Complications and pain after knee replacement: list

Knee replacement is done, of course, in compliance with the rules of asepsis and antisepsis. At the same time, not only doctors, but also patients themselves do everything necessary to avoid complications. But even preparation for surgery and rehabilitation do not always protect a person from unforeseen consequences.

Surgeons are increasingly wearing such attire so as not to become a source of infectious complications themselves.

Complications after endoprosthetics can be early and late. The former develop due to infection, improper installation of the implant, or a blood clotting disorder in response to surgery. The cause of early postoperative complications may also be the patient’s insufficient physical activity or failure to comply with the doctor’s recommendations.

In a later period (after a year or more), complications arise due to the gradual destruction of bones due to osteolysis. Less commonly, patients develop allergic reactions to metals in endoprostheses.

Knee replacement in the Czech Republic: guarantees, prices, rehabilitation, reviews and statistics.

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Pain as a sign of complications

Knee replacement is performed to relieve chronic pain and improve a person's quality of life. After surgery, people are able to move normally and stop taking pain medications (unless they have severe osteoporosis in other joints). However, sometimes, after endoprosthetics, the patient develops alarming symptoms. His temperature rises, severe pain, swelling, crunching in the knee and other unpleasant phenomena appear.

This is what a “quiet” seam looks like.

Painful sensations may indicate the development of infectious complications, contractures, synovitis, joint instability or other dangerous consequences.

With purulent-inflammatory complications, fever, chills, headache and general weakness appear. The knee also hurts, and the surrounding skin becomes red and hot to the touch. The pain is bursting in nature, and pain relief with ointments and tablets has no effect. Why is my knee hot? This is explained by the accumulation of pus inside the joint and the development of an acute inflammatory process.

This is what a knee looks like and should be further examined for complications.

With thrombophlebitis of the veins of the lower extremities, the leg swells and a feeling of fullness appears in the lower extremities.

What to do if pain in the knee appears after endoprosthetics? You need to go to the doctor immediately. In the worst case, he will recommend repeated surgery and revision of the joint cavity; at best, he will advise what ointment or medications to use. It is possible that knee pain is caused by nerve irritation and will go away within 2-3 months.

POLYTRAUMA / POLYTRAUMA

Vlasova I.V., Vlasov S.V., Milyukov A.Yu., Tsyuryupa V.N.

State Autonomous Healthcare Institution of the Kemerovo Region "Regional Clinical Center for Miners' Health", Leninsk-Kuznetsky, Russia

FEATURES OF THROMBOTIC COMPLICATIONS AFTER KNEE ENDOPROSTHETICS

Knee arthroplasty (KJA) is often complicated by deep vein thrombosis of the lower extremities. The incidence of thrombotic complications of EPCS is very variable in different clinics and, according to various studies, ranges from 9% to 64%. The deep veins of the leg are a difficult area to study. The sensitivity of duplex scanning (DS) in detecting thrombosis of the veins of the leg varies, according to various sources, from 60% to 90%. Purpose

This study was to determine the characteristics of the thrombotic process and the protocol for examining patients after total EPCS.
Material and methods.
570 patients who underwent total knee replacement were examined, of which 442 were women and 128 men.
DS of the great vessels of the lower extremities was performed before surgery to exclude the initial thrombotic process and on the next day after surgery. If thrombotic complications were detected, the examination was repeated every 2-3 days. Results.
Of all those examined, thrombotic complications were detected in 18%.
In 90.3% of cases, thrombosis was not widespread; the peculiarity was the involvement of one of the paired veins or its non-occlusive nature. Half of all cases represented thrombosis of the muscular venous sinuses only. With timely treatment, active recanalization of veins was observed. Conclusion.
Thrombotic complications with EPCS are detected in 18% of cases. Half of them are local thrombosis of the muscular venous sinuses of the leg. The peculiarity of thrombotic complications of EPKS is that the process is limited to the veins of the leg, the non-severe nature of the thrombosis, the preservation of sufficient outflow from the leg, active recanalization of the veins with timely initiation of therapy. The protocol for examining patients after EPCS during duplex scanning must include examination of the muscular venous sinuses and peroneal veins.

Keywords:

