Failed Knee Replacement: Revision Surgery in Birmingham
A failed knee replacement is one that is no longer functioning properly, causing pain, instability, or loss of movement. Mr Shakir Hussain, Consultant Orthopaedic Surgeon at the Royal Orthopaedic Hospital Birmingham, specialises in revision knee replacement surgery, restoring function for patients whose primary knee replacement has failed.
What is a failed knee replacement?
A failed knee replacement is a primary knee arthroplasty that no longer functions adequately, causing persistent or recurrent pain, instability, stiffness, or reduced function. Failure can occur for several distinct reasons, each requiring a different diagnostic approach and surgical treatment. Revision knee replacement surgery replaces the failed components with new implants and addresses the underlying cause of failure.
Knee replacement is one of the most successful operations in orthopaedic surgery, with approximately 90 per cent of implants still functioning at 15 years. However, around 5 to 8 per cent of patients will require further surgery during their lifetime, either because of implant-related problems or because the knee was never fully comfortable after the primary operation.
A failed knee replacement should not be confused with a knee that never met a patient's expectations but has no identifiable structural problem. True implant failure involves a demonstrable mechanical, infective, or structural cause that can be investigated and treated. Before revision surgery is considered, a thorough investigation programme is undertaken to identify the exact cause of failure, because each cause requires a different surgical response.
Mr Hussain specialises in revision knee replacement at the Royal Orthopaedic Hospital Birmingham, one of the leading specialist orthopaedic hospitals in the UK. The Royal Orthopaedic Hospital has access to the full range of revision implant systems, including stems, augments, and constrained implants required for even the most complex reconstructive cases.
How do I know if my knee replacement has failed?
Signs of a failing knee replacement include persistent or worsening pain after the expected recovery period of 6 to 12 months, swelling or warmth that does not resolve, a feeling that the knee is unstable or gives way, a grinding or clicking that was not present earlier, or a gradual reduction in function that was previously better. Any of these symptoms warrant prompt assessment by an orthopaedic surgeon with revision expertise.
Not every painful knee replacement has failed in the technical sense. Some patients experience pain that never resolves fully despite a structurally intact implant. However, the following symptoms suggest true implant failure and require urgent investigation:
Persistent pain after recovery
Pain that does not improve or actually worsens after the expected 6 to 12 month recovery period, particularly if it was better initially and then deteriorated, suggests an evolving problem requiring investigation.
Swelling, warmth, or redness
Persistent swelling, warmth, and redness after the acute post-operative period are red-flag signs of possible periprosthetic joint infection, which requires urgent investigation and treatment.
Knee instability or giving way
A feeling that the knee buckles, gives way, or is unreliable under load suggests soft tissue imbalance or ligament failure, which is a recognised mode of knee replacement failure requiring surgical correction.
New grinding or clicking
A grinding, clunking, or clicking sensation inside the knee that was not present during the early recovery period may indicate polyethylene wear, a loose implant component, or a periprosthetic fracture.
Reduced range of movement
A progressively reducing range of knee motion, particularly if extension (straightening) is becoming limited compared to the early post-operative period, may indicate implant failure, scar tissue, or infection.
Difficulty weight-bearing
A sudden inability or marked reluctance to put weight through the knee may indicate a periprosthetic fracture (broken bone around the implant) and requires emergency assessment.
What causes a knee replacement to fail?
The five main causes of knee replacement failure are periprosthetic joint infection, aseptic loosening, joint instability, periprosthetic fracture, and implant wear with osteolysis. Each cause presents differently, requires different investigations, and is treated by a different surgical approach. Identifying the precise cause before revision surgery is essential to a successful outcome.
Understanding the cause of failure is the most important step in planning successful revision surgery. The five principal failure modes are:
1. Periprosthetic Joint Infection (PJI)
Bacterial colonisation of the implant surface. Bacteria form a biofilm that protects them from antibiotics, making medical treatment alone insufficient. Revision surgery, either a single-stage or two-stage exchange, is required to eradicate the infection. PJI may present acutely (within the first three months) or as a late, low-grade infection years after surgery. Warmth, redness, and persistent wound problems are hallmark features.
2. Aseptic Loosening
Degradation of the bond between the implant and bone without infection. Over years, micro-motion at the implant-bone interface generates wear debris that triggers an inflammatory response, causing bone loss (osteolysis) and implant loosening. It is the most common cause of late failure. X-rays show a radiolucent line between the implant and bone, and the patient reports start-up pain and a deep aching that worsens with activity.
3. Joint Instability
Failure of the soft tissue balancing achieved at primary surgery, or subsequent deterioration of the collateral ligaments, leads to a knee that buckles and gives way. This can occur due to technical error at primary surgery, a mismatch between the implant design and the patient's anatomy, or progressive ligament degeneration. Surgical correction requires component revision with increased constraint to substitute for ligament function.
4. Periprosthetic Fracture
A fracture of the bone immediately above or below the knee implant, usually the distal femur or proximal tibia. Periprosthetic fractures most commonly occur after a fall in osteoporotic bone. Treatment depends on bone stock quality and implant stability: stable implants may be managed with fracture fixation, while loose or damaged implants require combined revision arthroplasty and reconstruction.
5. Implant Wear and Osteolysis
Wear of the polyethylene bearing surface generates microscopic debris particles that are engulfed by immune cells, triggering an inflammatory response that destroys the surrounding bone (osteolysis). Progressive bone loss weakens implant fixation and ultimately causes component loosening. Modern polyethylene manufacturing has significantly reduced wear rates, but it remains a cause of late failure, particularly in physically active patients.
