Revision Total Knee Replacement TKR

Revision Total Knee Replacement TKR

Introduction

We would like to welcome you our Worcestershire Acute Hospitals NHS Trust orthopaedic service.

It has been recommended by your consultant orthopaedic team that you need a Revision (Re-do) total knee replacement. This leaflet will explain what this means for you and will answer most of the questions you may have regarding your surgery and what will happen.

Please read this information carefully. Bring this information to all your appointments and on admission to hospital for your total knee replacement. If there is any thing you are still unsure about, please ask your consultant or one of the team. You should feel like you have all the information you need.

What is revision total knee replacement surgery?

Most primary knee replacements last at least 12-15 years. However, when necessary, particularly when the original replacement is adversely affecting your quality of life, after examination and assessment, an orthopaedic surgeon can replace the original replacement with a new one. Revision surgery takes longer than your original knee replacement surgery and is more complex because the orthopaedic surgeon must remove all or part of the original implant.

Please note your revision surgery might be performed by a different surgeon to your original knee replacement and might be in two stages, if infection is found.

Why do I need a revision total knee replacement?

A knee replacement may fail for a variety of reasons. Your knee can become painful, swollen, feel stiff or unstable resulting in difficulty performing everyday activities and a reduced quality of life. Reasons for failure include:

• Original replacement prosthesis worn or damaged
• Loosening of the parts and/or mechanical failure of the prosthesis
• Bone fracture or failure around the prosthesis
• Progression of arthritis if you had a partial knee replacement
• Infection

Planning your surgery

This will involve an assessment and examination in clinic, and investigations to help understand why your knee replacement is causing problems.
X-rays will be performed, and possibly CT or MRI scans, which provide important information about the structure of your knee assisting in the planning of your revision knee surgery.
Blood tests are performed to help understand if there is an infection in your knee.
Fluid (aspiration) and/or a biopsy of tissue is often removed from your replacement knee joint to test for the presence of an infection. This is performed in a surgical theatre where you will attend as a day case.

Your individual case will be discussed at a multidisciplinary team meeting involving consultant orthopaedic surgeons, consultant radiologists and surgical nurse practitioners who will agree a surgical plan specific to your individual needs. Specialist implants with longer stems are often used and where indicated, custom implants will be manufactured for replacement. The surgeon might also install metal pieces such as cones, wedges, wires and screws to reinforce the bone for the implant or aid fastening to the implant.

If your surgery is in two stages, because of infection, the first stage is removal of the old implant and the placement of a temporary joint. You will also be on course of antibiotics, provided by the infectious diseases team in conjunction with your orthopaedic revision surgeon.
The second stage is performed after the infection has been cleared, removing the cement and the replacement prosthesis is implanted. The timing of this will be discussed with you by the consultant team, which for guidance, can be a few months later.

How long will I be in hospital?

Depending on the revision surgery performed, your length of stay will be between 3-7 days. Occasionally a longer stay may be required if the revision is performed because of infection. Remember, you will be supported throughout by the orthopaedic team so please ask questions if you are unsure about anything related to your care.

There will be many similarities to your stay in hospital following your original total knee replacement surgery. This includes medication, administration of blood thinners, and physiotherapy. We aim to mobilise you as soon as possible after your revision surgery, which could be as early as the day of your surgery, or if not, the next day with assistance of a walking aid. This has the benefit of maintaining circulation and increasing your blood flow to the leg.

Differences immediately after surgery might include:

• Wearing a splint to keep your knee straight, protecting the wound in the first few days immediately post-operative.
• Intravenous (IV) antibiotic treatment administered during the operation and continued whilst on the ward.
• A specialist dressing to the surgical wound to aid healing

After discharge

You will attend a consultant outpatient appointment after the replacement at 6 weeks after surgery. Sometimes an earlier appointment at 2 weeks after surgery might be requested by your consultant. Further consultant clinic follow up appointments will be arranged depending on progress.  
Physiotherapy will be arranged as an outpatient, as previously, to continue your rehabilitation and recovery.

Wound concerns

PLEASE DO NOT ACCEPT ANTIBIOTICS FROM YOUR GP.
If you or your GP have concerns, please contact either Ward 16 directly on telephone 01527 512104 or the secretary of your consultant via switchboard telephone 01527 503030. Out of hours please attend the emergency department.  

Benefits of revision replacement knee surgery

The aim is to improve quality of life by decreasing pain in your knee, eradicating infection, if present, therefore improving mobility.

Risks of revision replacement knee surgery.

Risks following knee revision surgery are like those for your original knee replacement.
These include:

• Blood clots – Deep Vein Thrombosis (DVT, blood clot in the leg) or Pulmonary Embolism (PE, blood clot in the lung).
• Infection – Superficial infection around the wound or deep joint infection.
• Persistent pain – ongoing after your recovery and rehabilitation period.
• Stiffness in the knee – difficulty bending or straightening the knee which is worse than before your surgery.
• Instability – occasionally your knee replacement may feel unstable and require a brace or further surgery.
• Peri-Prosthetic fracture – this is a fracture that occurs in the bone around the revised joint replacement and can occur either during the operation or afterwards.
• Prosthesis wear or loosening – the mechanical joint may eventually wear out and need replacing. In some patients this can happen earlier.
• Nerve or vascular injury – It is normal to have some patchy areas of numbness on the skin at the front of the knee, which is often permanent but does not cause a problem. There are also several large nerves in the area, and although very rare, if damaged can lead to numbness and / or weakness lower down in the leg. This normally resolves in a few months but can sometimes be permanent.
• Medical problems – there is a small risk of developing medical problems which can include problems with breathing, the heart, a stroke or bleeding. There is a very small chance you will require a blood transfusion after the operation.

Reducing the Risks

To reduce the risk of some of these complications, the ward team will encourage you to mobilise early after your surgery.

• If you are overweight, losing some weight can help reduce your risk of infection, and developing some of the other medical problems.  If your BMI is >35 then commissioning guidance requires you to engage in weight reduction management demonstrating a loss of 10% of your weight. Your consultant team will agree a target weight with you.
• If you are diabetic, please ensure it is well controlled to help reduce the risk of infection. Blood tests might be requested by your orthopaedic consultant to check your blood sugar levels.
• Stopping smoking can also reduce these risks, as smoking can cause the wound to take longer to heal.
• Pre-existing medical conditions will be considered to ensure control is optimised, and where appropriate might require specific pre-operative specialist appointments. 
• Getting your knee moving soon after your surgery with the physiotherapy team will reduce your chance of getting ongoing stiffness and pain, improve your rehabilitation and maximise the chances of getting an excellent outcome from your revision surgery.
• Please let us know if you have any dental problems such as a broken tooth or infection because this could be a source of bacteria increasing the risk of joint infection.

Once you have been placed on the waiting list for surgery you will also be given the patient information leaflet about Total Knee Replacement which provides additional information about your surgical journey “The knee replacement journey – what happens next”. Please ask at a member of the team for a copy of this leaflet if you do not have one.

References:

Microsoft Word – 11.3.21 Revision Knee GGP AT v9.docx (bask.ac.uk)

MSK Policy Musculoskeletal Surgery and Therapeutic Interventions (non-Trauma) April 2024 Hereford and Worcestershire ICS

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you. 

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.  

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