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Are you unsure as to whether or not a total knee replacement is right for you? Before you make a decision it is essential that you know the potential issues or downsides associated with this operation. In this blog I will provide an overview of the most common issues that occur with total knee replacements, the downsides of having a total knee replacement, and how the alternative options to a total knee replacement compare. This blog is not meant to sway your decision in having a knee replacement or not, but to improve your ability to make an informed choice.

What are the most common issues with a total knee replacement?

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A study of 15,321 people who underwent a total knee replacement, with an average age of 67 and 64.5% being women provided a list of frequent complications I will discuss here.[1] The most common issues in descending order was a urinary tract infection with 228 cases (1.49%), a blood clot forming within a deep vein at 206 cases (1.34%), an infection of the surgical site with 121 cases (0.79%), and a blood clot traveling into the lungs and blocking an artery with 120 cases (0.79%).[1] Another common issue with knee replacements is a revision or undergoing another surgery to fix an issue with the first surgery. From 2009 to 2013 there were over 330,000 revision procedures in the United States of America. [2] Revisions are an expensive problem as it is estimated these procedures cost 2.7 billion dollars within the USA alone.[1] The most common cause of a revision was an infection at 20.4%, followed by parts of the knee implant coming loose at 20.3%.[2] To be clear, these percentages are not representative of how often an infection or an implant coming loose occurs with all total knee replacements.[2] In addition to revisions, a downside to total knee replacement is that they are not a permanent solution. Over time the implants will be worn down and another surgery might be needed to replace the replacement.[3]

Should I be worried about all these issues

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Not necessarily, first we should look at the people who took part in these studies as they may not be representative of everyone who is considering a total knee replacement. The first study with 15,321 people stated that the majority of the people who took part in their study were obese with a BMI over 30, and half had an ASA classification of 3 or higher.[1] An ASA classification of 3 signifies that this individual is living with a severe disease that greatly affects their everyday life, this could be alcohol abuse, hypertension or high blood pressure, and or heart disease. This study concluded that older age, longer operation times, more pre-existing diseases, and obesity were associated with higher rates of complications.[1] The takeaway from this is that there are many different factors that influence a person’s risk for complications. Everyone will have different factors that increase or decrease their risk for a certain complication. Knowing which factors play a role in your own situation is crucial to decreasing your risk. For instance, you may diminish the chance of complications associated with obesity and health conditions through exercise, diet and sticking with the medical management plan provided to you by your physician.

We should also appreciate that with the improvement of modern medicine the overall risk of major and minor complications is relatively small and continues to decrease. In fact, despite more people with obesity and diabetes undergoing total knee replacements, there has not been an increase in complications, nor an increase in hospital readmission.[4] In other words, even though more people who are thought to be in poor health are undergoing total knee replacements, they are not suffering from more issues.[4] This study included over 220,000 people with a total knee replacements and the total number of minor and major complications was less than 5% in total![4]

With regards to needing another surgery to replace a replacement, looking at the timeline for these events will help us get a better perspective. From a study of over 7000 people with total knee replacement and an average age of 69, it was found that even after 25 years 82% of the replacements were still functioning.[3] If the average age of the people within this study is also representative of the age at which most people get their first knee replacement then they would be 94 when they may need another. Let’s be realistic, with the average life expectancy in North America being 77 for men and 81 for women, the need for another knee replacement should not be of great concern as most will not live to this age.[5]

Can I go without a knee replacement? What are the alternatives?

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The choice of having knee replacement surgery or not is yours. If you truly are not comfortable with the idea of knee surgery it is best to evaluate your options and try some nonsurgical treatment options in the meantime. Jumping to surgery when you are psychologically unready may lead to worse outcomes. A study of 186 people who underwent a total knee replacement found that the people who had high levels of anxiety or depression before their surgery were 6 times more likely to be dissatisfied with their surgery.[6]

John Hopkins Medicine recommends three different alternatives; losing weight to take stress off the joint, low intensity exercise to reduce pain and strengthen the leg, and prudent use of medication for pain management.[7] How do these alternatives compare to having surgery? Consider a study comparing 50 people with moderate to severe osteoarthritis who had a total knee replacement and 50 people who used nonsurgical alternatives. The study found that people who underwent the surgery had better pain relief and functional outcomes relative to the nonsurgical group.[8] Approximately a quarter of the people who used nonsurgical treatment eventually opted for surgery.[8] A similar result was found from a comparison study with 100 people in each group. Wherein the people who had the knee replacement showed twice the reduction in pain and functional improvement relative to the group that used non-surgical treatment.[9] Within this study two thirds of the people who did not have the knee replacement were able to delay their replacement for 2 years.[9] It is important to note that the people who used alternative treatments did have noticeable improvements in pain relief and function.[8] [9] If you would like to know more about nonsurgical alternatives check out the GLAD program. This program is dedicated to nonsurgical treatment for knee and hip osteoarthritis and this program has shown excellent results for pain management, increased physical actiity, reduced anxiety and improved function with large groups of people. The consensus from the 2 comparison studies discussed above is that nonsurgical options are worth a try and may provide relief in the short term, but if debilitating pain persists and everyday activities become harder to achieve then knee replacement is an effective solution.

