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Lymphedema and Total Knee Replacement

Related Terms:  TKA, Arthroplasty, TKR, knee arthroplasty, knee prosthesis


From time to time there have been numerous questions posted on the lymphedema boards regarding complications involved with total knee replacement for those with lymphedema. There is only a limited amount of information available and only one published report of follow-up with lymphedema patients undergoing the procedure.

In that report the overall total complication rate was 31% in a group of  63 lymphedema patients.  There were ten superficial wound infections, six deep infections and three deep venous thrombosis.  The report does also conclude that despite the complications there was a significant improvement in knee function and patient mobility.  View the entire article at the link provided below.(1)

This is apparently further verified by the random discussions of list members who have undergone the surgery.  The other most commonly mentioned complications are set backs which include an increased time of post surgical rehabilitation and a temporary increase in the lymphedema as a result of not being able to undergo decongestive massage therapy and inflammations.

Preoperative Considerations for Lymphedema Patients:

1.  For the prevention of infection and/or to lower the risk of infection it may be necessary for you to be on a preventative therapy of antibiotics BEFORE surgery.

2.  For the prevention of blood clots (venous thrombosis) and based on any additional underlying medical conditions, you should also discuss the possibility of being on blood thinners before the surgery.

3.  Make arrangements and plans for the scheduling and/or resumption of decongestive massage therapy for the lymphedema after the surgery.

4.  Be sure to have your PCP, surgeon and lymphedema therapist working together to design a treatment/therapy modality that is best for you.

5.  Familiarize yourself with the knee replacement surgery so that you will know what to expect.  There are also support groups of patients undergoing this that you may want to participate in.

6.  Before the final decision to have a knee replacement discuss alternatives. It is possible for non-steroidal anti-inflammatory drugs (NSAIDs) to help or COX-2 inhibitors. With consideration of surgical complications, it is important to try all methods of treatment before a surgery is planned.

7.  What happens if the knee wears out? Knee replacement have an average usage expectancy from between eight to twenty years.  What are the considerations of the need for a future second surgery affect your lymphedema?

8.  Be sure to question your doctor about the possibility of using the minimally invasive partial knee replacement procedure.

9.  If you are obese or morbidly obese discuss how the added strain of the surgery will affect your lymphedema.

10. Be sure to understand the specifics of what you can or can't do, how long you will be off work, financial arrangement and the need for personal assistance you may have.

11. Discuss lymphedmea self care before the surgery. Your lymphedema therapist will, based on your personal situation let you know when you will be able to resume bandaging, wearing compression garments and/or use compression sleeves.


Potential Complications of Total Knee Replacement Surgery

Unfortunately, even the most minor of surgical operations carries some risk of complications occurring. Knee replacement surgery is very successful, and complications are relatively uncommon, considering the complexity of the procedure.

It is fair to say that you have about a 96% chance that you will go through the operation without any significant complication occurring.

The most common complication is blood clots in the legs. The most serious complication is infection. The most important long-term complication is loosening.

Bloodclots in the veins of the legs are the most common complication of knee replacement surgery. As long as the clots remain in the legs they are a relatively minor problem. Occasionally, they dislodge and travel through the heart to the lungs (pulmonary embolism). This is a potentially serious problem, since (very rarely) death can result from embolism. The chances of this are one out of several hundred. The internist will prescribe Coumadin (warfarin), heparin or Lovenox (blood thinning drugs) to help prevent clots from forming after your surgery. Additionally, compressive calf pumps are used and leg exercises are encouraged to prevent blood clots. Blood clots can occur despite all these precautions. They are usually not dangerous if appropriately treated, but may delay your discharge from the hospital for two or three days.

Infection. The risk of an infection in first-time knee replacement is currently reported as being about 0.5%. The risk of infection after joint replacement is much greater than with most other operations, unless special precautions are taken. Since bacteria can enter the open wound at the time of the surgery in a regular operating room, we operate in a laminar flow operating room in which special filters provide clean air, free of most bacteria. In addition, the surgeon and assistants wear a sterile space suit. The suit encloses the entire head and body, and includes a sterile face mask. Antibiotics given to you before, during and after the operation further help to lower the rate of infection.

