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.

31 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?

Pauline

5/18/2018 09:04:49 am

I had a total knee replacement done in March of this year and I’ve had nothing but problems with cramps from my hip down to my foot night and day the knee is sore. It try’s to fall out from underneath me all of the time and it’s hot I can’t lay on left side all I stand nothing touching my knee at all on the door it goes numb The doctor doesn’t like to answer questions and when he does all he has to say is I guess my pain doctor said there’s something seriously wrong with the knee you can tell by looking at the color of it the knee doesn’t look right he use to to knee surgery s and hips shoulder s I where to go from here

5/21/2018 10:32:14 pm

While some discomfort is normal in the early postoperative period, this is expected to improve over time. Unfortunately, it is impossible to make a diagnosis based on your comment. I suggest you seek a second opinion from another orthopedic surgeon. If you were to see me I would examine your knee, test the stability and range of motion. We would obtain fresh x-rays as well. Sometimes lab work would also be required. Your experience is not typical. You definitely need a second opinion.

Barbara

8/19/2018 05:00:57 am

I have had similar issues. Unfortunately, my surgeon has had zero interest in my post op care. PT has told my that I have lymphatic dysfunction and post operative neuropathic pain. They seem to be on track for my care as I am seeing improvements but my recovery has been horrifically painful. It was almost 3 weeks before I could sleep longer than 15 minutes at a time. During the first few days, I gained 12 lbs in edema and was running a low grade fever. I tried calling my surgeon daily to report my symptoms and got a generic answer that pain and swelling is normal. Home health reported my issues and they received no answers back either. I am definitely finding a new surgeon for my other knee.

christopher gorczynski, MD link

8/23/2018 09:47:01 pm

@Barbara

A low grade fever is quite common for a couple days after surgery. Deep breathing, coughing, and walking will help this to resolve. While some pain and swelling is normal immediately after major surgery, the trend should be one of gradual improvement after the first couple of weeks. There is a normal inflammatory response to trauma that tends to peak around 10-14 days. Cryotherapy using regular ice or more conveniently with an ice machine can make an enormous difference and I strongly recommend it. Your surgeon should be monitoring your progress, particularly when your progress seems to be slower and less pleasant than normally expected.

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.

Lynn Jovan

8/17/2018 11:10:18 pm

I'm two post knee replacement
And had a second knee replacement in the same knee. I too was allergic to the nickel. I've seen many doctors No one can help my pain and mobility, I will never walk right again.
The doctors all stick together, it's so sad for people like myself. The quality of my life is limited.

8/23/2018 10:03:02 pm

Your frustration is understandable. Unfortunately your comment does not provide enough information for me to make any recommendations.
How was metal allergy diagnosed? Was the offending implant removed? If so, how long ago and what materials were used? Has infection been considered and investigated? Is the alignment and soft tissue balance in the knee optimized?

Erica Hamilton link

7/19/2018 01:51:34 pm

I had a partial knee replacement two weeks ago. It never occurred to me that I might be allergic to the metals, but I now realise I cannot wear anything but gold in my pierced ears and I never told them this. I have 115 degrees of flex and it appears to be doing well but the knee is very very hot, the wound itself stands up a lot and the discomfort is not yet decreasing. Should I worry? I have stents in the ileac arteries which are blocked 30% so infection was always my chief worry.

Christopher Gorczynski, MD

7/20/2018 10:01:36 pm

At just 2 weeks- heat and pain is normal and anticipated. This is expected to improve for months. I recommend consistently using ice, working on range of motion, and being patient. True allergy to prosthetic materials is rare. It sounds like you are actually off to a good start.

Judy

8/1/2018 06:44:23 am

Thank you I was questioning it was my knee replacement why it gets hot and looks sunburn

Lidia Herrera

7/28/2018 01:20:54 am

I had a knee replacement about 4 months ago I’m still with pain and my knee still little warm . Is that normal.

8/23/2018 09:56:45 pm

At 4 months from surgery it is normal for the knee to still feel a bit warm. Your range of motion should be good (0-115+) by this point. While a little pain can still occur, it would normally be relatively mild and the trend should be one of continual improvement for up to an entire year from surgery.

Michael Holdren

8/11/2018 09:48:12 pm

3 and 1/2 years ago I had a total knee replacement. I am 70 yrs old excellent health, no arthritis in other knee or other joints. Knee replacement done because of playing traveling softball and too many slides!
I still have persistent swelling in the knee joint. I had significant nerve pain at 1 and 1/2 yrs out which was “cured” by several sessions of acupuncture. However, continued acupuncture and cupping have not reduced the swelling and aching.
I purchased a BEMER through my Sports Med doctor and we are trying it - I have been using it for 1 and 1/2 months. It seems that my metabolism has kicked up, more fluid intake is noticeable and my overall well being seems improved - but no improvement regarding reduced swelling.

