Revision Total Joint Replacement
Dr. Mosher is one of the few people in north Alabama (and the only person in the Athens or Decatur areas) with specific training performing revision knee and hip replacement. Patients need revision surgery for a multitude of reasons, including: infection, fracture, component malposition, stiffness, instability, bone loss, component loosening, etc. These surgeries are more involved and extensive than primary joint replacement. However, our goals remain the same—to get patient’s back doing the things they want to do.
For these surgeries, we do change some of the protocols given that this is not a first-time surgery and there is a higher risk of complications. Even then, out goal is for patients to be up and moving within hours of surgery to improve outcomes, satisfaction, and safety. We still push mobility, even if we are limiting weightbearing on the affected extremity.
For revision hip replacement, Dr. Mosher uses both the anterior and posterior approach, depending on the reason for revision and the prior surgical approach. For revision knee replacement, Dr. Mosher uses the traditional medial parapatellar approach or the less-invasive quad-sparing approach.
Risks, Benefits, and Alternatives
Revision Knee Replacement
Revision TKA can be performed for many reasons, including: infection, fracture, loosening, instability, pain, stiffness, wear, or other mechanical complication. As with any surgery, there are risks, benefits, and alternatives.
Benefits: Our goal is to give you a stable, well-functioning knee. We want you to get back doing the things you enjoy. The potential benefits of revision TKA include: pain relief, improved function, improvement of range of motion (if the cause of the revision), better stability, improved activity level, and ability to do moderate activities.
Notably, this is revision surgery, meaning more complex surgery and risks. We must temper expectations moving forward, with more muted expectations than your original TKA.
Risks: There are many risks associated with revision TKA. The risks and our mitigation of those are listed below. The cumulative risk of any one of these is about 5-6%.
Infection/wound healing complications: We use prophylactic antibiotics, antiseptic solutions, advanced wound healing devices, and maintain sterile technique. However, the risk of infection is never 0%. If an infection occurs, you will need another surgery, IV antibiotics, and oral antibiotics.
Fracture: Revision components are large components being fit into the bone. This leads to an increased fracture risk. We mitigate this with prophylactic wire placement and other options. We also get an X-ray while in the operating room.
Implant Loosening: We place your implants using a variety of cemented and cementless techniques. While they are the standard of care, they are not perfect. Thus, these uncommonly can loosen down the line. We will monitor this throughout the healing process.
Neurovascular Injury: Revision surgery requires increased exposure, placing the nerves and blood vessels at slightly increased risk. The tibial and peroneal nerves are the most common affected. Tibial nerve injury can lead to numbness, while peroneal nerve injury leads to a foot drop, both of which often improve on their own. The popliteal vessels are also at risk. All structures are protected by retractors during the surgery. You will also have superficial lateral knee numbness from the incision.
Extensor Mechanism Injury: The extensor mechanism (patella tendon, patella, and quadriceps tendon) can be scarred into place and stiff. We place retractors and obtain appropriate exposure to mitigate this risk.
Stiffness/Instability: These can occur with any knee surgery. We will get you into aggressive therapy early to mitigate these risks, and monitor your progress for early intervention if needed.
Dissatisfaction: In a revision surgery, the goal is to improve your knee, but it will never be “perfect,” so this can lead to some dissatisfaction. Our goal is to give you the best functioning knee possible.
Pain: Revision TKA involves larger exposure and surgery. We may not be able to alleviate all pain, but our goal is to place the components appropriately, respect the tissues as possible, and minimize your pain.
Altered Gait: It will take time for your body to accommodate the new surgery and implant. Furthermore, different insults to your knee can injure your thigh and leg muscles, leading to a limp. This should improve with time, but is not uncommon after revision TKA, and may be permanent.
Venous Thromboembolism (VTE): This includes DVT and pulmonary embolism. This risk is elevated after revision TKA. We give at least 1 baby aspirin twice daily for 4-6 weeks to prevent this.