What should I know or do before surgery?

There are a few things that you can do before your surgery to set yourself up for success. Check out this blog on Curovate to optimize your outcomes! Managing your expectations is critical! A total knee replacement likely will not feel completely natural. A study that followed over 500 people with a total knee replacement over a span of 5 years found that an artificial knee may feel very close to a normal knee but not truly natural. [10] Keep in mind that this does not mean a knee replacement is not worth it, in fact countless studies have proven that a knee replacement will improve knee function, quality of life, and provide the possibility of returning to everyday activities and sports.[11] The key to a successful procedure is being realistic with your expectations.[11] Knowing and being comfortable with the fact that the knee may not feel like a normal knee is already a huge step in the right direction! Image by NCI, from Unsplash

Conclusion

The purpose of this blog was to provide the readers with an understanding of some of the most common problems and issues related to a total knee replacement. We also discussed whether or not these issues should be a cause for concern for someone who is considering a knee replacement. Finally, we finished with a brief look at the alternatives and how they stack up against the surgery. The complications mentioned within these blogs are meant to be used as a point of discussion with your healthcare provider. Understanding your own risk and possibility of developing these complications allows for you and your healthcare provider to actively work towards mitigating the risks of this surgery and providing you with optimal outcomes.

Want to learn more about total knee replacements? Click here to visit the Curovate blog for more information and advice! Or are you in need of help to get you back onto your feet and doing the activities you love? Try the Curovate app, an evidence-based app that will provide you with a physical therapy plan, guided video exercises, and more to assist you along your journey to recovery! Download Curovate today by clicking the links below!

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References

1. Belmont, Philip J. Jr. MD1; Goodman, Gens P. DO1; Waterman, Brian R. MD1; Bader, Julia O. PhD2; Schoenfeld, Andrew J. MD1 Thirty-Day Postoperative Complications and Mortality Following Total Knee Arthroplasty, The Journal of Bone & Joint Surgery: January 1, 2014 - Volume 96 - Issue 1 - p 20-26 doi: 10.2106/JBJS.M.00018

2. Delanois RE, Mistry JB, Gwam CU, Mohamed NS, Choksi US, Mont MA. Current Epidemiology of Revision Total Knee Arthroplasty in the United States. J Arthroplasty. 2017;32(9):2663-2668. doi:10.1016/j.arth.2017.03.066

3.Cook R, Davidson P, Martin R; NIHR Dissemination Centre. More than 80% of total knee replacements can last for 25 years. BMJ. 2019;367:l5680. Published 2019 Dec 31. doi:10.1136/bmj.l5680

4.Sarpong NO, Boddapati V, Herndon CL, Shah RP, Cooper HJ, Geller JA. Trends in Length of Stay and 30-Day Complications After Total Knee Arthroplasty: An Analysis From 2006 to 2016. J Arthroplasty. 2019;34(8):1575-1580. doi:10.1016/j.arth.2019.04.027

5. Life expectancy in North America 2020. Statista. https://www.statista.com/statistics/274513/life-expectancy-in-north-america/. Published January 20, 2021. Accessed June 14, 2022.

6. Ali A, Lindstrand A, Sundberg M, Flivik G. Preoperative Anxiety and Depression Correlate With Dissatisfaction After Total Knee Arthroplasty: A Prospective Longitudinal Cohort Study of 186 Patients, With 4-Year Follow-Up. J Arthroplasty. 2017;32(3):767-770. doi:10.1016/j.arth.2016.08.033

7. Knee replacement alternatives to consider. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/knee-replacement-alternatives-to-consider. Published December 22, 2021. Accessed June 14, 2022.

8. Skou ST, Roos EM, Laursen MB, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015;373(17):1597-1606. doi:10.1056/NEJMoa1505467

9. Skou ST, Roos EM, Laursen MB, et al. Total knee replacement and nonsurgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthritis Cartilage. 2018;26(9):1170-1180. doi:10.1016/j.joca.2018.04.014

10. Carlson VR, Post ZD, Orozco FR, Davis DM, Lutz RW, Ong AC. When Does the Knee Feel Normal Again: A Cross-Sectional Study Assessing the Forgotten Joint Score in Patients After Total Knee Arthroplasty. J Arthroplasty. 2018;33(3):700-703. doi:10.1016/j.arth.2017.09.063

11. Canovas F, Dagneaux L. Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res. 2018;104(1S):S41-S46. doi:10.1016/j.otsr.2017.04.017