If you’re having knee pain and wondering if you need a replacement (and wondering how long you can put it off), rest easy. Dr. Daniel Pierce, an orthopedic surgeon with Novant Health Orthopedics & Sports Medicine in Thomasville (and coming soon to Lexington, North Carolina), said that, as elective surgery, that’s up to you.
“We don’t often save lives in orthopedics,” he likes to say. “We save lifestyles.”
As a joint replacement surgeon – one who also specializes in complex primary and revision surgery – what he sees often in clinic is arthritis-related knee pain, which is caused by wear and tear of the joint.
You don't have to live with joint pain.
“There are different kinds of arthritis,” Pierce said. “Primary osteoarthritis is when the cartilage wears out. There are inflammatory conditions, such as rheumatoid arthritis, which is an autoimmune disease that can attack the cartilage. And then there's post-traumatic arthritis, which arises from an injury – be it sports or traumatic, like a motor vehicle accident.”
We asked Pierce about delaying surgery, what knee-replacement surgery entails and what patients can expect during recovery.
Do your patients with knee pain often try to put off knee-replacement surgery?
Yes, and I don’t blame them! I’d put it off, too. I tell every patient I see that I love doing hip and knee replacements, but I don't want one. The thought of surgery can be scary, and patients should have a healthy amount of apprehension.
Why do they want to put if off?
There are lots of reasons. A common one I see is that they’re taking care of other family members and feel they can’t take time off themselves. Or they may have work commitments or big family events, such as weddings, coming up that they can’t afford to be down for.
Once they decide to do it, they choose the best time. I don’t choose for them. They need to choose the time when it works with their schedule and when they can get things set up for a successful recovery.
Do patients ever want to wait until they’re 65, hoping Medicare will cover it?
I actually see the opposite of that. Some people want to have it while they’re still working so their employer-funded healthcare plan will cover it. And occasionally I’ll see someone who wants to retire before they have their knee replaced – but it’s so they can complete their work responsibilities before committing to surgery and recovery. Not because of Medicare. Of course, everyone’s situation differs.
So, cost isn’t a factor in the timing decision?
Not from what I’ve seen. Unfortunately, when it comes to billing and insurance, it’s way out of my field. You do want to ask all the right questions and determine what will be covered and what you’d be responsible for prior to surgery.
How can a patient know when the optimal time is?
Knee replacement is an elective operation, meaning it’s one chosen by the patient versus being urgently necessary. The patient is the only person who knows how much pain they’re in, and they decide if it’s worth having surgery to relieve their pain and get back to enjoyable physical activity.
Recovery time is a concern patients have. Even though outpatient knee replacement surgery is becoming more common, I tell everybody: My two hours in the operating room with you is the easy part. The hard part’s the recovery. We know patients continue to make improvement for up to one year after knee replacement although most of that improvement is in the first three or six months.
As far as recovery goes, the biggest predictor of how active someone will be after surgery is how active they were before surgery. And if someone’s knee doesn’t straighten all the way prior to surgery, that’s the biggest predictor for having stiffness after surgery.
I have some patients who haven't meaningfully walked for a year or more and have been spending most of their time in a wheelchair. It’s a lot harder for that person to get up and start walking after surgery. Even though the pain is improved, there was a long period of time before surgery that their muscles haven’t been worked, so it's going to take them longer to build up that strength.
Most people, when they see me two weeks after surgery, have weaned from a walker to a cane. When I see them at six weeks, most everybody is off of assistive devices. They're getting around a lot better, but some discomfort, swelling and warmth in the knee is not unexpected for even a few months after surgery.
When can a patient start driving again?
Everyone has to be off narcotic pain medicine before they return to driving. For a right knee, the literature suggests that brake response times return to baseline by four weeks after surgery, so that is the earliest I would recommend for a right knee replacement. The vast majority of patients have returned to driving by 6 weeks post-operatively.
Can you be too young for knee surgery?
The indications for a knee replacement are based more on symptoms and radiographic findings. There is no age cutoff, young or old. Younger people, however, are more likely to outlive a knee replacement that lasts 15 to 20 years, meaning they will more likely, when compared to older patients, need revision surgery at some point.
Can you describe in layman’s terms what you do in the OR during knee replacement?
In the most basic terms, the worn surfaces of the knee joint are removed and metal implants are cemented or press-fit in to the bone with a polyethylene liner between them. The knee joint is transformed from rough, bony and cartilage surfaces to a smooth “metal-on-plastic” bearing surface.
The intricacies involve appropriately balancing the joint (ensuring just the right amount of laxity throughout the entire range of motion), achieving appropriate alignment of the knee and selecting correctly sized implants. These goals can be achieved with a variety of techniques and instrumentation.
What complications can arise?
Infection is the leading cause of failure of a knee replacement, especially within the first two years after surgery. Fortunately, the incidence of infection is still low – about 1 or 2%. Just like a native (non-replaced) knee, if the knee joint becomes infected, then surgery, as well as antibiotic therapy, are indicated.
Multiple risk factors have been identified that increase the risk of infection after surgery. Three well-known risk factors are elevated body mass index, active tobacco use and poorly controlled diabetes. Luckily, these risk factors are all modifiable and should be addressed prior to pursuing an elective operation.
The second-highest cause of failure is loosening of the implants. This more commonly occurs later – more than two years – after knee replacement surgery.
Other potential, although rare, complications include blood clots, stiffness, nerve injury, wound healing problems, implant failure and anesthetic complications.
What about patients whose conditions and whose pain forces them to spend most of their time in a wheelchair? How can they lose weight, if they need to?
I don’t expect a patient who’s in pain and spending time in a wheelchair to get on a treadmill to lose weight. I refer people to registered dietitians who can do a lot to help with portion control and choosing healthier food options. Some weight loss specialists even prescribe medications or address other underlying disorders to help with weight loss.
The important thing is that the weight loss occurs in a controlled, healthy manner. Crash diets resulting in malnutrition prior to surgery can result in harm. A lot of patients are incredibly successful with weight loss, even with minimal exercise. But I’m not going to pretend that any of this is easy.
What treatments do you try before surgery?
We try pretty much everything before we’ll jump to surgery. We’ll start with non-invasive approaches such as weight loss, activity modification, bracing and use of an assistive device. A lot of folks are resistant to using a cane, but I tell them a cane may enable them to participate in the activities they enjoy.
Other things that are helpful, specifically for knee arthritis, are knee conditioning exercises – specifically strengthening the quadriceps muscles. Squats and lunges fall into that category. The American Academy of Orthopaedic Surgeons strongly recommends a supervised exercise program. If patients have a barrier to attending formal physical therapy, then performing exercises at home is still better than nothing.
Over-the-counter topical and oral medications like anti-inflammatories and acetaminophen can be useful, but of course, all medications have side effects. Patients need to be healthy enough to take them, and they should be followed by their primary care clinician to make sure they’re not experiencing adverse effects such as stomach, liver or kidney issues or high blood pressure.
When the above options fail to provide adequate pain relief, a more invasive option is an injection into the knee joint. The two broad categories of injections are corticosteroids and hyaluronic acid. The amount and/or duration of pain relief is variable with injections.
When pain persists despite the above interventions and one’s quality of life is suffering due to the pain, then a knee replacement may be an attractive option.