Hello, fellow knee warriors!
It’s been a considerable amount of time since my last post and I am continuing to do well. The third anniversary of my left knee surgery is coming up in September, and it will be four years next January since I had my right knee done.
On that note, here is an article I found on Healthgrades on what doctors want patients to know about knee replacements.
Knee replacement is one of the most common orthopedic surgeries in the U.S. It has a high rate of success, but it’s not a walk in the park. Some top doctors talk about common misperceptions and the actual experience a knee replacement patient can expect.
The decision to have knee replacement surgery is YOURS.
“There have to be X-ray findings of arthritis, which means the cartilage is completely or almost completely worn out. But it is totally up to the patient when to proceed, based on how bad their symptoms are,” says Thomas Bradbury, MD, an orthopedic surgeon with Emory University Hospital in Atlanta. “Wear and tear of the knee is like treads on tires wearing out,” says David J. Mayman, MD, an orthopedic surgeon at the Hospital for Special Surgery in New York City. “If the ‘tire’ wears out, the only eventual option is going to be knee replacement. It depends on whether nonsurgical therapies are helping with pain and function.”
Patients who have realistic expectations about knee replacement surgery do best.
“I think the patient expectations part is huge. What’s critically important is that patients recognize what a knee replacement is,” says Dr. Mayman. “All too often patients come in and say, my knee hurts, and they assume they will have a knee replacement and all of a sudden they’ll have a knee just like when they were 16 years old. Knee replacements are very good, but they are not normal knees.” “If a patient is not given appropriate expectations, those are the ones that have a difficult time,” adds Dr. Bradbury. “I tell my patients for the first two weeks after surgery, ‘you will cuss my name on a daily basis, and then by two, three weeks you will have recovered enough to start to see the light.’”
You’ll probably do well, but your new knee will have some limitations (NOTE: I can certainly vouch for this!)
“Squatting and kneeling activities are difficult to get back,” says Scott Anseth, MD, an orthopedic surgeon with Abbott Northwestern Hospital in Minneapolis. Hiking, golf, and some tennis are all reasonable, but “impact activities, such as running, are unrealistic,” he adds. “You often end up with some numbness in the skin around the knee and the new knee looks bigger than the other side,” says Dr. Mayman. “A knee replacement makes noise,” he adds. “It’s metal and plastic, and the parts click a bit. The other issue is that probably 10% to 15% of people will still have some pain going up and down stairs—that’s something we have not solved.”
Get as healthy as you can before knee replacement surgery.
“Smoking dramatically increases the risk of delayed wound healing or infection,” says Dr. Bradbury. “Other medical problems like poorly controlled diabetes or obesity increase the risk of infection too. “Some obese people are malnourished, and they don’t heal well.” “My personal experience is that those who exercise generally have a much smoother progression during recovery,“ says Dr. Anseth. Your emotional well-being counts too. “Anxiety and depression have huge effects on recovery. We know that people who go into knee replacement with untreated anxiety and depression do not do as well,” notes Dr. Mayman.
Our pain management philosophy for knee replacements has changed for the better.
“We’ve made real improvements in pain management. We try to manage the pain the whole way through the system,” says Dr. Mayman. That includes a local anesthetic in the joint, a nerve block in the thigh, and an epidural during surgery. “We’ve found that if pain signals don’t get set up in the first couple of days after surgery, people tend to have a lot less pain overall,” Mayman says. Doctors minimize the use of narcotics these days. “By six to twelve weeks, we really need to start having these patients off narcotic medication,” notes Dr. Anseth.
Choose a knee replacement surgeon who does the surgery frequently.
“You want a surgeon that does a fair number of these surgeries so he can do it quickly but safely. Having the surgery done in an orthopedic specialty hospital is the ultimate option, because they do it every day, so the team works very well together,” says Dr. Bradbury. “Patients come in asking about small incision techniques. Quite honestly, that’s a small piece of what makes a knee replacement turn out great. Instead, ask, ‘Do you know how many patients are doing well? What is your complication rate?’” says Dr. Mayman. A low infection rate is also very important when choosing a surgeon.
The choice of implant is not important as you think.
“Patients come in and they’ve seen the latest ad and say, ‘what implant do you use? I want the best one.’ The fact is, there are five big orthopedic implant makers and there’s no difference in outcome between them,” says Dr. Mayman. “If there was one that was the best, we’d all use the one that’s the best. Patients should probably spend a little less time reading some of the marketing material and spend more time looking into the nuts and bolts of how the surgery gets done.”
We’ve made some significant changes in technique over the past few years.
“If you look at the things we’ve really improved on in the past five years, it’s decreasing the amount of bleeding people have with surgery and improving their postoperative pain management,” says Dr. Mayman. “We started using a medication cardiac surgeons have been using for more than twenty years, and it’s decreased the risk of needing a blood transfusion from 15% to less than 1%, so that’s a big advance. If there’s less bleeding, there’s less blood in the knee after surgery, and having less blood in the knee means less pain for patients and an easier time getting back range of motion.”
We are very cautious about replacing both knees at once. (NOTE: My own surgeon advised against this in my case)
Can you do both knees at once? “That’s a hotly debated topic. The answer is we can do both if the patient is healthy enough,” says Dr. Mayman. “Some institutions feel it’s too big an operation, but here [Hospital for Special Surgery] we do both knees at the same time in 10 to 15 percent of patients. We have very strict medical criteria, and we’re very experienced doing it.” “For me, that’s a difficult rehab pathway,” says Dr. Anseth. “Are the patients committed enough to go through that? I’ve had patients struggle mightily after bilateral knee replacement, for a long time, and they are not very happy with their decision.”
A knee replacement should last for decades, and is often a successful, life-changing surgery (NOTE: the latter is certainly true for me!)
“There are a lot of folks who have a lot of anxiety about the surgery so they don’t pursue treatment”, says Dr. Bradbury. “I think it’s important to understand that the safety profile of knee replacement is very, very good and it is typically capable of dramatically improving pain, function, and quality of life. My recommendation for someone who has a lot of concern about the operation is that the price tag you pay for the end result is well worth what you have to go through.”