Knee warm, swollen, pink after knee replacement

Skin warmth after total knee replacement

1/21/2017

Total knee replacement has become a very common elective surgery, and patients are often amazed at how quickly they can get back to "normal" life after surgery. Within hours of their surgery, my patients are often able to begin walking with the assistance of a physical therapist and a walker. While most of my total joint replacement patients can be discharged to home within 48 hours, many are stable for discharge within 24 hours of surgery.

In spite of the anticipated rapid early recovery following total knee replacement, there is still a significant healing process that must occur. This healing process progresses through an inflammatory cascade and continues for over a year from surgery. It is this inflammatory cascade that requires a dedicated stretching regimen to ensure optimal knee range of motion following surgery.

Many patients are concerned that their knee feels warm, and may appear swollen and/or pink in the early post-operative period following knee replacement. In the vast majority of cases, this is normal and an anticipated part of the recovery period. Of course, if there is ever a concern, you should always discuss this with your orthopedic surgeon. Why does this happen? Basically, the body increases blood flow to the knee region to support the healing process. This increased blood flow results in the warmth, swelling and redness often experienced by the patient.

As the healing process progresses, the warmth, swelling and redness dissipate. The warmth can take 6 months or longer to resolve. Swelling and redness generally resolve within a few weeks of surgery.

A bone scan is a nuclear medicine radiological study that reveals bone metabolic activity. It will light up in areas that are irritated such as fractures, stress reactions, tumors and arthritic joints. If a bone scan is performed within 2 years of a total joint replacement, it will show increased bone metabolic activity adjacent to the relatively new prosthesis (even when the prosthesis is functioning properly). This is further indication that the healing process following joint replacement progresses over a very long period of time. Thankfully, the replaced joint usually feels great, long before the body has fully recovered.

So, after total knee replacement you can monitor the healing process by feeling the skin overlying your knee. As your skin gradually cools off, month-by-month, you know the healing process is winding down.

Please note: Severe swelling/redness, drainage from the wound, increasing pain, and/or loss of range-of-motion should not be assumed to be normal. If there is any concern, you need to be evaluated by your orthopedic surgeon immediately.

163 Comments

trish erickson link

9/23/2017 07:51:23 pm

I had a total knee replacement 15 months ago. Since then 3 of my fellow co-workers have had the same procedure and they are pain free, no swelling and are can perform normal day to day activities. I am in constant pain, I have told this to my surgeon with every post surgery monthly visit. It is always hot to the touch and swollen. My surgeon prescribed a nuclear bone scan 15 months after surgery, he said I have a hot knees and he recommended I see another surgeon for a 2nd opinion. He said-worse case - i need another knee replacement. What does a hot knee mean and what causes it?

Christopher Gorczynski, MD link

9/24/2017 08:15:58 am

I am sorry to hear you are having difficulty. While this kind of scenario is relatively infrequent, it does present a challenge.

You need to have a consultation with an orthopedic surgeon.

As I mention in the blog posting above, a standard 3 phase bone scan may still be "hot" up to 2 years from surgery. It does not necessarily mean that there is a problem. Your ongoing pain, warmth, and swelling at 15 months from surgery is not normal, however. This indicates your knee is still inflamed.

The explanations for your situation (differential diagnosis) includes: infection, stress reaction due to poor bone quality or malalignment of prosthesis, early loosening, sensitivity or allergy to the metals or other materials used in the prosthesis.

To help determine the cause in your case I would recommend several things:

1- Blood work. Complete blood count with differential to evaluate white blood cell level and type, erythrocyte sedimentation rate, C-reactive protein. If these are elevated an infection is more likely.

2- White blood cell labeled scan. If this shows uptake around the prosthesis, infection is more likely.

3- Material sensitivity testing. Common materials used in total knee replacement include: Cobalt, chrome, nickel, titanium, polyethylene, polymethylmethacrylate. A history of irritation due to costume jewelry could indicate metal sensitivity.

4- An objective appraisal of the prosthesis alignment in all planes including rotation. This would potentially require a CT version study to help determine rotational alignment of prosthetic components.

5- Your surgeon is correct in that your operation might need to be repeated. It is very important to have a diagnosis and plan going into surgery, however. I would complete the entire workup prior to surgery to remove as many variables as possible. Then during surgery it is important to send multiple samples of tissue to the pathology lab for evaluation using a technique called a frozen section. The pathologist immediately evaluates the tissues for the presence of acute inflammation/infection, guiding the surgeon's decision.

If an infection is diagnosed, the gold-standard treatment recommendation is a 2-stage revision. This entails packing the knee joint with high-dose antibiotic cement while you receive IV antibiotics. Then, usually 6-8 weeks later, a new prosthesis can be implanted.

