Complex Revision Total Knee Replacement

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Introduction

A total knee replacement is a highly successful procedure that provides relief from chronic knee problems, allowing individuals to lead a pain-free life. However, in some cases, the original knee replacement may fail to function correctly, resulting in persistent pain, swelling, and difficulty performing everyday tasks. In such situations, patients may require a second operation called complex revision knee replacement, which involves removing and replacing some or all of the original implant components with new ones.

Revision surgery is a more complex operation that requires expertise, thorough planning, and specialised tools and implants.

Prof Munjed Al Muderis has extensive experience with thousands of knee surgeries and has achieved unmatched and extremely low complication and infection rates. Patients can request the professor’s data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) or the data of any other surgeon they may be considering for their care.

Indications and Contraindications

Indications for Complex Revision Total Knee Replacement:

Implant Failure: Complex revision total knee replacement is typically indicated when the primary knee replacement components have worn out, loosened, or failed, leading to persistent pain, instability, and decreased function.
Infection: In cases of deep or chronic infection in the knee joint, a revision surgery may be necessary to remove infected components and address the infection.
Instability or Malalignment: Patients experiencing recurrent knee instability or implant malalignment that significantly affects joint function and stability may require complex revision surgery.
Periprosthetic Fractures: Complex fractures around the knee implant that compromise the stability of the joint may necessitate revision surgery.
Extensive Bone Loss: Severe bone loss or compromised bone quality around the knee joint can make complex revision surgery necessary to provide stability for the new components.

Contraindications for Complex Revision Total Knee Replacement:

High Surgical Risk: Patients with significant underlying medical conditions that make surgery extremely high-risk, such as severe heart or lung disease, may not be suitable candidates for complex revision total knee replacement.
Active Infection: Ongoing infection in the knee joint is a contraindication, as it increases the risk of implant contamination and infection recurrence.
Severe Bone Loss: In cases where bone loss is so extensive that it limits the feasibility of revision surgery, impairing the stability of new components, complex revision may not be appropriate. Other reconstructive procedures may be considered.
Poor Overall Health: Patients in poor overall health or with limited life expectancy may not be ideal candidates for complex revision surgery.
Unrealistic Expectations: Patients with unrealistic expectations regarding the outcomes of the revision surgery may not be good candidates if their expectations cannot be managed or met.

The decision to pursue a complex revision total knee replacement should be made after a thorough evaluation by a healthcare professional, taking into account the individual patient’s specific medical history, condition, and overall health.

Benefits and Risks

Benefits of Complex Revision Total Knee Replacement Surgery:

Improved Functionality: Revision surgery aims to restore knee joint function, reducing pain and improving mobility, allowing patients to engage in daily activities more comfortably.
Correcting Implant Issues: Complex revision surgery can address issues such as implant malalignment or instability that may have resulted from the original knee replacement.
Infection Resolution: In cases of infection, revision surgery can remove infected components, clear the infection, and install new components to re-establish joint function.
Pain Relief: Patients often experience significant pain relief, particularly if their primary knee replacement was causing discomfort due to implant issues.
Bone Preservation: When possible, complex revision surgery aims to preserve as much healthy bone as possible to support the new components.

Risks of Complex Revision Total Knee Replacement Surgery:

Surgical Complexity: Revision surgeries are typically more complex and challenging, which may lead to longer operative times and increased surgical risks.
Limited Implant Longevity: The longevity of revised knee implants may not be as long as that of primary implants, and patients may require additional revisions in the future.
Infection Risk: There is a risk of post-operative infection, which may necessitate further surgery or prolonged antibiotic treatment.
Implant Wear and Loosening: The new implant components may also wear out or become loose over time, requiring further revisions.
Nerve or Blood Vessel Damage: Injury to nearby nerves or blood vessels during surgery is a potential risk, although it is relatively rare.
Bone Loss: In some cases, bone loss can be so severe that it limits the ability to anchor new components securely.
Functional Limitations: Some patients may experience residual functional limitations or require more extensive post-operative rehabilitation due to the complexity of the surgery.

Patients considering complex revision total knee replacement should have a thorough discussion with their healthcare provider to understand the potential benefits and risks, with decisions based on their individual medical history and the nature of their knee condition.

Surgical Approach

At our clinic, we employ a technology-driven approach, advanced imaging, CT scans, and 3D technology to create the best-fitting implants for each patient. We aim to provide the highest quality implementation using 3D modelling and printing technology to guide us.

Pre-surgery Information

The following is what can be expected before a complex revision total knee replacement surgery:

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

A revision knee replacement is a more complex operation than a primary total knee replacement, requiring more time.

Anaesthesia is given either locally or general, for the patient’s safety and comfort.

The surgeon begins by following the incision line from the patient’s initial knee replacement surgery. In some cases, the incision may need to be lengthened to facilitate the removal of the original components.

The knee joint is checked for any signs of infection or adverse reactions to the metal components. The condition of the existing implant is inspected for wear and tear, loosening, or movement. Implant is then removed, together with cement, preserving as much bone tissue as possible. It is a time-consuming and meticulous process.

In some cases, there may be a significant lack of bone in the knee area due to complications from the previous surgery. To address these bone deficiencies, the surgeon may add metal augments and platform blocks to the main components of the revision implants.

Lastly, the surgeon will insert specifically tailored revision implants based on the 3D modelling conducted by the surgical team before surgery. This personalised approach ensures a precise fit of the implant to the individual patient and a better outcome.

Final Steps

Once the revision implants are in place, the surgeon carefully evaluates the joint motion to ensure that the implants are securely positioned. Special screws may be used to stabilise the fresh components until the bone fully grows around them.

Post-Surgery Information

Post-surgery care following Complex Revision Total Knee Replacement is crucial to ensure a smooth recovery and the best possible outcomes. Here are key aspects of post-surgery care:
Immobilization and Weight-Bearing: Patients are typically encouraged to begin weight-bearing on the operated leg soon after surgery. The use of assistive devices, such as crutches or a walker, is common initially to promote stability and prevent complications.
Pain Management: Medications are prescribed to manage post-operative pain. Patients should adhere to the prescribed regimen and promptly report any concerns about pain control to their healthcare provider.
Physical Therapy: A structured physical therapy program is essential to improve strength, flexibility, and joint mobility. Patients are encouraged to actively participate in rehabilitation and adhere to the recommended exercises.
Wound Care: Proper care of the surgical incision is vital. Patients should keep the wound clean and dry, inspect for signs of infection, and follow the surgeon’s instructions for dressing changes.
Activity Restrictions: Patients should adhere to activity restrictions, especially during the early recovery phase, to avoid strain on the newly revised knee joint.
Follow-Up Appointments: Regular follow-up appointments with the surgeon are essential to monitor progress, assess the surgical site, and address any concerns or complications.

- 1 week postop: for wound check,

- 2 weeks postop: for suture removal
- 6 weeks postop: for x-ray assessment of healing and your progress,
- Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.
Medication Management: Some patients may need to continue medications, such as blood thinners, as directed by their healthcare provider to prevent blood clots.
Assistive Devices and Home Modifications: Patients may require assistive devices for a period, such as raised toilet seats or grab bars, and might need to make home modifications to improve safety and mobility.
Lifestyle Adjustments: Depending on individual circumstances, patients may need to adjust their daily routines and living environment to facilitate a smoother recovery.

Patients should actively engage in their recovery process, diligently follow the guidance of their medical professionals, and communicate any concerns promptly. Effective post-surgery care and adherence to the recommended rehabilitation program are critical for a successful outcome following Complex Revision Total Knee Replacement.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000