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.

6 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.

Lori Hartman

2/5/2018 11:35:06 pm

I had total left knee replacement 3 months ago and was doing great. Until 2 weeks ago, now going on 3 weeks. My knee swells all day and I am pain 24 hours a day. My knee is really warm. My right knee replacement never acted like this. Pain meds do nothing; ice does nothing. I limp all the time. I don't believe my ortho doctor knows what to do with me. I will now get a second opinion because I can't live like thisl.

2/5/2018 11:52:03 pm

This is concerning. It is unusual to have a major setback as you describe at this stage of the recovery period. If the knee is swollen it should be aspirated and the fluid sent for gram stain and culture. You should also have some bloodwork done. This should include complete blood count, erythrocyte sedimentation rate, and C-reactive protein. These tests will help to rule out an infection. A stress fracture should also be considered based on the history of going great for a couple months. Difficulty with range of motion can also cause pain. How was your range of motion prior to this setback? How is it now?

Marjorie Ruth Jones link

4/15/2018 01:08:58 pm

2013 I had TKR: prior to Surgery I informed Surgeon and Preassessment nurse and threatre nurse that I had metal alloy allergies: Unfortunatly I became very poorly. not getting any explanation from G.P.'s or Consultants I had a private metal allergy test done and the results showed strong positives to Nickel 1 and 11 as well as 8 other positives. I realised the implant was toxic to me and that I was being poisoned by the implant. Eventually 2 years following the 1st surgery I had revision surgery with a nickel free implant. My general health improved dramatically BUT I am now having problems with the new implant: I believe this implant also has a metal I'm allergic to namely Tatanium (I showed a positive to this metal). I have been diagnosed with Osteopenia which I believe has been caused by revision surgery. I now have to take medication for this condition. I am most unhappy that my declaration of metal alloy allergies was ignored and to compound this..my private allergy test results were either not read or simply ignored...I now have had revision surgery and suspect I am reacting to the new implant done 2015. The knee is constantly swollen, I have to use a wheelie to get around or I would be housebound. Its very painful. I was initailly told my TKR would change thing for the better... its much worse than I could have possibly imagened. I feel I have been decieved, feel like my health problems resulting from the initial knee implant were ignored. Whenever I tried to speak about the problems I was ignored and told its was most unlikely that the implant could effect my general health. My life has been ruined and every G.P. or consultant just don't want to know...What has happened to the duty of care "to do know harm". Why do medical "experts" refuse to acknowledge that things can go wrong and admit to ignoring my metal alloy allergy should not have happened. I have lost all trust in doctors and surgeons. I don't know what the future holds for me and the medicals don't care.
ruth jones

4/15/2018 05:18:44 pm

I am sorry to hear about your experience. Metal allergy is a known issue. Thankfully, it is a fairly rare problem. Metal allergy testing unfortunately isn't perfectly reliable, and is often quite expensive. In the ideal world everyone would be tested prior to implantation of a prosthesis.

It is truly unfortunate that you reported a sensitivity and then a nickel containing implant was used. Avoiding titanium is more difficult, but not impossible. This is because most knee implant systems use a titanium modular baseplate on the tibia. It is much easier when done as a primary knee replacement, as a non-modular, all polyethylene tibial component could be used. This is not possible at this point as revision surgery requires a stem. Nearly all stems are titanium.

I encountered exactly this problem in the recent past. We tested the patient for allergy to zirconium. Once we proved this material did not present a problem, we then worked with the implant company to fabricate a custom revision tibial component. The patient already had a zirconium femoral component. Getting this implant fabricated took a long time and many steps, but this is a potential solution to your predicament.

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Skin warmth after total knee replacement

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