The risk of infection in the weeks after the operation is increased if you have rheumatoid arthritis or diabetes, if you have been taking cortisone for prolonged periods of time, if the affected joint has had previous infection, or if you have infection anywhere else in your body" (teeth,bladder, etc) at the time of surgery. The artificial joint can become infected many years after the operation. The bacteria travel through the blood stream from a source elsewhere in the body" , such as from an infected wound, or a gall-bladder infection. Even regular dental work can release bacteria into the blood. Infections of the bladder, teeth, prostate, kidneys, etc. should be cleared up by appropriate treatment well before the day of surgery. Patients who have had joint replacements must take antibiotics by mouth before and after any dental workand must have all infections vigorously treated.

Loosening of the prosthesis from the bone is the most important long-term problem. How long the bond will last depends on a number of factors.

  1. How well the surgery is done. This is by far the most important factor. Choose a surgeon who has had a great deal of experience with knee replacement, and preferably one who restricts his practice to joint replacement surgery.
  2. The quality of your bones. The harder your bones are, the better the bond will be, and the longer the replacement will last. Osteoporosis is a factor of age, as well as the type of arthritis you have. People with rheumatoid arthritis have especially soft bones.
  3. How active you are. Excessive force on the implant can cause the bond to loosen. If you stayed in bed for the rest of your life the implant will probably never come loose! Activities such as running and heavy lifting should be avoided. The key thing is to use common sense. 
  4. Your weight. You should also keep your weight down because every pound you gain adds three pounds to the force to the knee.
  5. The design of the implant. Small abrasion particles from the implant may play a role in implant loosening. Some designs shed more particles than others.
Wound healing can occasionally be a problem after knee replacement. The skin wound over the knee sometimes does not heal completely. Parts of the skin may die after the surgery. This is a major complication which occurs very rarely. Every precaution is taken to prevent it. If it occurs it may require skin grafting and possibly "rotation" of a muscle from the calf to cover the implant and prevent it from becoming infected. Fat legs are more prone to this complication.

Nerve damage can (rarely) occur with knee replacement. The most common nerve damaged is the nerve to the muscles which bring the foot up toward the face (the peroneal nerve). The odds of this occurring are probaby one in many hundreds. If it does occur, the affected nerve usually recovers after 6 to 12 months. Quite commonly the skin around the knee feels "numb" because of small skin nerves that get cut at surgery. Sensation usually returns to normal within a few months.

Patellar complications can occur. Occasionally the knee cap does not track properly causing it to "jump" as the knee bends. The chance of this occurring is less than 1%. The plastic part on the patella can wear through. These problems sometimes need reoperation for correction.

Injuries to the arteries of the leg is a remotely possible but serious complication. The major arteries of the leg lie just behind the knee joint. Arterial injury can usually be repaired by a vascular surgeon. If not, you could even lose your leg. The chance of this occurring is extremely small.

Loss of knee motion: It is difficult to regain bending motion that has been lost for many years and if the knee only bends 90 degrees before the operation, it is unlikely to bend much more after the operation. For unexplained reasons, some patients form excessive scar tissue in the knee after surgery, resulting in diminished bending of the knee (a condition called arthrofibrosis). It is impossible to predict ahead of time which patients might develop arthrofibrosis. Sometimes it helps to manipulate the knee under an anesthetic to break down the excessive scar tissue 

Fracture of the knee bones rarely occurs during knee replacement. It is more common during revision knee surgery. Fractures can also occur later from any trauma such as falling down stairs, and (rarely) during manipulation for arthrofibrosis.

Bleeding complications.  Sometimes bleeding can occur into the wound several days after surgery (“hematoma formation”) as a result of the use of blood thinners. If it is excessive, it may require re-opening the wound under anesthesia to let the blood out. Occasionally the blood thinners may cause bleeding into the urine (or elsewhere), but this is usually temporary, and not of serious consequence.

Anesthetic complications can occur, and very rarely even death can occur from the anesthesia. Your anesthesiologist will see you before surgery and explain the risks involved.

