When is knee replacement necessary for daily life?

When has waiting stopped helping me?

Ask about surgery when the joint keeps you from sleeping, walking, dressing, or leaving home. Steady loss of use after you’ve followed the exercise, medicine, or therapy plan is another reason. If you choose surgery after a full exam, repeating care that didn’t help may only put off the operation.

Ask the doctor exactly why waiting would help. A delay can make sense when another health problem needs care first or the cause of soreness isn’t clear. Don’t keep waiting only because the subject is hard to discuss.

Set a reason and an end date.

What should I ask before I agree to surgery?

Ask which daily troubles may improve and which may remain, then discuss serious risks, the help you’ll need at home, and when driving may be safe again. Ask what the X-ray and exam show together. Find out whether health checks, medicine changes, exercise, or home help must come before setting the date.

Tell the surgery team when soreness first appeared, which movements worsen it, and how your sleep and walking have changed. They’ll need more than a pain score.

Keep asking until the answer is clear.

Which warning signs can’t wait for an office visit?

Get urgent care when a joint is hot, red, and swollen, especially when you also have a fever or feel ill. Sudden trouble standing after an injury needs prompt help, as does an injury that leaves the joint bent out of place or unable to move. A calf that becomes warm, red, swollen, or sore after a procedure can mean a blood clot.

New weakness, numbness, or loss of bladder or bowel control needs emergency care. Drainage or spreading redness around a joint replacement can’t wait either, so don’t rely on exercise or a routine appointment for these problems.

Some symptoms need help now.

Sources

1. The 2023 ACR/AAHKS timing guideline conditionally recommends AGAINST delaying hip or knee arthroplasty to pursue additional non-operative treatment - physical therapy, NSAIDs, ambulatory aids or intra-articular injections - in patients with moderate-to-severe osteoarthritis for whom non-operative therapy has already been ineffective and who have chosen surgery. It conditionally recommends delay for nicotine cessation and for better glycemic control in diabetes, states that obesity by itself is not a reason for delay while weight loss should be strongly encouraged, and conditionally recommends against delay in patients with severe deformity or bone loss. Evidence for all recommendations was graded low or very low quality.

   Hannon CP, Goodman SM, Austin MS, et al. — 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.. Arthritis & Rheumatology, 2023. DOI: 10.1002/art.42630.

2. Pooling the OAI and MOST cohorts (8,002 participants followed up to 8 years, 3,417 classifiable knees), validated appropriateness criteria classified only 290 knees (8%) as receiving a TIMELY total knee replacement, 2,833 knees (83%) as potentially appropriate but not replaced more than 2 years after replacement became appropriate, and 294 knees (9% of all knees, 26% of the 1,114 replacements actually performed) as PREMATURE. Of the potentially-appropriate-but-not-replaced knees, 1,204 (42.5%) had severe symptoms.

   Ghomrawi HMK, Mushlin AI, Kang R, et al. — Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts.. Journal of Bone and Joint Surgery (American), 2020. DOI: 10.2106/JBJS.19.00432.

3. A systematic review and meta-analysis of 89,996 patients (60.6% female, mean age 67.4) awaiting primary elective total hip or knee replacement found a significant deterioration in joint function (mean difference 0.0575% per additional day of waiting, 95% CI 0.0064 to 0.1086, p=0.028) and in health-related quality of life per additional day of waiting. Meta-analysis could not detect a relationship with post-operative outcomes, and patient responses to delayed surgery were unanimously negative.

   Cooper GM, Bayram JM, Clement ND. — The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients.. Scientific Reports, 2024. DOI: 10.1038/s41598-024-58050-6.

4. In a prospective cohort of 134 patients on an Australian public orthopedic waiting list for hip or knee replacement, 69% waited at least 6 months (median 286 days, IQR 169-375). Health-related quality of life deteriorated overall during the wait (mean AQoL change -0.04, 95% CI -0.08 to -0.01), with 53% of participants experiencing a clinically important decline.

   Ackerman IN, Bennell KL, Osborne RH. — Decline in Health-Related Quality of Life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.. BMC Musculoskeletal Disorders, 2011. DOI: 10.1186/1471-2474-12-108.

5. In the only randomised controlled trial to compare total knee replacement directly with non-surgical treatment in patients already eligible for surgery (n=100), the replacement group improved more at 12 months than the non-surgical group (KOOS4 32.5 vs 16.0; adjusted mean difference 15.8, 95% CI 10.0 to 21.5) but had four times the serious adverse events (24 vs 6, P=0.005). Only 13 of 50 patients (26%) assigned to non-surgical treatment alone had undergone knee replacement by 12 months.

   Skou ST, Roos EM, Laursen MB, et al. — A Randomized, Controlled Trial of Total Knee Replacement.. New England Journal of Medicine, 2015. DOI: 10.1056/NEJMoa1505467.

6. In 63,158 hip and 54,276 knee replacement patients in the Clinical Practice Research Datalink, the lifetime risk of requiring revision surgery was about 5% for patients operated on after age 70 with no sex difference, but rose to 35% (95% CI 30.9-39.1) for men having surgery in their early 50s, with women's risk about 15% lower at the same age. Median time to revision for patients operated on younger than 60 was 4.4 years. The authors state their evidence challenges the trend toward more replacements in younger patients.

   Bayliss LE, Culliford D, Monk AP, et al. — The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study.. The Lancet, 2017. DOI: 10.1016/S0140-6736(17)30059-4.