About a year ago I sought a second opinion. The doctor ordered chemical analyses of my blood/fluid and determined that I was highly sensitive to the metals, nickel and titanium. He said he could do revision surgery and replace the nickel with another metal but the titanium is in all devices so it could not be changed out. I went back to my original surgeon and also sought 2 more opinions and all 3 doctors said that the metals analyses results are highly controversial with previous studies show differing results.

Can you direct me to studies on metal sensitivities from TKR and perhaps other professional opinions on the value of the metal sensitivitiy tests?

8/12/2018 10:15:52 pm

I have experience dealing with sensitivity to both nickel and titanium in a total knee patient. This was resolved by first ruling out other issues. Because knee revision systems use titanium on the tibial component and any stems/augments we had to obtain a custom fabricated revision tibial base and stem made out of zirconium. This custom device was made by Smith and Nephew. They use zirconium routinely in femoral heads and femoral knee components. While this took a long time, it was an excellent solution to an otherwise very challenging problem.

I just wrote a new blog post discussing this issue further, and have a bibliography attached beneath the article.

Boguslawa Katyk

9/7/2018 10:26:07 pm

On January 25, 2018 I had a total knee replacement. After 8 weeks I had an infection, took strong antibiotic for 20 days, plenty of narcotics to ease pain, but my knee is still swollen and hot. I barely can walk, sleeping is difficult due to stiffness and pain, especially when trying to change positions.
My doctor finally got concerned and he did blood work and nuclear bone density test which shows inflammation.
I think I might be allergic to metal or glue (cement) but I don’t
know and also I don’t know where to do an allergy test and if it’s reliable.

Rose

9/15/2018 04:55:04 pm

I am 9 months post TNR and am active ; cycling 60k twice weekly,aqua aerobics twice weekly etc.I have no pain but find that my knee is very stiff still.Is this normal?

9/15/2018 09:54:24 pm

A patient will often report continued improvement for up to an entire year following total knee or hip replacement.This is because the healing process and post-operative inflammatory cascade takes a long time to resolve. To provide a more specific answer, I need a bit more information. What is your knee range of motion once warmed up? Does it get stiff only after exercise?

Donna Breault

9/28/2018 04:52:57 pm

I am a 52 year old female who had a TKR on my left knee 4.5 weeks ago. I am having a tough time increasing my range of motion despite doing my exercises 2-3 times daily and going to physiotherapy three times weekly. I am currently achieving in the low 70s. My surgeon told me yesterday that if I don't improve to 90+ within 4 weeks that I will have to have an additional surgery that will include a scope to help clean up scar tissue and to manipulate my knee while under anaesthetic. I found out the week that I had surgery that I am highly allergic to oxycodone, so I spent 5 days post operatively being unable to exercise because I was so sick. I only take extra-strength Tylenol now because I cannot take narcotics. My physiotherapist says that as long as I keep working hard that he believes that I will be fine in terms of being able to increase my range of motion over the next month. I don't want to have another surgery. How concerned should I be about this? Have other people had this happen? Are there any strategies that you can suggest that might help me improve my range of motion quickly?

Christopher Gorcynski, MD link

9/30/2018 11:05:33 am

In my experience, most patients have up to 6 weeks post-operatively to regain an acceptable range of motion following knee replacement surgery. I would recommend a manipulation under anesthesia if adequate range of motion has not been regained by 6 weeks. I would not recommend additional surgery at that time. A manipulation involves intravenous sedation and gentle progressive pressure applied to the knee to help it to bend. This breaks up adhesions between tissue planes. It usually allows much better/easier progression with PT/range of motion stretching. I would not recommend a surgical procedure this early. In my experience, once a patient gets beyond 6-8 weeks from surgery, manipulation is unlikely to be helpful because the scar tissue has had time to strengthen too much. It is at this point that an arthroscopic lysis of adhesions would be necessary. During this procedure, 2 tiny incisions are made in the front of the knee and the scar tissue that prevents motions is severed. Then the knee is manipulated as described above. The procedure itself is not a big deal. There is a small risk of infection- which is a big deal. It is for this reason I recommend early manipulation.

As far as pain control- NSAIDS tend to work better than narcotic pain medication for post-surgical inflammatory pain. I also highly recommend using ice, or purchase an ice machine which is much more convenient.