Allergy to the metal parts of the implant has occasionally been reported. People who know they have metal allergies should be tested with extracts of the various metal components of the implant prior to surgery. You should notify your doctor if you believe you have a metal allergy. Metal allergies are rare and the tests are not completely reliable, so they are only performed if a metal allergy is suspected. Allergy to the plastic parts has never been reported. Small particles of plastic or metal from the implant may cause a reaction in the bone but this is not a true allergy.
  1. Complications From Blood Transfusions. The risks of getting AIDS from screened, banked blood is thought to be in the range of 1 in 250,000 units transfused. The risk of Hepatitis B is estimated to be approximately 1 in 550 units, and Hepatitis C is 1 in 100. It is not known if the risk of disease transmission from directed blood (see Blood Transfusion for Total Joint Replacement) is lower than the risk from ordinary banked blood. The risk of an allergic reaction (hives) is 1 in 500. You can have an allergic reaction to donor blood even though it has been properly cross matched. The risk of a Hemolytic Transfusion Reaction is 1 in 10,000. The risk of a Fatal Hemolytic Transfusion Reaction is 1 in 100,000.

    All blood intended for transfusion (including your own) is screened by the blood bank for Hepatitis B virus, Hepatitis C virus, syphilis, Human T Cell Leukemia virus, and the AIDS virus.

  2. Fat Embolism. Fat from the bone marrow can get into the circulation and cause lung or neurological symptoms. This is a very rare complication.
  3. Numbness around part of the wound is common and permanent. Never apply hot packs to the area since you could burn the skin.
  4. Other minor complications can rarely occur. You should keep in mind that the chances of any significant complication are very small.

Special thanks to the Hip and Knee Institute - Tarzana, California


Revision Knee Surgery

Total knee replacement implants may fail after 10 to 15 years, or occasionally sooner. The parts may come loose or they may wear out. In either case an operation will be required to replace the damaged part or even the entire implant.

Revision surgery is much more complex and technically much more difficult than first-time surgery, and requires prolonged operating time.

It may also require an increase in the length of the hospital stay. The magnitude of this surgery depends on the difficulty of prosthesis removal and on the quality and quantity of bone left behind after the implant has been removed. The revision operation may require bone grafts from a bone bank to be used. A custom prosthesis is sometimes needed (a prosthesis specially manufactured for a specific patient). Patients who have had knee revision operations are frequently advised to continue the use of a full-time support (such as a cane), in order to protect the replacement. This is especially true of those who are younger than 70, have higher activity levels, increased weight, and other stress factors.

These complex operations are much riskier than first-time knee replacement surgeries. All the risks associated with first-time knee replacement are present, but the chances of these complications occurring are greatly increased.

There is a chance that your leg may be shorter than it was before the operation, there is also a great risk that the alignment of the leg will not be entirely normal. There is also a good chance that the range of motion in the knee will be much less than after a first-time knee replacement. 

These technically demanding operations should be performed by a surgeon skilled and experienced in both first-time knee replacement surgery and revision surgery.


From the British Lymphoedema Support Network (LSN) Newsletter.

Questions and Answers

The LSN's Chief Medical Adviser, Professor Peter Mortimer, MD, FRCP
Professor of Dermatological Medicine attended a meeting in March 2001 at the
Royal Marsden Hospital Chelsea and answered members' questions.

Question: Do you recommend hip or knee replacements?

Answer: My attitude has changed somewhat. Previously I was hesitant to
recommend joint replacements for patients with lymphoedema because of the
problems of poor healing, seepage or infection. But now that the replacement
operations are more generally performed, I have begun to see lymphoedema
patients who have successfully had it done. And, after all, if your mobility
deteriorates, your lymphoedema will get worse, so it's a Catch 22 situation.

The big enemy is the danger of infection in the prosthesis. Many orthopaedic
surgeons write and ask me what I would recommend at the time of the
operation to prevent problems. I say that the antibiotics are crucial and
obviously trying to reduce the swelling both before and after the operation
minimises problems.

We have been trying to audit lymphoedema patients who
have had a hip or knee replacement and we would like to know through the LSN
of patients who have had this done successfully.

Question: I have had lymphoedema for 35 years and it does not get any
better..... and have now developed arthritis of the knee.

