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A revision knee replacement is the operation I perform when a knee replacement has stopped doing its job. The old implant comes out, lost bone gets rebuilt, and new parts go in. After more than twenty years and over 700 joint replacements a year, I can tell you it is one of the most demanding operations in orthopaedic surgery. It is also one of the most rewarding when a patient who has limped for two years finally walks without pain.
What is a revision knee replacement?
A revision knee replacement replaces some or all of a failed artificial knee with new knee implants. Sometimes that means swapping only the plastic spacer between the metal parts. More often it means removing the metal components, cleaning out old cement, and rebuilding lost bone.
Patients ask me if this is “starting over.” It is not. The first surgery resurfaced a worn joint. The second rebuilds a joint that has already been operated on.
How is revision knee replacement different from your first knee surgery?
Revision surgery is longer, more complex, and built around rebuilding bone instead of cutting it. A first knee replacement usually takes about an hour. A revision commonly runs two to three hours.
The implants are different too: longer stems that anchor deep into the thigh bone and shin bone, metal wedges called augments that fill gaps where bone is gone, and thicker plastic that supplies stability the ligaments no longer provide. The incision usually follows the original scar, but often runs longer so the old parts come out safely.
Why do knee replacements fail?
Knee replacements fail for five main reasons: infection, loosening, instability, stiffness, and fracture of the bone around the implant. Everything else is a variation on these five.
The 5 most common reasons a knee replacement fails
- Infection. Bacteria can settle on the implant surfaces and form a film that antibiotics alone cannot clear. Infection after a first knee replacement is uncommon, under about 1 percent. Even so, it is the leading reason knees need revision at referral centers, driving roughly a quarter to a half of cases.
- Loosening and wear. Over years, tiny plastic wear particles can trigger the body to digest bone around the implant, a process called osteolysis. The parts then work loose.
- Instability. The ligaments around your knee do the balancing work. If they stretch out, the knee feels like it is giving way, even though the implant looks fine on X-ray.
- Stiffness. Scar tissue can lock a knee down. Many of these knees improve with a manipulation under anesthesia, but a few need the implant revised to regain motion.
- Periprosthetic fracture. A fall can break the bone right next to the implant. Whether that needs surgery depends on the fracture pattern and whether the implant is still solid.
Age and activity matter too. Someone who has a knee replaced at 55 puts more miles on it than someone who has it done at 78, so the odds of a second operation are higher.
What are the warning signs of a failing knee replacement?
The four signs I take most seriously are new pain, swelling that will not settle, a knee that gives way, and lost motion. Any of these deserves an appointment, not a wait-and-see approach.
Pain that comes back after a good result is the loudest signal. A knee that hurt, felt great for six years, then started hurting again is telling you something changed.
Warmth, redness, drainage, or fever means you call the office the same day. Those are infection symptoms, and infection is far easier to treat early.
Other symptoms worry me less. Clicking without pain, mild knee swelling after a long day of yard work, and kneeling discomfort are common and usually mean nothing is wrong.
How is a failing knee replacement evaluated?
The evaluation answers one question: why did this knee fail? Operating without that answer is the fastest way to a second disappointment. I will not take a painful knee to surgery until I can name the cause.
What tests come before revision knee replacement surgery?
The workup usually includes an exam, X-rays, blood work, and often a joint aspiration. Here is what each one does:
- Physical exam. I watch you walk, check your range of motion, and test the ligaments for laxity.
- X-rays. Standing views of the whole leg show alignment, implant position, and thin dark lines along the bone that suggest loosening.
- Blood tests. Sedimentation rate and C-reactive protein are inflammation markers, used as routine infection screening before any revision.
- Joint aspiration. Fluid is drawn from the knee with a needle and sent for cell counts and cultures. It is the most reliable way to confirm or rule out infection.
- CT or metal-suppression MRI. Used when bone loss, rotation, or soft tissue problems need clearer definition.
If every test is normal and the knee still hurts, the honest answer is sometimes to wait and repeat the workup.
What happens during revision knee replacement surgery?
