Post Operative Concerns & Recovery Options After Revision Knee Replacement Surgery
The postoperative concerns discussed below are based largely on an interview with Dr. Ira Kirschenbaum, a seasoned orthopedic surgeon practicing in New York City at the Bronx-Lebanon Hospital Center. The interview was conducted by Dr. Randale Sechrest, the host of eOrthopod TV, and can be viewed here.
Patients undergo revision knee replacement surgery when something fails in their original knee replacement(s) that causes problems they can’t live with any longer. All patients feel a certain amount of trepidation before surgery and it’s only natural that revision knee replacement patients would want to know if their recovery period will be longer and more intense for a revision knee replacement than what they experienced when they had their knee replaced the first time around.
Luckily, Dr. Ira Kirschenbaum has performed thousands of both types of knee replacement surgeries, at all levels of complexity, sometimes on the same patient in fact. In the interview, he emphasizes what he personally observes with his own patients in recovery after a revision knee replacement surgery compared to his own patients after a primary knee replacement procedure.
Dr. Ira Kirschenbaum stresses that the top concern immediately after a revision knee replacement surgery is blood loss. He explains that the scar tissue created during a revision knee replacement surgery is extensive and this can cause much more bleeding than during and after a primary knee replacement. Therefore, for the first twenty-four to forty-eight hours after revision surgery, doctors and nurses keep extra close tabs on blood cell counts to make sure these counts are not low or dropping. The patient is placed in the intensive care unit (ICU), or a step-down unit, for the first day after surgery so they can be monitored more closely.
Dr. Ira Kirschenbaum does interject some good news about improvements that are being made to reduce the loss of blood during and after revision knee replacements, “We’re using a lot of new techniques, such as trying to seal the bleeding surfaces with sprays, what’s called fibrin sealants, but even with these new techniques you’re going to get more blood loss with revisions.” Perhaps these sealants will continue to improve, or another method will be developed, reduce overall bleeding during revision knee replacements. Modern medicine is quite good at ingenuity when there is a real need.
Blood loss during these types of surgeries is actually greater than what many orthopedic surgeons realize. Researchers from the Avon Orthopaedic Centre at Southmead Hospital in Bristol, United Kingdom, studied the “hidden blood loss” in sixty-three patients undergoing total knee replacement surgeries. Through a well-designed method of measuring true blood loss, they were able to show that there was an average of fifty percent more blood loss than what is officially recorded during these surgeries. There is one caveat here, however. The study was conducted in 2000 and there have been improvements in this area since then, as Dr. Ira Kirschenbaum noted in his interview. Still, blood loss is always a major concern immediately after a revision knee replacement.
At any rate, Dr. Ira Kirschenbaum surmises that his revision knee replacement patients stay about two days longer in the hospital than his primary knee replacement patients. He says this is mostly due to medical reasons rather than pain issues or range of motion issues. He indicates the top medical reason is having to give patients one to two blood transfusions due to blood loss. He also says that patients are on average about fifteen years older than they were when they had their primary knee replacement so it’s not surprising they would have more medical issues on average. However, he also points out that he does have some revision knee replacement patients that don’t stay in the hospital any longer than most of his primary knee replacement patients.
Dr. Ira Kirschenbaum reports that the hospital protocol for revision knee replacement patients is otherwise basically the same as for primary knee replacement patients. The hospital staff gets them up early and tries to get them walking as soon as possible. They have one or two sessions of physical therapy per day. When they’re in bed resting, they use a machine to move their knee joint to increase their flexibility and not allow the knee to get too stiff.
The recovery time at home tends to be significantly longer for revision knee replacement patients than for primary knee replacement patients. Most of Dr. Ira Kirschenbaum’s primary knee replacement patients gain 90–95% of their motion in the affected knee by about the three-month mark. However, for his revision knee replacement patients, it can take double this time to achieve the same degree of recovery. Tasks, like driving and walking up stairs, can take a few more weeks to accomplish as well. A full recovery, with a maximum range of motion and no pain, can take up to eighteen months with a revision knee replacement.
One thing that Dr. Ira Kirschenbaum discussed that many patients probably don’t realize is they may have to have one or more of a follow-up procedure called “manipulation under anesthesia/” If the knee is too stiff, it is often due to scar tissue forming around the trauma of the operation. Aggressive manipulation of the knee joint under anesthesia, so the patient doesn’t feel it, can break up this scar tissue, allowing for more flexibility and a larger range of motion. Dr. Ira Kirschenbaum indicated that in some cases a revision knee replacement patient may have to have this procedure two or three times to achieve full range of motion.
Dr. Ira Kirschenbaum received his Bachelor of Science in neuroscience from Brown University and his Medical Degree from Albert Einstein College of Medicine of Yeshiva University. He has also received executive training at Harvard Business School. Dr. Ira Kirschenbaum is currently the Chair of the Orthopedic Department at the BronxCare Heath System in the Bronx borough of New York City, a department that attends to 1.4 million patients a year. He’s been practicing orthopedic medicine for almost three decades and has risen to be a leader in his field. In addition to orthopedic medicine, Dr. Ira Kirschenbaum has a real zeal for technology and finds many innovative ways to incorporate the latest technology into his practice.
Interview With Dr. Ira Kirschenbaum on Post-Operative Care
How much blood is really lost in total knee arthroplasty?. Correct blood loss management should take hidden loss into account.