Incomplete pain relief

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The most common scenario after a total knee replacement is a significant improvement in knee pain, albeit with some degree of lesser tolerable pain that no longer interferes with a basic level of ambulatory activity. The vast majority of these patients are very glad they had the surgery and report high satisfaction with their procedure. However, across the nation, there is a small but notable minority of patients who do not derive the level of pain relief they expected and are unsatisfied with their result. Dr. Lee believes the most important factor in maximizing your chances of satisfaction are to help you understand and manage expectations surrounding the replacement surgery.

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Instability

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Knee instability can be an immediate result from surgery, but is far more commonly encountered years after the operation. This may occur as a result of the stabilizing ligaments being stretched out, or replacement components wearing out, subsiding within the bone, loosening, or a combination of all of the above. In some cases, this may become severe enough that is becomes difficult to trust the knee, and in select cases, a second operation may be warranted to tighten up the knee.​

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Stiffness

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Knee stiffness can result after a total knee replacement if range of motion exercises are delayed too long in the recovery process. In particular, full knee extension (getting the knee fully straight) is very difficult to recover if not achieved and maintained early in the rehabilitation process. It is important to work on regaining your range of motion within several weeks after your operation. The best predictor of your maximum range of motion post-operatively is your range of motion pre-operatively. That is, if you start with a stiff knee, there is a higher likelihood you will remain with a stiffer knee compared to someone with full range of motion. If you are unable to regain your motion in the first six weeks, you may benefit from a secondary procedure to stretch your knee out.

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Loosening

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Component loosening most commonly occurs years after your operation. It can be a source of pain. The term loosening in this context usually refers to microscopic motion. That is, the components are not typically grossly loose, but micro-motion can be a source of pain. The most definitive solution for this issue is a revision total knee replacement.

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Infection

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Infection is the most dreaded outcome of any joint replacement surgery. In most cases, the preferred treatment is surgical removal of the existing implants, with temporary implantation of antibiotic-loaded cement, intravenous antibiotics through a long-term IV line, and subsequent re-implantation of final components once the infection has been cleared. These can be long processes for patients and families, therefore Dr. Lee takes very deliberate measures to make sure your risk of infection is minimized. In some cases, less invasive options can be pursued, but these are highly dependent on the clinical scenario.

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Fracture

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Patients undergoing joint replacement often have a co-existing condition called osteopenia, or poor bone quality. In this setting, even minor falls can lead to lower extremity fractures. If this occurs, there are several potential treatments, depending on the scenario, which include non-operative treatment, operative fixation with plates and screws or a rod, or removal of your existing joint replacement and placement of new larger components that stabilize across your fracture site.

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Blood Clots

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Blood clots are a serious complication of joint replacement surgery. Deep vein thrombosis, the most concerning type of blood clot, has the potential to dislodge and travel to your lungs, impairing the ability of blood oxygenation, and can be a catastrophically lethal complication. Because of this, we always recommend a blood thinning anti-coagulation agents for a period of time after your surgery and encourage early and aggressive mobilization.

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Total Hip Replacement

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Residual Pain

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Total hip replacement is an effective pain relief surgery. Despite this, it is not uncommon to have a minor degree of soreness post-operatively. Most frequently, the level of discomfort is not prohibitive and patients are very satisfied with the degree of pain relief when asked at subsequent follow-up visits.

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Leg Length Discrepancy

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Arthritic hips have by definition loss of joint space and cartilage. Sometimes this erosion is so severe that it can cause shortening of the diseased limb. When this happens over many years, it is easy to grow accustomed to this shortened length. During surgery, in most instances, an attempt is made to restore your natural limb length, which can be noticeable. In addition, there is a technical trade-off between limb lengthening and risk of hip instability/dislocation. A further detailed discussion and operative plan is made on an individual case-by-case basis.

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Dislocation

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Dislocations are a dreaded complication of total hip replacement. This occurs when the ball pops out of the socket and needs to be placed back into the socket. The causes of dislocation can be multi-factorial, including a breach of hip range of motion precautions, technical considerations at the time of surgery, mechanical impingement due to patient's natural anatomy, and a stiff spine.

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Bursitis

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Hip bursitis can occur after a hip replacement when the soft tissue are placed under greater tension by having newly implanted parts. This is often a self-limited condition and can be a necessary trade-off to achieve a stable hip to minimize the risk of dislocation.

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Tendonitis

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The most common tendon irritation after total hip replacement is psoas tendinitis. This tendon passes through the pelvis and helps flex the hip (the action your leg undergoes when you bring your knee up toward your body). If the tendon grinds against the new socket of a total hip replacement, it can lead to psoas impingement. This condition can have a spectrum of severity, ranging from no action needed, to injections, hip scope surgery to release the tendon, to full revision hip surgery.

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Metallosis

 

Metallosis occurs when microscopic metal debris is generated from the prothestic implants. This was one major reason why metal-on-metal hip replacements failed in the early 2000's. Most hip replacements performed today are metal-on-plastic or ceramic-on-plastic. However, even these replacements have an interface that can potentially generate metal debris. The metal debris can cause a local tissue reaction and cause pain, muscle weakness, and in high enough concentrations can cause systemic toxicity. Metallosis is not a common complication but is still encountered on a daily basis by busy joint replacement surgeons.

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Wear

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Wear refers to erosion of the plastic parts that house the ball inside the socket of a hip replacement. Wear can cause plastic particulate debris that causes bones to be resorbed and weaken, and when very severe, can cause dislocations and implant loosening. In the early 2000's, several ways to overcome this problem were introduced: metal-on-metal hip replacements, which have not born out to be a great solution due to metal debris particles (see above). Another more lasting solution was highly-cross linked polyethylene. This was a treatment of the plastic molded parts that enhanced their wear properties. Many of these plastic parts that were implanted twenty years ago appear to have promising wear characteristics. Thus, these improved plastics parts are routinely used today.

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Loosening

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Although the vast majority of implants are consolidated and become integrated with the host bone, in a minority of cases, components can loosen over time. This can lead to activity-related weight-bearing pain. If this is the case, x-rays and bone scans can help diagnose the condition. The only definitive treatment for component loosening is a revision operation.

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Infection

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Infection is the most dreaded outcome of any joint replacement surgery. In most cases, the preferred treatment is surgical removal of the existing implants, with temporary implantation of antibiotic-loaded cement, intravenous antibiotics through a long-term IV line, and subsequent re-implantation of final components once the infection has been cleared. These can be long processes for patients and families, therefore Dr. Lee takes very deliberate measures to make sure your risk of infection is minimized. In some cases, less invasive options can be pursued, but these are highly dependent on the clinical scenario.

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Blood Clots

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As mentioned previously, blood clots are a serious complication of joint replacement surgery. Deep vein thrombosis, the most concerning type of blood clot, has the potential to dislodge and travel to your lungs, impairing the ability of blood oxygenation, and can be a catastrophically lethal complication. Because of this, we always recommend a blood thinning anti-coagulation agents for a period of time after your surgery and encourage early and aggressive mobilization.

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