While your physical therapist might be correct, my experience suggests that patients that do not achieve an acceptable range of motion by 6 weeks will not ultimately do so without either a manipulation then or more invasive treatment, as described above, later on.

Please look through this website as I have written a variety of articles with regard to knee rehabilitation, manipulation, viscoelasticity, and anatomy.

The best way to stretch is to hold the knee at the endpoint of motion while attempting to relax the thigh muscles. I recommend long duration stretching...this means minutes or hours as opposed to seconds. Most physical therapists do not do this. Check out my viscoelasticity article to understand why this technique works better.

Good luck to you.

9/30/2018 11:54:15 am

Thank you very much for your detailed and informative response- it is very much appreciated! I think that the website is amazing and has a wealth of information available to people.

Lee

9/29/2018 04:33:05 pm

8 weeks ago I had total knee replacement on my right leg. I am 86 years young and have been blessed that I was off the walker in one week and off all meds including tylenol in two weeks. I could move and stretch my knee almost immediately, and my PT people said I was doing better than some fifty year olds.The first three weeks there was some pain, but I had no trouble sleeping nights. I had hesitated about having this done at my age, but had been getting injections in both knees for six years, for the arthritis. My friends can not believe how well I could walk almost immediately. My knee still feels a little warm, but I know I am blessed to have recovered so quickly.

9/30/2018 11:10:05 am

Lee- I am happy to hear about your successful early knee replacement rehabilitation. Your experience is thankfully the most common experience patients have. Most patients, once rehabilitated, tell us they wished they had decided to have their joint replaced earlier. Warmth after surgery will gradually resolve over months. Congratulations on your success and enjoy your new knee!

James

10/2/2018 02:27:34 pm

My wife had knee implants done over month ago she still has pain knee hot to touch her skin has discoloration has sharp shooting pain for her knee to her thigh the Dr said it was from scar tissue ?

10/2/2018 10:05:00 pm

It is totally normal for a knee to remain warm and somewhat painful for the first 4-6 weeks following knee replacement surgery. Warmth is actually normal for many months after this surgery. Discoloration is often normal following knee replacement for several weeks or longer. This is because there is often some bleeding into the soft tissues- this would appear as a deep bruise or simply darker skin. The inflammatory process associated with healing after surgery will often make the skin somewhat pink for a couple of months. Knee replacement rehabilitation is really a race between regaining range of motion and developing scar tissue that restricts motion. This can be challenging for some patients. I have several articles within this blog discussing this and providing strategies to facilitate a good outcome.

I don't have enough information with regard to this specific case to comment any further. Specific issues should be directed to her orthopedic surgeon. In general, worrisome signs include: fevers, chills, drainage, shiny red skin, extremely poor or progressive loss of range of motion, and increasing pain. Any of these should result in an immediate call to her surgeon.

Sarah Hermanauer

10/10/2018 09:59:37 pm

I had a dkr seven months ago and made astounding recovery in the first three months, walking with just a cane after just two weeks. Now after seven months I am in agony getting up from a chair, going down stairs and recently just walking. My knees are still warm to the touch and I am often awakened at night with pain. Any ideas of how I should proceed??

10/12/2018 10:28:36 am

Most concerning is the deterioration in function you describe. This is not normal. Typically patients will experience continued improvement in pain, motion, strength, and endurance for an entire year or more.

The first thing you must do is speak to your orthopedic surgeon. I would expect him/her to examine your knees and obtain X-rays. Depending on findings additional lab evaluation or advanced imaging may be required.

Some more information would be helpful to me to help narrow down the differential diagnosis (list of possible explanations).
1- Was the deterioration rapid or gradual
2- Have you begun any new activities?
3- How is your range of motion?
4- How is your hip strength?
5- Is there a place you can touch that hurts (tenderness to palpation), or is the pain diffuse?
6- Do your hips rotate normally and symmetrically?
7- Do you experience fevers/chills?
8- Do your knees feel stable (not wobbly when moving around)?
9- Does the pain radiate down your entire leg into your feet/ankles?

Basically- the differential diagnosis includes: referred pain from your back or hips; anterior knee pain due to patellar (kneecap) maltracking or hip weakness; instability of the knee; poor range of motion in the knees; stress fracture/reaction; infection. There are, of course, additional possibilities as well. This is why it is important to be seen by your orthopedic surgeon. If there is an inadequate explanation or plan offered, I would suggest a second opinion. Good luck, and please update us with your progress.

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Skin warmth after total knee replacement

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