Artificial Joint Replacement Revision

Overview

Total knee replacement is one of the most successful medical procedures. It allows people to live richer, more active lives free of chronic knee pain in the vast majority of cases. A knee replacement, on the other hand, may fail for a variety of causes over time. Your knee may become painful and swollen as a result of this. It may also feel stiff or unstable, making it difficult to carry out daily tasks.

If your knee replacement fails, your doctor may advise you to have a revision complete knee replacement surgery. During this operation, your doctor will remove some or all of the original prosthetic elements and replace them with new ones.

 

What is knee revision?

The knee implants utilized in 85% to 90% of complete knee replacement patients will survive 15 to 20 years. This means that some younger patients who receive a knee replacement may require a second procedure to clean the bone surfaces and refixate the implants. Others may require that one or more of their implants be completely replaced with new ones. This procedure is known as revision complete knee replacement or knee revision.

The knee joint is replaced with an implant, or prosthesis, comprised of metal and plastic components during primary complete knee replacement. Although the majority of total knee replacements are highly successful, complications such as implant wear and loosening may necessitate a revision treatment to replace the original components over time.

Some knee revisions may necessitate the replacement of only one implant, whilst others necessitate the exchange of all prosthesis inserted during the original knee replacement operation (known as "revision total knee replacement"). This sort of total revision is a demanding treatment that needs substantial preoperative planning, sophisticated implants and instruments, extended operating durations, and knowledge of challenging surgical procedures.

Although both operations aim to alleviate pain and increase function, revision surgery differs from original total knee replacement. To obtain a successful result, it is a longer, more difficult surgery that needs significant preparation as well as specific implants and instruments.

There are several kinds of revision surgery. Only one implant or component of the prosthesis may need to be altered in some circumstances. At times, all three components which are femoral, tibial, and patellar, must be removed or replaced, and the bone around the knee must be repaired using augments (metal pieces that replace missing bone) or bone transplant.

The clinician may be unable to utilize normal complete knee implants for revision knee replacement due to bone damage. For added support, he or she will usually employ customized implants with longer, thicker stems that fit deeper within the bone.

 

Why Hip Replacements Wear Out?

Hip replacements can fail for a number of reasons. Aseptic loosening is the most prevalent reason of a hip replacement failing. 3 When hip implants become loose within the bone, this is known as aseptic loosening. A loose hip implant is frequently uncomfortable and necessitates a revision hip replacement.

Infection, breaking of the prosthesis, breaking of the bone around the prosthesis, and other problems are other causes of a hip replacement wearing out. Treatment other than revision hip replacement may be required depending on the cause of the implant failing. In the event of an infection, for example, the hip replacement may need to be removed to treat the infection, followed by the revision hip replacement months later.

 

When Revision Total Knee Replacement is Recommended?

• Implant Loosening and Wear

An implant must remain securely linked to the bone for a complete knee replacement to operate effectively. The implant was either cemented into the bone or press-fit to allow bone to grow onto the surface of the implant during the initial operation. In either case, the implant was securely in place. However, with time, an implant may break free from the underlying bone, producing discomfort in the knee.

High-impact activities, extra body weight, and deterioration of the plastic spacer between the two metal components of the implant are all variables that may lead to loosening. Furthermore, individuals who are younger at the time of their original knee replacement may "outlive" the life expectancy of their prosthetic knee. These individuals are at a higher long-term risk of requiring revision surgery owing to loosening or wear.

Tiny particles that wear off the plastic spacer collect around the joint in some situations and are targeted by the body's immune system. This immune reaction also affects the healthy bone surrounding the implant, resulting in osteolysis. The bone around the implant deteriorates during osteolysis, causing the implant to become loose or unstable. Osteolysis is less prevalent today than it was in previous decades due to advances in material science and plastic quality.

• Infection

Infection is a risk in every surgical operation, including total knee replacement. Infection might happen while you're in the hospital or after you leave. It might happen years later.

If an artificial joint becomes infected, it may stiffen and become uncomfortable. The implant's connection to the bone may deteriorate. Even if the implant is adequately secured to the bone, discomfort, swelling, and drainage from the infection frequently necessitate revision surgery. Revision for infection can be accomplished in one of two methods, depending on the kind of bacteria, length of illness, degree of infection, and patient preferences.