deep vein thrombosis; veins of the leg; knee replacement

One of the main tasks of orthopedics and traumatology is the treatment of diseases and injuries of large joints, almost a quarter of which (24.7%) is deforming osteoarthritis of the knee joint. It is the cause of 31.2% of primary disability among all pathologies of the musculoskeletal system [1, 2]. A highly effective treatment method that allows normalizing the function of a damaged joint and relieving pain is, in most cases, endoprosthetics [1]. Like any major orthopedic surgery, knee arthroplasty (TKA) can be accompanied by various complications [3]. Deep vein thrombosis (DVT) occurs most frequently in the lower extremities. Greater invasiveness of the intervention, blood loss, the use of bone cement, a high patient comorbidity score according to the nomogram and the ASA scale (classification of the objective status of the American Society of Anesthesiologists) are provoking factors for thrombus formation. In addition, the features of the surgical intervention, namely the forced position of the limb during surgery (flexion), lead to a temporary disruption of the venous outflow from the limb. All of the above factors determine a high risk of developing DVT with EPKS, which is 1.5-2 times higher than the risk with hip replacement [4]. The incidence of thrombotic complications of EPCS is very variable in different clinics and, according to various studies, ranges from 9% to 64%. Thromboembolic complications worsen treatment results, prolong hospitalization, increase financial costs and can lead to pulmonary embolism [1-5]. The use of various preventive measures is aimed at reducing the incidence of complications [3-7]. Thus, the problem of timely and high-quality diagnosis of DVT in patients after EPCS is relevant. To diagnose DVT in clinics, duplex ultrasound (DS) scanning using color Doppler blood flow mapping is widely used [8-12]. The sensitivity and specificity of the method in diagnosing proximal thrombosis is high and reaches 98-100%. The deep veins of the leg are a difficult area to study. The sensitivity of DS in detecting venous thrombosis of the veins of the leg varies, according to various sources, from 60% to 90%. The difficulties in studying the veins of the leg are primarily due to their anatomical features. The deep veins of the leg are represented by paired posterior tibial veins (PTV) and anterior tibial veins (ATV), forming the popliteal vein, peroneal veins (FTV) and sural veins. The number of veins varies from 2 to 4 around the artery of the same name. Also developed and very variable is the system of anastomoses between all the veins of the leg, as well as between the superficial and deep venous network. Of great interest are the sural veins (SV), which are muscular venous sinuses in the thickness of the gastrocnemius and soleus muscles, which play an important role in the pathogenesis of chronic venous insufficiency [13, 14]. The diameter of the SV is very variable: from large, more than 1 cm, to inconspicuous (Fig. 1). However, careful scanning in various planes using color, energy mapping, and B-flow mode makes it possible to visualize the veins of the leg in approximately 90% of cases [15].

Figure 1.
Muscular venous sinuses of the leg during transverse and longitudinal scanning of the gastrocnemius muscle
Purpose

This study was to determine the characteristics of the thrombotic process and the protocol for examining patients after total EPCS.

MATERIAL AND METHODS OF RESEARCH

570 patients who underwent total knee replacement from 2014 to 2021 at the regional clinical center for miners' health were examined, of which 442 were women and 128 men. Average age 64 years (range 47 to 79 years). The study was carried out in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013) and the “Rules of Clinical Practice in the Russian Federation” (Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266) with written consent from patients to participate in the study and approved by the local ethics committee of the center (protocol No. 3 of February 15, 2018). To prevent thrombotic complications, all patients were prescribed low molecular weight heparin (fraxiparine 0.3 mg/day, clexane 0.2 mg/day) 10-12 hours after surgery. From the second day, aspirin and trental were used. Nonspecific prophylaxis included the use of compression stockings. Physical rehabilitation was carried out with an exercise therapy instructor and early activation of patients. When DVT developed, warfarin was prescribed at an initial dosage of 5 mg/day. DS of the great vessels of the lower extremities was performed on an expert class ultrasound system MyLab Class (Esaote, Italy). The examination was carried out before surgery to exclude the initial thrombotic process, on the 2-3rd day after EPCS. If thrombotic complications were detected, the examination was repeated every 2-3 days. The patients were examined in a horizontal position on their back. Given the impossibility of changing posture, to improve visualization, the popliteal veins were examined with slight flexion of the limb at the knee joint and abduction of the limb outward. The greatest difficulties arose when scanning the veins of the lower leg. On the first day after surgery, all patients had severe swelling of the soft tissues of the periarticular area and lower leg. In some cases, swelling led to compression of the tibial veins and the inability to visualize them. In addition, many patients (mostly women) were overweight, and thick subcutaneous fat on the legs also made it difficult to visualize the veins. To overcome these difficulties, techniques were used to help visualize the veins of the leg. The limb was placed with support on the foot (or heel) with slight flexion at the knee joint. In this case, maximum relaxation of the lower leg muscles was achieved. In this position, a thorough transverse sliding scan was performed using intense compression with the sensor at every centimeter of sliding. First, the sensor was moved from the popliteal region down the posteromedial and posterolateral surfaces of the leg. In this case, the medial and lateral sural veins were visualized, as well as the SVV in their proximal part. Then a thorough scan was performed along the medial surface from bottom to top from the ankle to the popliteal region. In this way, we examined the entire length of the SWV, as well as the SV in the thickness of the muscles at the level of the middle and upper third of the leg. In some patients, the MBV was visualized from this approach, but compression of the MBV through the muscle mass could not always be complete due to the great depth. For the same reason, research in color mapping mode did not always lead to complete “coloring” of the veins, which made a false positive result possible. Therefore, the study of the MBV was necessarily duplicated from the lateral approach. The best visualization of the MBV was achieved with transverse scanning along the lateral surface of the leg at the level of the middle third. When performing a compression test, it was very helpful to use counter pressure with your hand on the lower leg muscles on the opposite side. During the study, to obtain a final judgment about the patency of the vein, a transverse scan was necessarily used, in which the entire lumen of the vein and the degree of its compressibility were visible. Strict adherence to the research algorithm made it possible to achieve satisfactory visualization of all veins of the leg in most cases.