Revision knee replacement follows three stages: remove the old implant, rebuild the bone, and reconstruct the joint with new parts. The first stage matters more than patients expect. Every millimeter of bone saved during removal is bone I do not have to replace.
Once the old parts are out, gaps get filled with metal augments, porous metal cones, or bone graft. The new implant then goes in, with stems that reach into healthy bone farther down the leg for a solid grip.
The last step is balance. I bend and straighten the knee, adjust plastic thickness, and choose how much built-in stability the implant needs.
What if the knee is infected?
Infected knees are usually handled in two stages. The implant comes out, a temporary cement spacer loaded with antibiotics goes in, and you take intravenous antibiotics for several weeks. Once the infection clears, a second operation places the new knee.
It is a long road. It also gives the best chance of ending the infection for good.
How long does recovery take after revision knee replacement?
Recovery takes longer than after a first knee replacement. Formal therapy runs about three months, and full recovery is often closer to a year. Physical therapy typically starts within 24 hours of surgery.
Most patients use a walker for a few weeks, then a cane, then nothing. Some need protected weight bearing or a brace, depending on how much bone was rebuilt.
Swelling that lingers three to six months is normal. Elevation, ice, and compression stockings help more than people expect.
Is revision knee replacement worth it?
For most patients, yes. Good to excellent results are the rule, with meaningful pain relief and a knee that feels stable again.
You deserve the other half of that answer. Up to 1 in 5 patients still has some pain afterward, and results are less predictable than a first knee replacement. Revision implants also tend not to last as long, so a younger patient may face another operation later.
That is why I spend so much time on expectations before we schedule. A revision that ends chronic pain and instability is a success even if the knee never feels brand new.
Can you lower your chances of needing a revision?
Some risk is out of your hands, but three things move the needle: weight, dental and skin health, and speaking up early. Extra body weight raises the risk of both wear and infection. Treating dental infections and skin wounds promptly lowers the chance of bacteria reaching the joint.
The third one is the simplest. Call when something changes, not a year later.
I use the Mako® robotic platform for my first-time knee replacements because it helps me place and balance implants precisely, and I serve as a paid consultant to Stryker on that platform. I will be straight about the limits: precision is a good thing, but no one has proven yet that robotic assistance means fewer revisions 20 years out. I use it because I believe the data will get there, not because it already has. For more, read how long a knee replacement lasts and the evidence on knee replacement success rates.
Talk with a knee replacement specialist in Franklin, Tennessee
If your knee replacement hurts, swells, or gives way, get it looked at. I see patients from Franklin, Nashville, Columbia, Spring Hill, and across Middle Tennessee at the Bone and Joint Institute of Tennessee, 3000 Edward Curd Lane, Franklin, TN 37067. No referral is required.
If your first surgery was elsewhere, bring the operative report and any X-rays. It saves weeks.
Schedule a consultation with Dr. Calendine or call (615) 791-2630. You can also review the total knee replacement and robotic joint replacement pages, or read about preparing for knee replacement surgery.
The American Academy of Orthopaedic Surgeons patient guide to revision total knee replacement is a reliable independent overview.
This article is for educational purposes only and is not a substitute for medical advice. Individual results vary. Always consult a qualified orthopaedic surgeon about your own knee. In a medical emergency, call 911.
References
- Evans JT, et al. How long does a knee replacement last? A systematic review and meta-analysis with more than 15 years of follow-up. Lancet. 2019;393(10172):655-663. View study
- Postler A, et al. Analysis of total knee arthroplasty revision causes. BMC Musculoskeletal Disorders. 2018;19(1):55. View study
- Lee DH, et al. Causes and clinical outcomes of revision total knee arthroplasty. Knee Surgery and Related Research. 2017;29(2):104-109. View study
- Parvizi J, et al. The 2018 definition of periprosthetic hip and knee infection. Journal of Arthroplasty. 2018;33(5):1309-1314.e2. View study
- Sheth NP, et al. Bone loss in revision total knee arthroplasty: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons. 2017;25(5):348-357. View study
- Salari P, Baldini A. Revision knee surgery: the practical approach. EFORT Open Reviews. 2021;6(6):495-500. View study
