FRCS (Edin) 
Trauma & Orthopaedic Surgeon 
Specialist in Arthroscopy & Joint replacement Surgery 
Ex Chairman , Osteoporosis Subcommittee, WBOA

Knee Osteoarthritis; When to Consider Surgery?

 Knee osteoarthritis (OA) can affect our every move: walking, climbing stairs, even sitting or lying down. Surgery can help bring relief, but doctors almost always advise trying other treatment options first. These include:

Medications we take by mouth. Over-the-counter options include acetaminophen as well as nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. NSAIDs fight inflammation. Stronger NSAIDs are available by prescription.Creams or ointments we rub onto the skin. Different forms are sold over the counter. We can get stronger versions with a prescription.Medications injected into the joint. Corticosteroid injections, also called cortisone shots, fight inflammation and can offer fast pain relief that may last up to several months. Injections of hyaluronic acid boost the natural joint fluid that keeps knees moving smoothly. They may take up to a couple of months to have their full effect but can last up to 6 months or more.

Visual Guide to Knee Replacement

 Start Exercise and physical therapy. Exercise strengthens the muscles that support our knee. Physical therapy also helps. A physical therapist can design the program for we and see if we need supportive braces, splints, or canes. If we need to lose weight, diet and exercise can help we shed some kgs and take some of the pressure off our knees through weight loss. Every kg we gain puts an extra 3 kgs of pressure on our knees. If we eventually need knee replacement surgery, our chances of success are much greater if we first lose extra weight.

Nutritional supplements are also effective. Some people take glucosamine and chondroitin for OA. Studies on how well they work have had mixed results. Another supplement, called SAMe, has been shown to work as well as nonprescription pain relievers and may have fewer side effects. It takes longer to work, though. Before we start taking any supplements, even if they’re natural, consult with the doctors so they can check for any side effects.

These treatment options may provide enough relief to keep us moving comfortably. If they don’t, they become less effective over time, or we can’t tolerate them, our doctor may suggest considering surgery. The two types of surgery most often recommended for knee OA are arthroscopic surgery and knee replacement surgery.

 What are the risks of delaying the knee replacement surgery?

 Patients delay knee replacement surgery for a number of reasons, mostly out of fear and misinformation. Most patients delay unnecessarily for several perceptual reasons: fear of the unknown, fear of surgery, fear of ‘losing’ a body part, fear of the post-op surgery pain, fear that they will end up worse than they started.” But eventually it is observed that majority of the patients are thankful after they get surgery on their knees, and wish they would have done it earlier.

The risks related to delaying knee replacement surgery often involve the deterioration of the joint, increased pain, and lack of mobility. Depending on the severity of the joint disease, a surgeon may attempt several less invasive, non-surgical methods first, including glucosamine, anti-inflammatory medications, cortisone injections, and physical therapy. If none of these methods appear to be working or if the patient has become sedentary due to joint pain, a surgeon may recommend knee replacement surgery. For many of the reasons listed above, patients sometimes consciously delay their knee replacement surgery, which can have some of these risks:

  • Risk of deformities developing inside and outside the joint
  • Risk of muscles, ligaments and other structures becoming weak an
  • Increased pain / inability to manage pain
  • Increased disability/lack of mobility
  • Difficulty with normal activities of daily living

When a knee replacement surgery is delayed, there are also several risks that arise with regard to the surgical procedure. For example, the risk of deformities due to postponement tends to make knee replacement surgery a more complicated process. The surgery may then take longer and require a longer amount of time under anesthesia. In addition, postponement can limit knee replacement options. For example, joint disease that is spotted early on and treated may only require a unicompartmental knee joint on the medial side. But after delay, destruction to the knee joint becomes so severe that a total knee replacement will become more complex surgery can lead to a less successful one with possibly even the addition of a knee cap (“patellar”) resurfacing.

Recent studies have shown that timing does make a difference in joint replacement surgery. Timing of surgery may be more important than previously realized and, specifically, that performing surgery earlier in the course of functional decline may be associated with better outcome. In other words, if surgery can be performed early it may be more successful.

When a patient is relatively healthy and gets a knee replacement, s/he is more likely to recover sooner and with fewer complications. Knee replacement surgery is not recommended for everyone, and doctors do suggest that patients must visit doctors at the early stage to find out what is best for them. But if the case is a knee replacement surgery case, postponement can lead to a number of unnecessary and unavoidable issues.

Post Operative care of Knee Replacement Surgery & conclusion

After total knee replacement surgery, patients are monitored for 1–2 hours until the anesthesia wears off. Depending on the specific type of surgery performed and the patient’s overall health and recovery, most patients remain in the hospital for several days after the procedure. Prescription pain medication usually is used to relieve postoperative pain.

Several therapies are used soon after knee surgery to encourage circulation in the leg and prevent blood clots. These therapies include the following:

  • Compression boots that wrap around the lower leg and expand and contract to apply gentle pressure
  • Continuous passive motion (CPM) machine that gently moves the leg while the patient rests in bed
  • Movement of the foot and ankle while resting in bed
  • Medication to thin the blood
  • Elevation of the leg for short periods of time

In many cases, a physical therapist consults with the patient the day after knee replacement surgery. Physical therapy involves movements and exercises to help the patient adjust to the new joint and gradually begin to walk again.

Recovery after Knee Replacement Surgery

Before being released from the hospital, patients should make sure they are aware of warning signs that might indicate blood clots or other potentially serious complications. After knee replacement surgery, patients should seek immediate medical attention if any of the following develop:

  • Chest pain
  • Shortness of breath
  • Sudden increased swelling, pain, redness, or tenderness in the lower leg

Much of the success of total knee replacement surgery depends on the patient’s willingness to follow his or her surgeon’s instructions during the recovery period. Pain is normal for several weeks after the surgery and usually is treated with medication. Postsurgical pain usually subsides after a few weeks of rest and strengthening exercises.

Surgical wounds should be kept clean and dry until area heals. Patients should avoid soaking (e.g., in a bath) for about 6-8 weeks after total knee replacement surgery. If redness or swelling occurs near the incision, the surgeon should be contacted immediately.

A low-grade fever is normal for the first few days after surgery. However, if fever persists, rises above 101 degrees , or is accompanied by chills, sweating, pain or drainage at the incision site, the surgeon should be contacted.

Swelling is normal for several months after knee replacement surgery. Elevating the leg for 30–60 minutes every day can help reduce swelling. Patients often experience less swelling in the morning and more in the afternoon and evening. If significant swelling occurs in the morning, the surgeon should be contacted.

After knee surgery, a physical therapist will provide the patient with a clear and specific program of activities and movements to do during the recovery period. Daily movement and exercise can help patients to regain strength and get back to normal activities faster, and can prevent complications such as blood clots. Patients who have difficulty walking or doing the recommended exercises and activities after total knee replacement should consult with their physical therapist.

During the first weeks of recovery, patients are not able to drive. Knee replacement patients can drive when they:

  • Are no longer taking any narcotic pain medication,
  • Are able to get in and out of the car easily and comfortably, and
  • Respond appropriately to reflex and strength testing.

After knee replacement, patients should be sure to eat a healthy diet and should talk with the surgeon about specific dietary instructions. It may take as many as 6 weeks before the patient feels steady on his or her feet, and a walker or crutches should be used until he or she is able to walk unassisted. Once the patient begins using the stairs, he or she should always use the handrail. To reduce stress on the replaced knee, patients should lead with their old knee when going up the stairs and lead with their replaced knee when going down the stairs.

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