee will always look more swollen than the other
knee.
  • For some people there will be a persistent swelling in the knee joint. This should 
be assessed either by Nigel or your GP to rule out infection or a problem with the knee replacement.

Damage to nerves and blood vessels

  • Seventy percent of people at one year will have numbness on the outside part of their knee following total knee joint replacement. This occurs because small nerves that are involved with touch need to be cut to do the knee replacement. You should not notice any difference after your revision total knee joint replacement.
  • 1-2% of patients having a revision knee replacement will have an injury to the nerves and blood vessels at the back of the knee. In revision total knee joint replacement this number is higher because of scar tissue and adhesions. This is a serious complication, but thankfully occurs incredibly rarely.

General Risks

There are general risks of having a knee replacement that are non-orthopaedic related. Your Anaesthetist will be the best person to answer these questions but generally include:

  • Stroke
  • Heart-attack
  • Death
  • Post-surgery confusion
  • Not being able to empty the bladder