RESEARCH RESULTS

Of all those examined, thrombotic complications were detected in 103 patients, which amounted to 18% (Table).

Table.
Distribution of patients by location of venous thrombosis

Prevalence of thrombosis	Number of patients (n = 103)	%
All veins of the leg and popliteal vein	4	3.9
Posterior tibial, peroneal, sural veins	6	5.8
Posterior tibial and sural veins	10	9.7
Posterior tibial, peroneal veins	2	0.3
Posterior tibial veins	24	23.3
Isolated sural vein thrombosis	57	55

In almost all cases, the thrombotic process was limited to the veins of the leg. Only in 4 cases did thrombosis extend to the popliteal veins. In 6 patients, the thrombotic process was widespread, involving the PSV, MSV and SV (Fig. 2).

Figure 2. Occlusive masses in the peroneal veins with widespread thrombosis of the veins of the leg

Thus, DVT with a significant impairment of outflow from the leg was observed only in 9.7% of cases of all thromboses (in 10 people). In all other cases, DVT was not common. In case of thrombosis of the PVS only (24 patients) or in the case of a combination of thrombosis of the PVS and SV (10 patients), the peculiarity was either damage to one of the paired veins or the non-occlusive nature of the process. Often the veins were thrombosed in the middle and proximal third of the leg with normal patency in the distal third. At the same time, satisfactory outflow from the lower leg was maintained through paired patent veins and through anastomoses with other veins of the lower leg. It was noteworthy that half of all cases of DVT were thrombosis of only the muscular venous sinuses. At the same time, the patency of all main veins of the leg was preserved. When performing DS, hypoechoic or isoechoic fusiform structures were visualized in the thickness of the gastrocnemius or soleus muscles, with a lack of compressibility, without blood flow inside or with a weak parietal flow during distal compression. The thrombotic process was limited to the sinuses, without spreading to the orifices of the SV (Fig. 3).

Figure 3.
Occlusive thrombosis of the sural veins
Thrombosis of the SV had no clinical manifestations, and no pain was noted when the muscle was compressed by the sensor during the examination. In all cases, when DVT was diagnosed, active anticoagulant therapy was prescribed (fraxiparine 0.6-0.9 mg/day, clexane 0.4 mg/day) with a transition to warfarin 5 mg with achievement of the target INR value of 2-3, with continuation of therapy for outpatient stage up to 3-6 months. Patients continued to wear compression stockings. During DS over time, no progression of the process was observed in any case. In all cases of thrombosis of the spinal vein and spinal vein, signs of recanalization were revealed by the end of the week. Blood flow was restored most quickly in the distal part of the leg, in the area of the perforators. The dynamics of the process in isolated SV thrombosis proceeded according to 2 options. In most cases, the vein decreased in diameter due to thrombus retraction, but the occlusion process persisted during the hospitalization period. Rarely, in the SV, the process of recanalization began in the form of a small parietal blood flow with distal compression of the leg (Fig. 4).

Figure 4. Beginning of recanalization in the sural veins

Dynamic observation continued after discharge from the hospital, and DS was repeated a month later. No ascending thrombosis was observed in any case. The process of recanalization in the SVV, MSVV was active, and when the patency of the vein was restored, residual phenomena were observed in the form of incomplete compressibility of the vein and its valvular insufficiency. With existing SV thrombosis, the vein was obliterated, and after a month it was impossible to differentiate it from the surrounding tissue in most cases.

