The Unhappy Total Knee Replacement Patient: Figuring out What Is Wrong

The sad truth is that too many people regret having undergone a total knee replacement (TKR). It is estimated that at least 20 percent of patients are not happy with the result of TKR.

The process of defining a successful TKR starts before the surgery begins. This requires an open discussion between the surgeon and the patient. Clear goals need to be set, and the surgeon needs to clarify which objectives are appropriate and achievable. Some patients simply have unrealistic goals, like wanting to run a marathon or join a soccer team, especially if they want the new joint to serve them well for the long-term.

It is important to understand why a patient is disappointed after TKR surgery. Oftentimes the underlying issue is revealed in the specific complaints. Total knee replacement works great when all the essential variables come together properly. These are the surgeon’s goals to alleviate pain and achieve stability in the knee. It is also important that the patient leaves happy with the results.

During TKR the implanted components resurface the ends of bones to prevent bone on bone rubbing. This is one of the main reasons for pain and arthritis in the knees. To achieve optimal results, a surgeon must meet these three conditions. But, this can be difficult considering underlying conditions and unique deformities that some patients present.

• Recreating proper limb alignment for equal weight bearing between in the inner and outer knee. Also, this can correct issues with knock-knees or bowed legs.
• Balancing the sleeve of soft tissue that encompasses the knee for equal pressures and tension in the ligaments when in movement.
• Producing more normal knee movements from extension to flexion and back.

When a person is unhappy after TKR surgery, it is important to determine the main complaint. Is it stiffness, pain, instability in the knee or poor range of motion? For some patients the new knee is feeling foreign, it isn’t comfortable. Is pain is only experienced during activity? Does the knee hurt all the time? Does the discomfort respond to pain relievers, ice or a shift in position?

Was there a point where the patient was coming along well, or start to improve steadily, but something changed along the way? Are the unpleasant symptoms getting better slowly, stabilizing or declining?

Besides asking the right questions, it is also necessary to examine the knee. Is the knee properly aligned? Has the incision healed correctly? Is the surgical site hot, tender or red? If so, in what area? Is it leaking or swollen? Can the patient fully extend the knee? Does the kneecap slide to the side during flexion?

In addition, test the stability of the knee by checking how well it extends and different degrees of flexion. Establish front and back stability. Other problems can also be ruled out.

Digital imaging that includes the knee, hip and ankle will provide valuable information. X-rays reveal alignment, loose or stable joints, and sizing, soft tissue balance, the presence of bone spurs, etc. It will also display if the components were cemented or press-fit to the bone. Post-surgical images should be compared to x-rays take prior to total knee replacement to look for subtle changes.

By now, the surgery is likely to have come up with an idea of what is causing the issue. If necessary, more x-rays will be taken and further studies including blood work.

Aspiration might be suggested to look for signs of infection in the knee. It can be difficult to detect a joint infection. But, a test is now available that has improved the ability of medical professionals to diagnose such infections. Sometimes, a bone scan, CT scan or MARS MRI will be requested get a better look at the positioning.

The surgeon will review the operative report for any peculiarities or signs of difficulty during the procedure. A scan of the implant record is equally important. This is a permanent record that contains information on the implant manufacturer. If more surgery is deemed necessary, this becomes vital information if the knee is not performing as it should. Certain brand or types of implants have a track record of causing problems.

If the root cause of dissatisfaction is identified, that is a plan can be made to correct the problem. Depending on the specific diagnosis, the fix may be nonsurgical or the second round of surgery.