Stiffness and Arthrofibrosis
Excessive scar tissue formation around the knee replacement severely restricts movement, particularly flexion. This can occur in patients with pre-existing stiffness, certain soft tissue conditions, or as a complication of technical problems at primary surgery. Treatment ranges from physiotherapy and manipulation under anaesthetic to surgical release of scar tissue in severe cases.
How is a failed knee replacement diagnosed?
A thorough investigation is essential before any revision surgery, because the surgical approach differs fundamentally depending on the cause of failure. Blood tests screen for infection; X-rays assess implant position and bone stock; CT scanning provides detailed three-dimensional analysis; and joint aspiration with culture is performed whenever infection is suspected.
The investigation of a painful or failing knee replacement follows a systematic protocol to identify the cause:
- Blood tests. CRP, ESR, and white cell count screen for systemic markers of infection. Elevated CRP and ESR together raise strong suspicion for periprosthetic infection, even in the absence of obvious clinical signs.
- Serial X-rays. Current AP and lateral weight-bearing radiographs are compared with the immediate post-operative films to identify any change in implant position, new radiolucent lines at the implant-bone interface, bone loss, or fracture. The pattern of bone loss helps distinguish infection from aseptic loosening.
- CT scan. Provides detailed three-dimensional assessment of bone stock, implant position, and bone loss before revision surgery. Essential for pre-operative planning of augment and stem requirements. Metal artefact reduction sequences (MARS) improve image quality around metallic implants.
- Joint aspiration and culture. In any case where infection is possible, the knee is aspirated under sterile conditions and the fluid sent for cell count, culture, and sensitivity. This is the most important single investigation for diagnosing or excluding periprosthetic joint infection before revision surgery.
- Nuclear medicine scanning. Labelled white cell scan or bone scan may be used in diagnostically difficult cases to detect areas of increased bone turnover or infective activity when other investigations are inconclusive.
- Intraoperative samples. At revision surgery, multiple tissue samples are taken from around the implant and sent for microbiological culture, providing the definitive test for low-grade infection.
Revision knee replacement surgery at the Royal Orthopaedic Hospital Birmingham
Revision knee replacement surgery removes the failed implant components and replaces them with new implants designed to restore bone stock, stability, and function. The complexity ranges from a simple bearing exchange to a major reconstruction requiring stems, augments, and constrained implants. Revision surgery should be performed at a specialist centre by a surgeon with dedicated revision experience and access to the full range of implant systems.
Revision Knee Replacement
Mr Hussain performs revision knee replacement surgery at the Royal Orthopaedic Hospital Birmingham, a specialist orthopaedic centre with full access to primary and revision implant systems. Revision surgery is tailored to the specific cause of failure identified during the pre-operative investigation programme.
- Single-stage or two-stage revision for periprosthetic joint infection
- Aseptic revision for loosening, wear, and instability
- Augments and stems to rebuild bone stock after osteolysis
- Constrained implant designs where ligament function is absent
- Periprosthetic fracture management with combined fixation and revision
- Full range of revision implant systems available at the Royal Orthopaedic Hospital
What are the outcomes after revision knee replacement?
Revision knee replacement is more complex than primary surgery and carries higher complication rates, longer operating times, and a more demanding recovery. However, when performed by an experienced revision surgeon at a specialist centre, the large majority of patients achieve significant improvement in pain and function. Outcomes are best when the cause of failure is precisely identified and the revision surgery is tailored to address it.
Revision surgery outcomes depend heavily on the cause of failure, the patient's bone stock, the complexity of the reconstruction required, and the surgeon's experience with revision procedures. For patients referred to a specialist revision centre with a clear diagnosis and a well-planned surgical strategy, the prognosis is significantly better than for revision performed without adequate investigation or at a general centre with limited revision experience.
Mr Hussain prepares a detailed pre-operative plan for every revision case, including CT-based analysis of bone stock, selection of appropriate implant systems, and, where infection is involved, coordination with the microbiology team to select optimal antibiotic therapy.
Expertise in revision knee surgery in Birmingham
Consultant at the Royal Orthopaedic Hospital
Mr Hussain practises at the Royal Orthopaedic Hospital Birmingham, one of the largest specialist orthopaedic hospitals in Europe, with full access to the complete range of primary and revision implant systems.
3,000+ arthroplasty cases
From a total of more than 5,000 procedures performed, giving the operative volume and case complexity required for consistently excellent outcomes. Read more about Mr Hussain's training and background.
MAKO, ROSA, and CORI robotic certifications
Mr Hussain holds certifications on all three major robotic knee replacement platforms, allowing precision alignment to be achieved even in complex cases with prior deformity or bone loss.
Dedicated revision surgery expertise
Mr Hussain specialises in revision knee replacement for all causes of failure, including infection, loosening, instability, periprosthetic fracture, and implant wear. See full details of revision surgery at the Royal Orthopaedic Hospital Birmingham.
Doctify Outstanding Patient Experience 2024, 2025, and 2026
Awarded in three consecutive years, recognising consistently high patient-reported outcomes and communication throughout the surgical journey.
4.98 out of 5 from verified reviews on Doctify. Outstanding Patient Experience Award 2024, 2025, and 2026.
Frequently asked questions about failed knee replacement
For more questions about revision surgery, recovery, fees, and what to expect, see the full frequently asked questions page or read recent patient testimonials.