DISCUSSION

EPCS has a high percentage of thrombotic complications. DVT was detected in 18% of operated patients. Despite the large number of cases of DVT, 90% of them were limited in nature. Half of the thromboses were localized only in the muscular venous sinuses, without spreading into the main veins. SV thrombosis can be the beginning of a widespread thrombotic process, which we have repeatedly observed, for example, in severe patients with polytrauma during prolonged immobilization. Therefore, it is unacceptable to ignore these changes, despite their local nature. Timely initiation of therapy after detection of a thrombotic process led to active recanalization of the veins; in no case was progression of the complication observed. The outflow from the SV largely depends on the normal functioning of the muscular-venous pump; the speed of blood movement along the SV at rest is very slow, and blood stasis easily develops, leading to thrombus formation. With prolonged flexion of the limb during surgery, the venous outflow is disrupted and the spinal veins are the most vulnerable. This explains the lesion of the SV in 77 out of 103 cases (74.7%). Monitoring of thrombotic complications during major orthopedic surgeries has been carried out in our clinic for almost 20 years. An analysis of complications carried out in 2008-2009 revealed a high percentage of thrombosis of the veins of the lower extremities, which forced an analysis of the causes. It was shown that one of the provoking factors for thrombus formation in EPCS was the use of a hemostatic tourniquet during surgery to prevent intraoperative blood loss. Refusal to use a tourniquet, as well as reducing the duration of surgery, reduced the number of thrombotic complications from 19% to 9.5% [11]. However, the ultrasound protocol at that time included only the study of the main veins of the leg - the PBBV, PBBV, MBV. The experience gained over time, as well as the use of ultrasound scanners with higher resolution, forced us to reconsider and clarify the scope of the study. The inclusion of all available vein visualizations, including muscular venous sinuses, in the mandatory research protocol led to an increase in the percentage of thrombotic complications by almost 2 times compared to the achieved 9.5%, but determined the true picture of the postoperative state of the venous system [16]. In the practical work of ultrasound diagnostic doctors, the examination of the veins of the lower leg is mostly not carried out in full, which is associated both with the difficulty of identifying all deep veins, due to various options for connecting them to each other, and with a significant increase in the time of their assessment. Studies have shown that including assessment of the muscular and peroneal veins in the DS protocol can reduce the number of false-negative results for DVT by 64 and 15%, respectively [8, 16].

CONCLUSIONS:

1. Thrombotic complications during EPCS were identified in 18% of cases. Half of them were local thrombosis of the muscular venous sinuses of the leg, which is apparently due to the peculiarity of the position of the limb during surgery, leading to a temporary disruption of the venous outflow from the leg. 2. A feature of thrombotic complications of EPCS is that the process is limited to the veins of the leg, the non-severe nature of the thrombosis, the preservation in most cases of sufficient outflow from the leg through patent paired veins, active recanalization of the veins with timely initiation of therapy. 3. The protocol for examining patients after EPCS during duplex scanning must include examination of the muscular venous sinuses and peroneal veins.

Funding and conflict of interest information

The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

LITERATURE / REFERENCES:

1. Shevchenko YuL, Stoyko YuM, Zamyatin MN, Gritsyuk AA, Kuzmin PD, Dzhodzhua AV et al. Complex prevention of venous thromboembolic complications after replacement of knee and hip joints. Medical Board.

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2002; (1): 85-88. Russian (Matveeva N.Yu., Eskin N.A., Z.G. Natsvlishvili and others. Venous thromboembolic complications in injuries of the lower extremities and hip and knee replacement // Bulletin of Traumatology and Orthopedics named after N.N. Priorov. 2002 No. 1. pp. 85-88) 3. Alabut AV, Sikilinda VD, Chesnikov SG, Timoshenko ME, Skarzhinskiy AA, Khammad MOKh. Analysis of complications of knee joint replacement. News of Higher Educational Institutions.
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2000; 1(6): 43-48. Russian (Shevchenko Yu.L., Stoyko Yu.M., Shaydakov E.V., Skrabovsky V.I. Anatomical and physiological features of the musculovenous sinuses of the leg //Angiology and vascular surgery. 2000. T. 6, No. 1. P. 43-48) 14. Semenyago SA, Zhdanovich VN. Anatomical features of venous bed of the leg (literature review). Problems of Health and Ecology
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Infectious complications after knee replacement

The frequency of infectious complications after surgery is 0.2-4.5% for primary prosthetics and 4.5-12% for revision (repeated) prosthetics.

The development of purulent-inflammatory complications in the first 12 months is due to microbial contamination during surgery. Pathogenic microorganisms can penetrate the knee joint aerogenously or by contact. They are carried into the wound with dirty air, the surgeon's hands or surgical instruments.

Things are bad.

The risk of postoperative complications is especially high in elderly patients with diabetes mellitus, obesity, rheumatoid arthritis, immunodeficiency conditions and in patients taking corticosteroids. The prognosis is also worsened by the limited experience of the operating surgeon, large blood loss, the duration of the operation over 3 hours and the use of bone cement without an antibiotic in the composition.

In a later period (a year or more after surgery), inflammatory complications are a consequence of the hematogenous spread of microorganisms. Pathogenic microbes penetrate into the joint cavity through the bloodstream from foci of chronic infection.

Possible sources of hematogenous dissemination:

skin;
organs of the genitourinary system;
Airways;
oropharynx;
lower parts of the gastrointestinal tract.

Often before operations the oral cavity is not even examined, which as a result causes severe complications.

The severity of clinical manifestations in a patient depends on the source of infection, the virulence of the pathogen and the time of development of the pathology. The classic bright picture of purulent inflammation (fever, swelling and hyperemia of the knee, fistula formation) is observed in less than half of the patients. Others may be bothered by constant pain in the knee joint, which intensifies with movement.