For simple malalignment, a single stage reconstruction can be done, correcting the prosthetic position.

For material sensitivity/allergy, a prosthesis that does not include the offending material is needed. This can present a challenge in certain circumstances. The most common sensitivity is to nickel. For this, an oxidized zirconium implant could be used. Sometimes, unfortunately a custom implant, or other solution like a knee fusion (arthrodesis) needs to be considered.

This is clearly a complicated scenario, and my intention is not to frighten you. All of the possible issues I discussed can have a good outcome when handled properly.

I would not go directly to an early revision based on the scenario you describe. More information is needed to formulate a diagnosis and plan. This is very important. I would not recommend simply taking the prosthesis out and putting a new one in. Your surgeon needs to understand what is going on. That way the issue can be corrected.

Cary

2/16/2019 03:25:27 pm

I been 9 month of total knee replacement and i still have pain , swalling and only 50 rom. My last visit to my my surgeon was im going to stay like that for the rest of my life waking with a cane and limping and pain im only 52 years old i gain wait not able to walk only around my house because i have pain and is dificult to walk to do my normal life . i have never been able to drive again because of my bending of the knee please nee help can at this time ice will help me i stop ice 3 month because was not help. Thank you cary

Reuben O. Martinez link

6/29/2022 03:51:02 pm

It's been 2 years now since both my knees were replaced and they are still hot and wake me up every night and have to take the bed sheets off them as it gets too hot and sweaty and they still feel weak 😓 Should I be worried????

Peppy Walsh

11/22/2022 10:52:21 am

I had a TKR in October 2022. While I do not have this person’s issues, I was happy to read your EXCELLENT reply to this gentleman. There were many options to be looked at before having surgery again because of the possible situations for his pain. I still have some swelling and discomfort but I am able to function well by doing my exercises daily, going to outpatient Physical Therapy, and icing. Because my surgery is still relatively new, your information was very helpful.
Thank you,
Peppy Walsh

Debbie

12/14/2018 08:02:41 pm

I had TKR 3 years ago. When I got home they didn’t set up therapy for 10 days. Needless to say my leg got stiff and at 100 degrees back and still could put two hands under it. A year later I went back and the same Dr. did an in and out surgery. This was not an augmentation but he cleaned it up.
I went to therapy the next day lightly. The following day we worked more on it then I worked it over the weekend. I went back to therapy on Monday at 9 am and did 1/2 hour therapy, by 6:00 pm my upper thigh swelled so bad and I was in so much pain I called the Dr and he said it was bleeding inside around the surgery sight. Keep it elevated for 2-3 days. I went back to therapy with still some pain but continued to work it. Two weeks later I had 110 degree Bach and one hand under to flatten. I got gout so severe in my ankle I couldn’t walk for four days so by the time I finished my 20 days of therapy I was at 120 and close to being flat. My knee still hurts bad I limp all the time and the knee has been warm to touch since I had theTKR 3 years ago. What should I do? My hips also hurt along with the other knee.

12/14/2018 08:41:35 pm

I try my very best to have patients understand that the best total joint replacement results happen when patients take responsibility for their own rehab. Rehabilitating a total knee requires stretching the knee straight and bending it, for long periods of time, until an acceptable range of motion is gained. This needs to be done throughout the day, every day, with no days off. Formal physical therapy then serves only to help reduce inflammation and encourage patients. Patients that work diligently on their own rehabilitation from the beginning do best. It is extremely difficult to get an outstanding result when trying to play "catch up." It sounds like your surgeon performed an arthroscopic lysis of adhesions and manipulation under anesthesia. This helped you get an acceptable range of motion. Generally, a well rehabilitated total knee should become close to, if not completely, pain-free. When this does not occur we need to make sure the alignment of the prosthesis is optimal, there is no infection, there is no loosening, and there is no referred pain from another joint or nerve. This requires evaluation by an orthopedic surgeon. Rarely, patients experience ongoing pain we can not explain. There are still additional treatment options in this unusual situation. Unfortunately, I can not tell you exactly what to do. If you have hip arthritis (you mentioned hip pain) this often causes pain that radiates into the knee, and thus I am suspicious of this. An x-ray would help to evaluate this, a hip joint injection could be done to confirm this diagnosis. Whenever a patient experiences ongoing pain after total joint replacement, they need to follow-up with their orthopedic surgeon for evaluation and guidance.

Libby

8/21/2020 03:08:19 pm

I had both total knee replacements 15 months ago and I have had what I think a slower recovery. I do believe I'm still recovering getting better but I do know people who have seemed not to have the hurt I still feel at times. I have and still do some therapy at home. I'm very active in push mowing our yard and yes I've done this every since about 4 months after surgery. This was my