Answer:  As far as joint replacements are concerned, which is of course an
option, I used to say "If you cannot walk very well, it does not help the
lymphoedema and you are probably in pain". More and more lymphoedema
patients are having joint replacements and in general if we have managed to
avoid infection and look after the lymphoedema, the likelihood of problems
seems to be small. More mobility afterwards means that exercise will help to
keep the lymph moving, but make sure the orthopaedic surgeon is fully aware
of lymphoedema and what should be done.


Medical Encyclopedia

Knee joint replacement prosthesis

Knee joint replacement prosthesis


Knee joint replacement - series: Normal anatomy

  Normal anatomy

The knee is a complex joint, which is made up of the distal end of the femur (the femoral condyles), and the proximal end of the tibia (the tibial plateau). The femoral condyles usually glide smoothly on the tibial plateau, allowing for smooth, painless motion of the lower leg.

Update Date: 7/6/2001

Updated by: A.D.A.M. Medical Illustration Team


Knee Illustrations

Gray's Anatomy


Technique for Total Knee Replacement


Cross Section of Knee Joint


Medline Plus

National Institutes of Health

Total Knee joint replacement

Alternative names

Total knee replacement; Knee arthroplasty


Knee joint replacement is surgery to replace a painful damaged or diseased knee joint with an artificial joint (prosthesis).


The operation is performed under general anesthesia. The orthopedic surgeon makes an incision over the affected knee. The patella (knee cap) is moved out of the way, and the ends of the femur and tibia are cut to fit the prosthesis and to provide better adhesion of the prosthesis. Similarly, the undersurface of the knee cap is cut to allow for placement of an artificial component.

The two parts of the prosthesis are implanted onto the ends of the thigh bone (femur), the shin bone (tibia), and the undersurface of the knee cap (patella) using a special bone cement. Usually, metal is used on the end of the femur, and plastic is used on the tibia and patella, for the new knee surface. However, newer surfaces including metal on metal, ceramic on ceramic, or ceramic on plastic are now being used.

You will return from surgery with a large dressing to the knee area. A small drainage tube will be placed during surgery to help drain excess fluids from the joint area.

Your leg may be placed in a continuous passive motion (CPM) device after surgery. This is a mechanical device that flexes (bends) and extends (straightens) the knee to keep the knee from getting stiff.

Gradually, the rate and amount of flexion will be increased as tolerated. The leg should always be in this device when in bed. The CPM device helps speed recovery, decreases post-operative pain, bleeding and infection.

You will experience moderate pain after surgery. However, you may receive injections of narcotic medications, patient-controlled analgesia (PCA) or epidural analgesics (spinal) to control your pain for the first 3 days after surgery.

The pain should gradually decrease, and by the third day after surgery, oral medications may be sufficient to control your pain. Try to schedule your pain medications about one half hour before walking or position changes.

You will also return from surgery with several IV lines in place to provide fluid and nutrition. The IV will remain in place until you are taking adequate amounts of fluids by mouth.

Antibiotics may be given to reduce the risk of developing an infection, necessitating removal of the artificial joint.

You will also return from surgery wearing anti-embolism stockings or inflatable pneumatic compression stockings. These devices are used to reduce your risk of developing blood clots, which are more common after lower extremity surgery.

Additionally, you will be encouraged to start moving and walking as early as the first day after surgery. You will be assisted out of bed to a chair on the first day after surgery. When in bed, bend and straighten your ankles frequently to prevent development of blood clots.

You may be instructed on how to use an incentive spirometry device (a plastic device to encourage deep breathing), and cough and deep breathing exercises to gradually increase the depth of your respirations in order to prevent lung collapse and pneumonia.

A foley catheter may be inserted during surgery to monitor the function of your kidneys and hydration level. This will be removed on the second or third day after surgery. You will be encouraged to try to walk to the bathroom with assistance.


Knee joint replacement may be recommended for: Knee joint replacement is usually not recommended for:


The risks of this surgery include:

People who have a prosthetic device (such as an artificial joint) need to take special precautions against infection. You should carry a medical identification card indicating that you have a prosthetic device. Also, always inform your health care provider of your prosthetic knee joint. You should receive prophylactic antibiotics prior to dental work or any invasive procedure.