To successfully combat paraprosthetic infection, an integrated approach is required. The most effective is open sanitation of the joint cavity with complete removal of all components of the prosthesis (preservation of any of the components of the implant may ultimately lead to repeated surgery). At the same time, the patient is prescribed local antibiotic therapy by creating a depot in the inflammatory focus.

On the left is the implant after the primary operation, on the right after the revision surgery, it is significantly larger in size for strong fixation.

Conservative treatment of infectious complications is possible only with early diagnosis, low virulence of the pathogen and the presence of contraindications to surgery.

What is special about your new knee joint?

After surgery, you may feel numbness in the skin around the scar. You may also feel some difficulty bending your knee joint. Restoring movement in the joint is one of the goals of total arthroplasty, but complete restoration is not always possible.

The metal components of the joint may be detected by metal detectors at airports and other facilities. In such cases, inform the security staff that you had an operation with metal implantation. You can ask the surgeon for a certificate stating that you have had an endoprosthesis implanted.

After surgery, be sure to do the following:

Participate in training programs to maintain stability and mobility of the new joint
Follow specific guidelines to prevent falls and injuries. Patients who have suffered a fracture after total joint replacement may require new surgery.
Let your dentist know that you have undergone total endoprosthetics. It is necessary to take antibiotics before dental procedures for two years after surgery, possibly more, depending on the course of the postoperative period. Antibiotic guidelines for the surgeon and dentist are available on the AAOS and ADA websites.
Periodically see the surgeon for examination and x-ray control, even if you do not experience any problems with the joint.

Implant dislocations and ways to solve the problem

Dislocations after knee replacement are very rare. The hip and shoulder joints are less favorable in this regard - their endoprostheses are displaced much more often.

This may be due to inappropriate design of the prosthesis, incorrect installation, or incorrect behavior of the patient during rehabilitation. The components of the implant may become dislodged in the early postoperative period when the patient first attempts to move the leg. Dislocations occur more often after revision arthroplasty than after primary arthroplasty.

Most often this is the result of a fall or other injury.

Displacement of the implant parts causes severe pain in the patient and leads to impaired joint mobility. The patient cannot move normally. A dislocated part of the endoprosthesis injures nearby tissues.

Implant dislocations can be treated using several methods. The simplest and cheapest of them is closed reduction. After it, relapses often occur. In case of repeated dislocation, the patient is recommended to undergo primary total arthroplasty or open revision prosthetics.

Contracture - the knee does not bend

Contracture is a restriction of mobility of the knee joint, which is accompanied by aching pain and difficulty walking. The operated leg may be in a forced, incorrect position.

It is impossible to fully straighten the leg.

The reason for the development of contracture is prolonged inactivity of the limb. Muscles weaken and their functionality is impaired. When a person begins to move the operated leg, a reflex muscle contraction occurs. Due to the spasm, the patient cannot bend and straighten the knee freely. Temporary contractures soon pass without any consequences.

If for any reason the patient requires long-term immobilization of the joint, there is a high risk of developing persistent contracture. It occurs after three weeks of inactivity of the limb. Persistent contracture is much more difficult to treat than temporary contracture.

In advanced cases, surgical treatment of contracture is used.

The most effective methods of combating this pathology are adequate physical activity and physical therapy. Exercises help develop muscles and return them to normal functional activity. Treatment includes physiotherapy and massage.

Wrong location

Incorrect installation of the hip joint endoprosthesis leads to the fact that anatomically correct comparison of the articular surfaces becomes impossible. In this case, the implant will not be able to fully replace the natural connection, which will also lead to negative consequences:

pinched nerve endings (pain in the thigh or lower leg);
muscle damage caused by the prosthesis;
overexertion of the legs when walking;
increased stress on the leg muscles due to their reflex overstrain.

As a result of incorrect orientation of components in the bone bed, the entire surgical treatment program may be ineffective. The patient will not be able to lead an active lifestyle, will experience pain, and leg mobility will remain severely limited. As you wear the prosthesis, its elements, being crookedly installed, can become loose, leading to permanent dislocations.

Venous thromboembolic complications

Deep vein thrombosis of the lower extremities develops in 40-60% of patients who have undergone major orthopedic surgery. An analysis of a number of clinical studies has shown that after knee replacement, this complication occurs in 85% of patients. In 0.1-2% of cases, thrombosis leads to fatal pulmonary embolism (PE).

Scheme of thrombosis formation.

Risk factors for thromboembolic complications:

obesity ІІ-ІІІ degree;
age over 75 years;
chronic heart failure;
varicose veins;
diabetes;
oncopathology;
previous heart attack;
long-term immobilization;
taking steroids and hormonal contraceptives;
chronic nonspecific lung diseases (CNLD).

During the operation, the human body begins to release substances that increase blood clotting. Thrombosis begins during surgery, so they occur in the early postoperative period. In 50% of cases they appear on the first day, in 75% - in the first 48 hours after surgery.

These compression cuffs are used for the first hours and days.