• Debridement and implant retention. In some cases, the bacteria can be washed out, the plastic spacer can be exchanged, and the metal implants can be left in place.
• Staged surgery. In other cases, the implant must be completely removed. There are two types of staged surgery:
• The implant is removed in two stages, the joint is rinsed out, and a temporary cement spacer is inserted in your knee. This spacer is antibiotic-treated to combat infection and will remain in your knee for several weeks. You will also be given intravenous antibiotics at this period. When the infection is gone, your doctor will conduct a second operation to remove the antibiotic spacer and replace it with a new prosthesis.
• A 1-stage surgery, which is less common, removes the implant, washes out the joint, and replaces it all within the same procedure. Following that, intravenous antibiotics are administered.

Your doctor will consult with you to determine which choice is best for you. Removing the implant increases the chances of healing the infection, but comes with a lengthier recovery time.

• Instability

Your knee may become unstable if the ligaments around it become injured or out of balance. Because most implants are intended to interact with the patient's existing ligaments, any alterations in those ligaments may cause the implant to malfunction. You may notice recurring swelling and a sensation that your knee is "giving way." If nonsurgical treatments such as bracing and physical therapy are ineffective, revision surgery may be required.

• Stiffness

A complete knee replacement may not always provide the range of motion required to conduct daily activities. This might develop if scar tissue has accumulated around the knee joint. If this happens, your doctor could try manipulation under anaesthetic.

You are given anaesthetic throughout this treatment so that you do not experience any discomfort. The doctor will then attempt to break up the scar tissue by bending your knee. In the majority of instances, this surgery improves range of motion. However, the knee might get stiff at times. If you have substantial scar tissue or the location of your knee components is restricting your range of motion, revision surgery may be required.

• Fractures

A periprosthetic fracture happens when a bone breaks near the components of a total knee replacement. These fractures are frequently the consequence of a fall and need revision surgery.

Your doctor will examine many aspects when deciding the amount of the revision required, including the quality of the remaining bone, the kind and location of the fracture, and if the implant is loose. When the bone is broken or weakened as a result of osteoporosis, the damaged part of bone may need to be replaced entirely with a bigger revision component.

 

Preparing for Surgery

Several weeks before revision surgery, you will be asked to schedule a comprehensive physical examination with your primary care doctor. This is required to ensure that you are in good enough health to have surgery and recover fully. Patients with chronic medical issues, such as heart disease, may also be assessed by a specialist before surgery, such as a cardiologist.

Tests

Imaging tests. Your doctor will usually order imaging tests to learn more about the condition of your knee.

• X-rays. These show photos of thick structures like bone. Your doctor may request x-rays of the joint replacement region to check for loosening or changes in the location of the components.
• Other imaging studies. A nuclear medicine bone scan may be used to assess whether the prosthesis has become free from the bone. A magnetic resonance imaging (MRI) scan or a computed tomography (CT) scan may be performed in some circumstances to assist discover why your knee has failed and to offer further information about the bone's state.
• Laboratory tests. Your doctor may prescribe blood tests to check whether you have an infection. He or she may aspirate your knee as well. In this treatment, joint fluid is extracted using a needle and syringe and tested in a laboratory to identify the presence of infection.

 

Home Planning

Because your movement will be limited following surgery, you may require assistance with duties such as cooking, shopping, bathing, and laundry for many weeks if you live alone.

Your doctor's office, a social worker, or a hospital discharge planner can aid you in making early plans to have someone support you at home. Depending on your condition, you may need to spend some time in a nursing home or rehabilitation center when you leave the hospital. If necessary, your healthcare team can assist you in arranging for a short stay in an extended care facility throughout your recuperation.

 

Surgical Procedure

You will either be admitted to the hospital or discharged the same day as your procedure. Before your operation, talk with your doctor whether you want to be hospitalized or go home.

• Anesthesia

You will be assessed by a member of the anesthesia team prior to surgery. General anesthesia (putting you to sleep) or spinal, epidural, or regional nerve block anesthesia are the most frequent forms of anesthetic (you are awake but your body is numb from the waist down). The anesthesia experts will decide which form of anesthesia is ideal for you based on your feedback.