Medical Complications: These include: heart attack, stroke, pneumonia, UTI, VTE, kidney injury, bleeding, even death. However, these are present with any surgery, and not specific to revision THA. The more common “medical complications” we manage are nausea/vomiting, narcotic intolerance, drug interactions, urinary retention, pain, etc, which can usually be managed over the phone.
Alternatives: Continued nonoperative management. This is a continuation of your current management, including: anti-inflammatories, physical therapy, bracing, and injections. These may be helpful in a short-term situation, but are not a long-term solution.
Revision Hip Replacement
Revision THA can be performed for many reasons, including: infection, fracture, loosening, instability, pain, limb length discrepancy, wear, or other mechanical complication. As with any surgery, there are risks, benefits, and alternatives.
Benefits: Our goal is to give you a stable, well-functioning hip. We want you to get back doing the things you enjoy. The potential benefits of revision THA include: pain relief, improved function, correction of limb length discrepancy (if the cause of the revision), improved activity level, and ability to do moderate activities.
Notably, this is revision surgery, meaning more complex surgery and risks. We must temper expectations moving forward, with more muted expectations than your original THA.
Risks: There are many risks associated with revision THA. These risks and our mitigation of those are listed below. The cumulative risk of any one of these is about 5-6%.
Infection/wound healing complications: We use prophylactic antibiotics, antiseptic solutions, advanced wound healing devices, and maintain sterile technique. However, the risk of infection is never 0%. If an infection occurs, you will need another surgery, IV antibiotics, and oral antibiotics.
Dislocation: After revision surgery, you have an increased risk of dislocation. We work to mitigate this with component placement, computer assistance with implant positioning, and alternative implant options. Sometimes for hip stability, we have to increase length and offset of the hip, which can give you a limb length discrepancy or lateral prominence. This is a tradeoff to help make your hip stable.
Fracture: Revision components are large components being fit into the bone. This leads to an increased fracture risk. We mitigate this with prophylactic wire placement and other options.
Neurovascular Injury: Revision surgery requires increased exposure, placing the nerves and blood vessels at slightly increased risk. If present, these often improve on their own. The femoral nerve, sciatic nerve, and lateral femoral cutaneous nerve are the most common affected. Specifically, lateral femoral cutaneous nerve injury will occur on every revision via the anterior approach, yielding superficial lateral thigh numbness. Femoral nerve injury can lead to quadriceps weakness and sciatic nerve injury leads to a foot drop, though these are far less common. The femoral vessels are also at risk, but far less than the nerves.
Dissatisfaction: In a revision surgery, the goal is to improve your hip, but it will never be “perfect,” so this can lead to some dissatisfaction. Our goal is to give you the best functioning hip possible.
Pain: Revision THA involves larger exposure and surgery. We may not be able to alleviate all pain, but our goal is to place the components appropriately, respect the tissues as possible, and minimize your pain.
Heterotopic ossification (HO): HO is the calcification of the soft tissues. It is common after trauma, but can happen after revision THA. All patients receive an anti-inflammatory for at least 1-2 weeks after surgery, to mitigate this risk.
Altered Gait: It will take time for your body to accommodate the new surgery and implant. Furthermore, different insults to your hip can injure your hip muscles, leading to a limp. This should improve with time, but is not uncommon after revision THA, and may be permanent.
Venous Thromboembolism (VTE): This includes DVT and pulmonary embolism. This risk is elevated after revision THA. We give at least 1 baby aspirin twice daily for 4-6 weeks to prevent this.
Medical Complications: These include: heart attack, stroke, pneumonia, UTI, VTE, kidney injury, bleeding, even death. However, these are present with any surgery, and not specific to revision THA. The more common “medical complications” we manage are nausea/vomiting, narcotic intolerance, drug interactions, urinary retention, pain, etc, which can usually be managed over the phone.
Alternatives: Continued nonoperative management. This is a continuation of your current management, including: anti-inflammatories and physical therapy. Patients with chronic dislocations can also attempt to use long term bracing. This can be helpful for a short period in conjunction with physical therapy, but is not a long term solution.