In orthopedics, mechanical and medicinal methods are used to prevent postoperative thrombosis. The first include compression, electrical neurostimulation and physical therapy. As for medications, unfractionated and low molecular weight heparins, vitamin K antagonists, and coagulation factor X inhibitors are used for prophylactic purposes. In recent years, doctors increasingly prefer oral anticoagulants (Apixaban, Rivaroxaban, Dabigatran etexilate).

The minimum duration of taking prophylactic doses of anticoagulants is 10-14 days, the recommended is 35 days. Premature withdrawal of medications can lead to spontaneous development of thrombosis. Therefore, doctors recommend long-term courses of prevention to patients. If thromboembolic complications nevertheless occur, the doses of anticoagulants are increased to therapeutic levels.

Knee replacement in the Czech Republic: guarantees, prices, rehabilitation, reviews and statistics.

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Rehabilitation complex

Rehabilitation of the lower limb takes place in several stages:

Period	Goals
Stationary	Removing the risks of complications, gradual development of muscles and joints, getting used to the vertical position
Early	Mastering walking on stairs, restoring knee function, strengthening the muscles of both legs to evenly distribute the load
Late	Full restoration of natural mobility, training of muscle mass of the whole body to minimize the risk of long-term complications

The inpatient stage lasts the first two weeks after surgery (sometimes the patient is discharged home earlier, after 4-6 days). All activities and procedures are carried out under control. To prevent thrombophlebitis, a compression bandage is worn, which limits mobility. The limb cannot be loaded for 1-3 days; the kinematics will be checked by the attending physician. The following is a recommended exercise:

bending the knee from a supine position. Perform 10 approaches several times a day, but without overexertion;

Gently slide your foot along the surface, pulling your leg toward your buttocks.
raising your legs from a prone position. A bolster or hard pillow is placed under the ankle. The goal is to lift your knees off the surface, fixing the position for a few seconds; This is done with fixation at the top point for a couple of seconds.
raising/lowering the straight sore leg;

A healthy leg stands on the foot.
From a standing position, lift your limbs one by one at an angle of 45 degrees. The back should be straight when performing.

A month after knee replacement: “home” rehabilitation

The home environment is relaxing - this is its danger. For recovery to proceed correctly, there is no need to go to extremes: inactivity and vigorous activity are equally harmful. By adhering to medical recommendations, you will ensure successful rehabilitation and save the endoprosthesis. The guaranteed service life of the artificial joint is 10 years, but under incorrect loads the elements wear out faster.

Gymnastics for the first month:

Print the picture and keep it as instructions.

According to current legislation, a certificate of incapacity is issued for 15 working days. If you work with physical exertion or being on your feet, it is better to go to the hospital at your place of residence to extend your sick leave. To make a decision, a special commission will be assembled, which, after familiarizing itself with the medical history, will issue a verdict - whether to extend the sick leave, and for how long.

The maximum period of validity of the commission's decision is 10 months. If the certificate of incapacity for work needs to be extended for a year, another consultation is held. The timing depends on the characteristics of the body; you may need a trip to a sanatorium or hospitalization to identify signs of implant instability. Failure to comply with recommended exercise therapy is the reason for refusal to extend sick leave.

5 months after discharge, you can begin training on special simulators and return to an active lifestyle. If you still have pain during this period, consult an orthopedist. Most likely, the matter is in a pathological process.

Allergy to metal

According to foreign studies, allergic reactions may occur in 10%. According to statistics, allergies are the cause of 5% of unsuccessful joint replacements. Allergens include chromium, cobalt and nickel.

Knee implant.

Metal-containing endoprostheses are widely used in orthopedics. According to statistics, 99% of implanted prostheses contain metals or their alloys. Their contact with biological fluids causes corrosion of implants, which leads to the entry of metal salts into the human blood and the development of a delayed-type hypersensitivity reaction.

An allergy to the metal components of the endoprosthesis usually manifests itself as pain, redness of the skin and itching in the knee joint.

People who have had allergic reactions to any metals throughout their lives undergo patch testing before endoprosthetics. Skin patch tests determine microelement intolerance. This avoids the implantation of a prosthesis, which will ultimately cause allergies.

For patients who have already undergone endoprosthetics, patch tests are performed to confirm the diagnosis of allergy. The combination of a positive skin test and characteristic symptoms of an allergic reaction is an indication for reoperation. The patient's old prosthesis is removed and a new one is placed in its place.

Instability at the patellofemoral joint

One of the complications of total arthroplasty is instability of the knee joint in the area of the patella. The reason is a violation of the normal sliding of the latter in the frontal plane due to incorrect orientation of the implant. During the first year after surgery, instability in the patellofemoral junction is detected in 1.5% of patients.

The incidence of complications does NOT depend on the type of prosthesis and the experience of the surgeon who performs the operation.

An example of incorrect installation of the femoral component and the consequences in the form of increased wear.