• Procedure

Revision total knee replacement is more complicated and time-consuming than original total knee replacement. The procedure may take many hours in severe circumstances.

To begin, your doctor will trace the incision line from your original total knee replacement. However, the incision may be longer than the original to allow for the removal of the old components. After making the incision, the doctor will pull the kneecap and tendons to the side, revealing your knee joint.

Your doctor will inspect the soft tissues of your knee to ensure they are infection-free. He or she will examine all of the prosthesis's metal and/or plastic components to discover which have gotten worn, loose, or moved out of position.

If required, your doctor will gently remove the original implant to preserve as much bone as possible. If cement was utilized in the first complete knee replacement, it is also removed. Removing this cement from the bone is a time-consuming operation that adds to the revision surgery's complexity and duration.

Your doctor will prepare the bone surfaces for the revision implant after removing the initial implant. There may be substantial bone loss around the knee in rare situations. If this happens, metal augments and platform blocks can be added to the primary components to compensate for bone inadequacies.

 

Why Revisions are Complex?

Revision hip replacements are more difficult operations, and the results may not be as excellent as the original hip replacement. The quality of the bone and the capacity to effectively hold the revision hip replacements into position are also challenges during surgery. Additionally, removing the prior hip replacement may entail more invasive surgery.

These issues, when combined, frequently necessitate a considerably more complicated revision hip replacement. Your orthopedic surgeon must prepare carefully to guarantee that they can create a hip that will allow you to function normally.

Another issue with revision hip replacement is that the procedure itself might be more difficult. Patients are often older and less tolerant of lengthy surgical procedures. The technique is technically more complex than primary hip replacements, and the patient's consequences are more severe (longer surgery, more blood loss(

As a result, revision hip replacement must be properly planned and executed. The involvement of general practitioners, anesthesiologists, and orthopedic surgeons is critical.

 

Knee Revision Recovery

The recovery period for knee revision surgery is not as set as it is for first knee replacements and can vary greatly from person to person. It might take up to a year to fully recover.

Three to six months following surgery, most people will feel comfortable returning to work and continuing some of their typical activities. Physical rehabilitation can usually begin two weeks after knee revision surgery. Exercises will be designed by your physical therapist to improve your range of motion, strength, and gait. Our objective is to gradually transition you from a walker to a crutch, then to a cane, and then to walking without help.

The majority of patients who have revision surgery have positive long-term results, including pain alleviation and enhanced stability and function. However, complete pain alleviation and function restoration are not always possible, and some patients may still feel discomfort or knee stiffness after revision surgery.

 

Knee Revision Complications

A revision operation sometimes takes longer than the initial joint replacement treatment, increasing the risk of complications. Following hip or knee revision surgery, you may have the following complications: 

• Infection - There is a danger of infection whenever you have surgery, and serious consequences from infection can be catastrophic or even life-threatening. If you are more susceptible to infection, the advantages of a total hip or total knee replacement may not exceed the dangers.
• Blood clots - You may be restricted in your activities while recovering after revision surgery. This increases your chances of getting a blood clot, including a potentially fatal pulmonary embolism (blood clot in the lungs).
• Dislocation or injury - Hip or knee revision surgery may not address the problem and may even cause more damage or instability in the joint, as well as harm to the nerves and blood vessels in the region of the prosthesis.
• Joint stiffness and mobility issues – Recuperating from a revision hip or knee replacement is more difficult and time-consuming than recovering from the original joint replacement surgery. This can result in joint stiffness, movement limitations, and other issues.
• Health hazards in general - Surgical treatments and rehabilitation can place additional strain on your heart and body. It may also expose you to a hospital setting, where you may develop other infections such as pneumonia.

To choose the best course of action, your orthopedic surgeon will go through all of the hazards with you. He or she will also advise you on how to prepare for surgery in order to minimize your risks as much as feasible.

 

Conclusion 

A revision hip replacement operation replaces a worn-out or faulty hip replacement device. Hip replacements are among the most frequently done surgeries by orthopedic surgeons. In the great majority of patients, this procedure is quite successful and yields good results. Despite this, hip replacements can break down over time.