Expectations after surgery  

The results of a total knee replacement are often excellent. The operation relieves pain in over 90% of patients, and most need no assistance walking after recovery. Most prostheses last 10 to 15 years, some as long as 20 years, before loosening and requiring revision surgery.


The hospital stay generally lasts 4-5 days, but the total recovery period varies from 2-3 months to a year. Walking and range-of-motion exercises will be started immediately after surgery. Some surgeons recommend using a machine that will bend the knee for the patient in bed.

Some patients require a short stay in a rehabilitation hospital to become safely independent in their activities of daily living. It may be necessary to use crutches or a walker for a few weeks or even months after surgery.

The physical therapy initiated in the hospital will continue after discharge until your strength and motion return. Contact sports should generally be avoided, but low impact activities, such as swimming and golf, are usually possible after full recovery from surgery.

Update Date: 10/28/2003


Abstracts and studies


Primary TKA in patients with lymphedema.

Orthop Relat Res. 2003 Nov

Shrader MW, Morrey BF.

Departmentof Orthopedic Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.

Lymphedema is a relatively common disorder; wound and vascular complications after orthopaedic surgery are assumed, but not previously shown, to be higher in this population. We reviewed the outcome and complications of knee arthroplasty in patients with lymphedema, documented by physical examination at their preoperative medical assessment. This was a retrospective analysis of prospectively collected data compiled on all patients having knee arthroplasty at our institution. Eighty-three knee replacements were implanted in 63 patients. Patients were followed up for a minimum of 2 years, with a mean followup of 58 months (range, 24-228 months). No patients were lost to followup. We noted significant improvement in the Knee Society score from a preoperative mean of 47 points (range, 16-75 points) to a postoperative mean of 87 points (range, 53-100 points). The knee functional score also improved significantly from a preoperative mean of 36 points (range, 0-80 points), to a postoperative mean of 59 points (range, 0-100 points). The total complication rate was 31%, with 10 superficial wound infections (12%), six deep infections (7%), and three deep venous thromboses (3.6%). We concluded that although knee arthroplasty can be successful in reducing pain and improving function in patients with lymphedema, the complication rate is greater than that seen in patients without this diagnosis.


Total Knee Replacement - OrthoInfo

Minimally Invasive Total Knee Replacement - OrthoInfo


Total Knee Arthroplasty in Patients with Lymphedema (1)

Dr. M. Wade Schrader, Dr. Bernard F. Morrey

Scroll dow, the article is #50


Total Knee Replacement: A Patient's Guide

University of Iowa Department of Orthopaedics
Orthopaedic Nursing Division


Total Knee Replacement - Surgery

Healthline provides a very comprehensive overview of knee replacement surgery as 
a critical starting point for individuals and/or their loved ones. The site
includes a cost estimator, real patient stories, medically reviewed advice,
videos, tools to explore the knee in 3D, and more.

Healthline Medical Information for Health

Healthline Home Page


Robin's Total Knee Replacement site

Excellent - from a patient's perspective


Total Knee Replacement

American Academy of Orthopaedic Surgeons


Total Knee Replacement

Evidence Report/Technology Assessment: Number 86


The minimally invasive partial knee replacement procedure


Basic knee replacement information


Edheads Virtual Knee Surgery


Computer-assisted surgery in total knee replacement.

May 2008

Elsevier Science Direct


Quality of tibial cementing in total knee arthroplasty: One or two phase cementing of the tibial and femoral implants.

May 2008

Elsevier Science Direct


Total knee replacement performed with either a mini-midvastus or a standard approach: A PROSPECTIVE RANDOMISED CLINICAL AND RADIOLOGICAL TRIAL

May 2008

Journal of Bone and Joint Surgery


Patients' perspectives on total knee replacement.

May 2008



See also:


Edema and Chronic Venous Insufficiency

Edema and Deep Venous Thrombosis

Edema and Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

Edema and Venous Pooling


Edema of the Neck

Edema and Nephrotic Syndrome

Edema of the Face


Edema and Diabetes


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For information about How to Treat a Lymphedema Wound

For information about Lymphedema Treatment

For information about Exercises for Lymphedema

For information on Infections Associated with Lymphedema

For information on Lymphedema in Children

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