To eliminate patellar instability, the patient undergoes revision arthroplasty. During the intervention, surgeons eliminate errors in the orientation of parts of the implanted implant. At the same time, superficial prosthetics of the patella is performed.

Less common complications of the femoral-patellar joint:

damage to the patellar prosthesis;
aseptic loosening;
patella fractures;
rupture of the patellar ligament;
snapping patella syndrome.

Preparing for surgery

When preparing for surgery, the doctor must examine the sore leg and joint, and then prescribe a number of additional examinations. Both lower extremities are subject to examination. X-rays, ultrasound and MRI are often recommended to the patient. The patient also needs to get advice from a cardiologist, therapist and other specialized specialists (it all depends on the specific case). You won’t have to go through all the doctors if your blood and urine test results are normal. Elderly people and heart patients are required to undergo an ECG. In preparation, doctors often draw blood for possible transfusion during surgery.

Osteolysis and aseptic loosening of components

Osteolysis is a pathological process that leads to bone destruction at the site of fixation of the endoprosthesis. The main reason for this phenomenon is the prevalence of resorption processes over bone formation processes. Over time, osteolysis causes aseptic (non-infectious) loosening of the endoprosthesis parts.

Pathological mobility of the implant can also be a consequence of the destruction of the cement that was used to fix it. Due to the disruption of the strong connection between the surfaces of the bones and the endoprosthesis, the latter loses support. This leads to its loosening. The patient may experience knee pain, discomfort, and difficulty walking.

There should be no areas of distinct color or outline between the implant and the bone. This may indicate loosening and instability.

Aseptic loosening of the endoprosthesis occurs at a later stage. According to statistics, in the first ten years after surgery it develops in 10-15% of operated people. Instability of the knee joint is an indication for revision arthroplasty late after surgery. The patient is given an implant with longer legs. Such an endoprosthesis provides reconstruction of lost bone tissue and allows for durable fixation.

A number of medications are used to prevent aseptic instability and implant loosening. These include bisphosphonates, calcium supplements and vitamin D. In addition, the patient is recommended to eat a calcium-rich diet. The intake of osteolysis inhibitors, vitamins and minerals into the body slows down the development of osteoporosis. The bones of the lower extremities stop deteriorating. This allows you to avoid pathological loosening of the endoprosthesis or delay the occurrence of unpleasant complications.

Incorrect (inappropriate) type of fixation

Installation of a hip and knee endoprosthesis involves fixation in one of 2 ways – cemented or cementless. The doctor must decide which option to use in a particular case, taking into account the patient’s gender, age, weight and lifestyle, diagnostic results (density and shape of the bone canal), and the characteristics of the prosthesis components.

At the same time, in practice, some decision-making rules have already been formed:

cemented knee joint prosthesis is considered preferable for women and older patients (60 years and older), as well as people with severe symptoms of osteoporosis, wide channels and thinned walls of the femurs;
installation of an endoprosthesis without cement is more often suitable for men and young people without severe forms of osteoporosis.

Errors in choosing the type of fixation

Choosing a cement method instead of a cementless one, and vice versa, can lead to serious complications. So, if a cemented installation is more suitable for a patient, and the elements of the implant were fixed without cement, the likelihood increases:

crack formation;
bone fractures (especially if it is the installation of a hip joint endoprosthesis );
the need for reoperation.

When cementless fixation is required according to indications, and the implant is installed in a cemented composition, the patient will not simply require re-installation due to frequent dislocations or fractures. The revision operation will become significantly more complicated.

Errors when attaching components

An important point: even the correct method of fastening (cemented, cementless) does not eliminate the likelihood of complications associated directly with the process of installing a hip joint endoprosthesis, namely:

insufficient amount of cement, which must be used to fill the acetabulum and femoral canal when installing a hip joint endoprosthesis using the cement method;
uneven distribution of medical cement around the elements of the prosthesis (again, we are talking about a cement installation);
incorrect choice of fixation site (orientation in the space of the bone bed). This error is possible with any method of fixation - cemented or cementless.

LEFT: Normal cement-metal interface (yellow arrow). However, there is weakening at the cementum-bone interface (orange curved arrow). RIGHT: Weakness at the cement-metal interface.

Prevention of complications in the first month

In the first 5-6 days after, the patient is in the hospital, where he receives all the necessary medications and procedures. To prevent thromboembolic complications, the patient is given anticoagulants to avoid infection - antibiotics. In the early stages after surgery, the patient is recommended to wear compression stockings.

The day after endoprosthetics, doctors remove drainage from the wound, which served to drain fluid. Afterwards, walking with elbow crutches or walkers is allowed. The medical staff helps the patient get up and explains how best to walk and what exercises to do. Early physical activity and exercises help avoid the development of contracture.

Arthromot provides passive development of the joint.

If the patient does not experience any complications, he is soon discharged from the hospital. Working people are given sick leave. The length of sick leave can range from 1.5 to 3 months. Upon discharge, doctors give the patient a number of recommendations for caring for the postoperative wound. After two weeks, the patient will need to come to the hospital to have the stitches removed.

