This blog is going to help you answer the question of whether or not you need a total knee replacement. The information provided will be divided into two sections. The first section will be dedicated to discussing the signs and symptoms a surgeon would like to see before they offer the option of a total knee replacement. The second section will explain what you would see in your own knee that is suggestive of needing a knee replacement.Image by akramhuseyn, from Unsplash
What signs would make a surgeon suggest a total knee replacement
A survey asked all the registered orthopedic surgeons within the province of Ontario, Canada about which characteristics would make them more likely to suggest a knee replacement. Although there wasn’t a perfect consensus among the 234 surgeons, there were certain features that the majority agreed would make them suggest a total knee replacement:
- Pain that is resistant to medication (173 of the surgeons agreed)
- X-ray imaging that shows moderate to severe knee osteoarthritis (154 of the surgeons agreed)
- Pain that continues throughout the night (149 of the surgeons agreed)
- Pain that prevents the person from standing on that leg (144 of the surgeons agreed)
- The person is unable to walk without pain (140 of the surgeons agreed)
- An age of 80 years old (73 of the surgeons agreed)
- Should I put off my total knee replacement? What are my other options?
- Am I too young to get a knee replacement?
- What is a total knee replacement?
- What kind of exercises and sports can I do after a total knee replacement?
- My surgeon said I have knee osteoarthritis but I don't have pain, should I get a knee replacement?
The surgeons were also given 3 different hypothetical cases and asked to pick the one that they believe is the best fit for a total knee replacement. The case that was chosen by the majority described a 70 year old woman with knock knees (knees that tilt inward towards each other) and osteoarthritis that affected the entire knee joint. If the details of this case or the features above sound familiar to your situation then chances are a total knee replacement could be an option for you. However, simply having knee osteoarthritis on your X-ray without knee pain is usually not an indication for a knee repalcement as you can read in this blog.
Another study consulted 20 different healthcare professionals who have experience with total knee replacements and found 3 different variables or factors that affected a surgeon's decision in suggesting a total knee replacement. The first factor was the severity of damage within the knee. Damage within the knee is assessed in 3 ways: the intensity of pain, the degree of disability, or some form of imaging. The second factor is how the person presents as a whole, for instance the surgeon will consider how quality of life would change with a surgery, the individual’s mental health, and the person’s motivation. People who are more motivated to get back to work, in good mental health and obtain an improved quality of life from the procedure will most likely be selected. To read more about how to overcome mental block during surgery and injury recovery check out this blog. In certain countries, the socioeconomic status of the person and their insurance coverage is also a factor the surgeon considers before offering a total knee replacement. The final variable is the environment as access to surgical procedures of any kind is based on the availability of a hospital and a surgeon. For instance, rural areas struggle with long waitlists and poor access to elective surgeries such as a knee replacement. This is an important consideration because even if you have all the signs and symptoms that point towards a knee replacement, you may not be able to get the operation in a timely manner because of your geographic location.
The Ontario criteria is a tool used by some surgeons to determine the appropriateness of a total knee replacement and where on the waiting list someone should be placed. This tool calculates appropriateness based on how functional an individual is and the type and level of pain they are experiencing. This tool is unique because it clearly defines each one of the factors, for instance functional ability is separated into 4 different classes with class 1 being normal and 4 being a person with severe osteoarthritis and is bedridden or immobile. The tool is meant to help the surgeon in their decision by categorizing the person into groups that would benefit the most or the least from a knee replacement. The full breakdown of the tool is outside the scope of this blog, but know that this tool may be used to assess your need for a knee surgery.
As you can see there is not a universal sign or method that can be used to determine who is the best fit for a total knee replacement or when in their life they should get the operation. Overall, you can expect your healthcare team to assess your need for a total knee replacement by looking at your pain levels and how the issue is affecting your everyday life and considering the healthcare resources that are available in your geographic location.Image by rolleflex_graphy726, from Unsplash
How would I know if I need a total knee replacement?
The most noticeable sign or symptom is severe and persistent pain within your knee. This pain may be causing you to lose sleep and it could get worse with use.  People with an osteoarthritic knee often describe the knee as feeling extremely stiff, aching with movement, looking swollen and puffy, and that the knee will buckle at any moment. The second indication is that your knee is causing severe disability. This may look different from person to person, it could be that you’re unable to walk the distances that is normal for you, do the physical activities and sports that you enjoy, or you’re missing work because of knee pain or disability.  Finally, if pain medication or other treatments are no longer effective, total knee replacement will likely be suggested to you by your healthcare practitioner. To be quaint, if you can’t sleep, can’t walk, and can’t work then you know you need a knee replacement.
As it was mentioned above, there is still a lack of agreement among surgeons on what signs or indications definitively point towards a knee replacement. Most studies have found that a combination of severe pain and loss of ability to participate in activities of daily living will be key indicators for the surgeon. This is not to say that someone who does not exhibit these exact issues will be prohibited from undergoing a total knee replacement or that someone who does show these signs must absolutely have their knee replaced. Fortunately, in the current era of informed and shared decision making, the person with the knee pain has a lot of control over what to do next. However, your socioeconomic status, or how much money you make, can be a limiting factor in your ability to access a knee replacement in many parts of the world where this procedure is paid for by the person who needs it. Also if you live in a rural part of the world you may have limited access to this procedure. Previously younger people were prevented from having a knee replacement as it was suggested that their knee repalcement would not last long enough. But now younger people with a strong desire to go back to work or have family obligations that require a functional knee may opt for an early surgery and their surgeon must respect and support that decision.
Having a total knee replacement is no easy task and optimizing the recovery process after a total knee replacement surgery is crucial to getting back to a normal life. To help get you on track with your recovery the Curovate App is an essential resource! An evidence-based app that provides you with personalized physical therapy recovery plans for knee osteoarthritis, before a knee repalcement and after a knee replacement, daily guided video exercises, ways to measure your knee range of motion and monitor your recovery progress! Download the Curovate App from the Google Play store or the Apple App store by clicking on the links below.
If you need further customized assistance to help you decide if you need a knee replacement check out our Virtual Physical Therapy page to book your 1-on-1 video session with a physical therapist.
1. Wright JG, Coyte P, Hawker G, Bombardier C, Cooke D, Heck D, Dittus R, Freund D. Variation in orthopedic surgeons' perceptions of the indications for and outcomes of knee replacement. CMAJ. 1995 Mar 1;152(5):687-97. PMID: 7882231; PMCID: PMC1337616.
2.Dieppe P, Basler HD, Chard J, et al. Knee replacement surgery for osteoarthritis: effectiveness, practice variations, indications and possible determinants of utilization. Rheumatology (Oxford). 1999;38(1):73-83. doi:10.1093/rheumatology/38.1.73