Total Knee Joint Replacement Revision Surgery
Clinically Relevant Anatomy
Total Knee Joint Replacement (TKR) revision surgery is an orthopaedic surgical procedure in which the prosthetic pieces(s) of the previous TKR surgery are removed. New prosthetic pieces are then replaced within knee joint joint. The components consist of the femoral condyle component, the tibial plateau component, the polyethylene spacer and the patella component. All or some of these may be replaced depending on reason for replacement.
Revisional TKR surgery is a more complicated operation requiring longer time in theater and rehabilitation is slower and takes a more cautious approach.
Many reasons exist for the failure of a TKR. A meta analysis in 2011 found that TKA for OA has a revision rate of < 5% within 10 years. The reason for this failure can be classified into long or short term reasons.
Short term pathological process or injury include
- Infection. This is a significant risk and is the reason antibiotics are given pre and post surgery.A 2011 meta analysis reported that infection happened more regularly in obese recipients . Smokers also have a higher rate of infection (due to the decreased blood flow effect nicotine and cigarette chemicals cause). Poor nutrition also has an adverse affect on healing time and increased risk of infection.
- Mechanical failure
- Implant loosening from failed procedure
Long term pathological process or injury include
- Loosening due to wearing of the TKR ( life span of a replacement varies from approximately 10 to 20 years).
- Stiffness. A possible indicator that the prosthesis has become loose or has an infection.
- Mechanical failure over time through eg. biologic reactions.Biological reactions can occur due to generation of wear particles ( both polyethylene and metal ions) that cause a chronic inflammation causing systemic and local effects to the immune system. This is thought to play major role in osteolysis around the implant and hence loosening of prosthesis. This is often termed as loosening due to wear ( life span of a replacement varies from approximately 10 to 20 years).
- Pain. May be an indication of loosening of the prosthesis or infection is present.
- Dislocation from a fall or direct blow.
- Periprosthetic fracture. This is a fracture that occurs around the prosthetic piece(s). Often from a fall or direct blow.
- Leg length discrepancy or angular deformity
- Instability or a feeling that knee will give way. This occurs with ligament damage or loosening. eg from rheumatoid arthritis or poor muscle strength.
Clinical PresentationPain is the most common presenting sign. The cause of the pain could be for many reasons: infection; mechanical failure; loosening of the prosthetic implant; metallosis; disclocation or peri prosthetic fracture.
- X-rays, MRI, CT for closer visualization of anatomy
- Joint aspiration to analyse joint fluid for infection
- Blood tests to check no infection present
- Nuclear Bone scans to look for any loosening
The below is a great Physiopedia page that has a efficient way to read set of outcome measures with each stage of rehabilitation awarded it's own set of measures.
The pre and post op physiotherapy protocols follow the along the same lines as for the primary TKR. See the comprehensive guidelines in physiopedia TKR.
Note however a more cautious approach is often taken due to the more involved nature of the operation: Surgery is longer; the release of the quadriceps tendon or patella tendon may be more extensive; complex techniques are employed to rebuild the missing bone. e.g. Bone graft, bone substitution, long stemmed implants, screws and metal augments. All of these factors lead to greater recovery periods than in the primary TKR.
A 2004 report found that after primary TKR (and this could reasonably be extrapolated to revision TKR) found that proprioception, balance and kinaesthesia all improved with TKR. Thses results were thought to occur due to the pretensioned capsuloligamentous structures and reduced pain and inflammation.
The goal is to have a pain free, functional and stable knee joint, however knee outcomes are not as predictable as in a primary TKR and despite the best intentions the research finds that 10% of patients have a poor outcome.
Below is a good Physiotherapy rehabilitation approach for the later stages rehabilitation. Take note that proprioception and balance both need to be retrained along with strength and flexibly of the whole kinetic chain.
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