For 5-6 weeks the patient is forced to walk with crutches. After this period ends, he will no longer need them. However, you can return to long walks, swimming and other vigorous activities in 5-6 months. The question of playing sports is decided together with the attending physician. Orthopedists prohibit heavy physical activity.

This is what the suture should look like 3-4 months after surgery.

A follow-up examination of the patient is usually carried out 2-3 months after surgery. If, during the examination, doctors identify signs of instability, infection, thromboembolic or other complications, the patient is given the necessary assistance. After the first scheduled examination, a person visits a doctor once every 2-3 years.

Operation

You will arrive at the clinic some time before the operation. Next, you will be examined by an anesthesiologist. The most common types of pain relief for total arthroplasty are endotracheal anesthesia (you will sleep during the operation and the ventilator will breathe for you), spinal or epidural anesthesia (in which you will be able to breathe on your own, but your legs will not feel anything. Anesthesiologist will discuss with you the advantages and disadvantages of these methods and help you choose the most suitable type of anesthesia.

The operation lasts on average about two hours. The surgeon will remove the damaged cartilage and some bone and then install new metal and polymer joint surfaces to restore the axis of the limb and the function of the knee joint.

Many different types of prostheses are currently used in total knee replacement. Almost all of them consist of three components: the femoral component (made of a highly polished, durable metal), the tibial component (consisting of a strong polymer, often located on a metal platform), and the patella (also polymer).

After the operation, once you are fully awake, you will be transferred to your room.

You will be in the clinic for several days. After the operation, you will feel pain in the operated joint. You will receive painkillers to relieve pain.

Walking and gentle exercise of the operated joint are essential for recovery and should begin soon after surgery.

To prevent pulmonary complications, you should breathe deeper and cough more often.

The surgeon will take certain measures to prevent thrombosis and prevent swelling, such as elastic bandages, stockings, and the use of anticoagulants.

Foot and ankle exercises should also be done immediately after surgery and will help increase blood flow to the extremities, reducing swelling and the risk of blood clots. Many patients begin knee exercises the day after surgery. Your physical therapist will teach you specific exercises to strengthen your knee joint and restore the movements needed for walking and normal daily activities shortly after surgery.

Prevention of late complications of endoprosthetics

At the end of the rehabilitation period, it is worth continuing to do the exercises for several more years. Therapeutic exercise is necessary to maintain normal muscle tone and functional muscle activity. Exercise helps a person maintain weight. Since obesity accelerates the development of osteoporosis, preventing it helps prevent loosening and instability of the knee joint.

The ligamentous and muscular system around the implant must be strengthened with regular training.

Endoprosthetics are often performed on older people prone to osteoporosis. Surgery further traumatizes the bones, which contributes to their further destruction. Therefore, to prevent osteolysis, the patient needs to take drugs that normalize metabolic processes. Medicines must be taken daily.

Drugs used for preventive purposes:

Alendronate;
Recostin;
Fosamax;
Alendronic acid;
Bonviva;
Rizendros;
Zolerix.

The listed drugs inhibit proteolysis, that is, they slow down the destruction of bone tissue. Along with them, doctors recommend that patients take calcium, phosphorus and vitamin D supplements. They saturate bone tissue with essential minerals, thereby strengthening them. Particularly effective in this regard are medications containing hydroxyapatite (Calcimax, Ossein-Hydroxyapatite). This substance is very well absorbed and acts much more effectively than calcium carbonate or calcium citrate.

And even 20 years after primary endoprosthetics, the patient needs to consult a doctor to monitor the need for revision surgery. The specialist must carefully examine and examine the person. If the patient shows signs of instability of the knee joint, re-endoprosthetics may be necessary. After revision surgery, the incidence of complications is higher than after primary surgery.

How to prevent the problem

If you decide on joint replacement, be prepared for regular visits to doctors and clinical examinations. Periodic x-rays will help to identify the problem in advance - changes in bone tissue or implant. You should sound the alarm at the slightest hint of “problems” in the endoprosthesis - disturbances in its functions, redness, swelling.

If you have not yet decided on a treatment method for arthrosis or osteoarthritis, consider an alternative option that does not cause complications and has a minimum of contraindications. Intra-articular injections of Noltrex, a synovial fluid substitute, are indicated for arthrosis of the second and even third degree. The course includes several injections at weekly intervals, after which the viscosity of the joint fluid is restored, the cartilage stops rubbing against each other - the patient can return to their usual lifestyle for a long period.

Unlike surgery, Noltrex intra-articular injections are not hazardous to health and do not require significant effort from you during the recovery period. Infection and postoperative complications are excluded if you complete the course in a medical office, under ultrasound control, at the recommended frequency. The operation, in turn, is a huge risk, and it does not matter at all whether it is emergency or planned.

Complications and pain after knee replacement: list of main ones