“I replaced three joints in my hips and one in my knee. I’m
hoping that other knee doesn’t have to be done. It’s one of
the toughest things to overcome.” ~Phil Jackson
“I figured my body always would be able to repair itself. I think
all of us believe that – until you begin to age and get hit with
deteriorating joints. ~Lee Majors
This blog is an outlier of sorts. Based on my normal format, this is at
least one standard deviation from the median. Normally, I like to start
with some quippish anecdote, a humorous hook of sorts relating a past
personal experience with the topic at hand. However, today I start with
a question. A question that I get a dozen times or more every day in my
clinic: Do I need a knee replacement?
In my residency at Medical College of Georgia, my attending, Dr. Young—a
tall, blustery, full bird colonel—ran the Total Joint Services department.
Under his tutelage, I must have watched him brow beat patients a thousand
times for asking that question. He wanted to make sure they didn't
go into surgery lightly. What I learned from him back then still holds
true today: regardless of all the advances in technology, total knee replacement
is a big deal.
First, a little background. We have just entered the second half-century
of total knee arthroplasty. The first total knee replacement was performed
at Hospital for Special Surgery (HSS) in 1974 by John N. Insall, M.D.,
and Chitranjan Ranawat, M.D. Their implant was designed to recreate how
the real knee works, and it became a game changer in the field. These
days, due to innovations based on Dr. Insall’s sentinel work, total
knee arthroplasty has a 10-year survivorship of 98 percent and a 20-year
survivorship of 95 percent. So by those numbers, it sounds like everyone
should get a total knee replacement. Right?! No!
Here are some questions I like to ask first:
How bad do you hurt?
This is probably the most nebulous question, especially since the onset
of the fifth vital sign—pain—which to this day must be documented.
In the past, people said we weren’t treating their pain; therefore,
we needed to prescribe pain medicine which in turn spawned the opioid
epidemic. My pain scale is pretty basic.
- Zero to three: things kind of hurt, but I can live with it.
- Four to six: I have pain every day, and it affects my quality of life.
- Seven to nine: The pain is causing physical and mental distress.
- Ten: You should be in the ER and not my office.
Now, I can’t truly measure this pain, but it does give me a good
perspective about how the knee pain is affecting one’s life. If
it’s bothersome, I wouldn’t recommend a total knee arthroplasty (TKA).
What conservative measures have you tried first?
I ask this question for a few reasons. First off, there are significant
risks involved with surgery; however, there are no risks involved with
conservative treatment. It just might not work. Secondly, it shows me
that the patient is not just looking or believing that a total knee replacement
is a quick fix. Conservative management, including exercise and weight
loss, can be very hard but also rewarding and eliminate the need for surgery.
What are your expectations?
The main reason to perform a total knee replacement is to decrease pain.
With that said, many people will gain more function and are able to perform
quite rigorous exercises. I’ll give a shout out to my old high school
tennis coach, Mr. Etheridge, who is constantly taking arduous hiking trips
to Sequoia National Park, Glacier National Park and Yellowstone on his
new total knee.
Are you willing to undergo a prolonged rehabilitation?
Even with all the advances in technology, the rehabilitation for a total
knee replacement averages eight to twelve weeks, and it must be completed
in order to obtain good results. The main goals of therapy are to initially
decrease swelling and regain range-of-motion (ROM) for the first four
to six weeks followed by strengthening and getting back to normal activities
of daily living. Functional ROM is zero degrees extension (fully straight)
to around 110 degrees of flexion. The extension is important to allow
for a normal gait while the flexion is important for getting out of a
car, chair or toilet seat. This usually requires biweekly appointments
with a physical therapist and additional “homework” exercises
on off days. I normally check my patients one week after surgery, three
weeks, six weeks, and three months. If I’m concerned that a patient
isn’t regaining ROM, I double up on physical therapy, and if needed,
take the patient back to the operating room to break up early adhesions
Are you willing to accept the risks for this elective procedure?
All surgery has risks involved. There are minor risks, such as a surgical
scar that didn’t heal as cosmetically as wished, as well as major
risks, including blood clots, pulmonary embolism, infection, Myocardial
Infarction and unfortunately, even death. We try to decrease these risks
by undergoing an extensive pre-operative screening with your primary physician
or other specialist as needed.
In the end, I want to say that I’m not trying to frighten anyone;
I’m trying to educate. I’ve seen many of my patients return
to a life with decreased pain and increased function after a total knee
replacement. If you’ve tried prolonged conservative treatment but
still have knee pain that impedes daily activities and affects your quality
of life, and if you’re willing to undergo the rehabilitation after
surgery, than I truly think a total knee replacement is the right choice.
If you want your knee looked at, come on in, and we’ll have a chat.