This is a lingering question in the minds of a lot of elderly people with prolonged knee pain after consulting a lot of orthopedic surgeons. This article will provide some insight for patients before contemplating knee replacement.
Total knee replacement has emerged as a highly successful surgery for management of endstage knee arthritis. 15 - 20% of patients undergoing knee replacement surgery continue to suffer and feel dis-satisfied with their surgery. Reasons could be manifold including poor surgical technique on part of the surgeon. The most important factor contributing to poor outcome is improper patient selection.
So what are the risk factors for dis-satisfaction after a knee replacement?
- Wrong diagnosis
Various conditions may mimic arthritic pain from the knee and it is the responsibility of the surgeon to exclude these before attributing the knee as the source of pain. Disorders of the spine and hip can co-exist and if identified as a possible source of pain, may require treatment before addressing the knee.Ruling out other sources is an important part of the preoperative evaluation to avoid a major cause for dis-satisfaction after knee replacement surgery.
- Lack of symptoms and low demands
Patients with no, minimal or tolerable pain without need for medications tend to have inferior results with knee replacement irrespective of what is seen on their x-ray. Knee replacement is mainly performed to address pain due to arthritis and lack of pain pre-operatively will mean that patient will not benefit much after surgery. Similarly a very elderly patient with very low demands, home bound with medical issues and low motivation levels will not realize the entire benefits of knee replacement surgery.
- Extremes of age
Though no arbitrary age cut off could be defined, knee replacement is generally preferred in a slightly older patient with end stage arthritis. Knee replacement in a very active young patient places higher loads on the prosthesis increasing risk for early failure and may require multiple revision surgeries later. On the contrary young patients with severe arthritis due to rheumatoid conditions,preceding trauma or infections may actually do much better with a knee replacement than going through severe pain and disability during their productive age. Similarly the satisfaction rates can be low in very elderly patients with extremely limited mobility and cognitive impairment. We don’t define age limits and the decision is purely made based on functional demands of the patient, degree of pain and disability. After all age is just another number.
- Unrealistic expectations and poor preoperative counseling
Failure to counsel the patient properly can result in unrealistic expectations, which can have a huge bearing on satisfaction rates following knee replacement. A patient undergoing a total knee arthroplasty needs extensive counseling and education regarding the outcome of the procedure in a personalized manner. The dos and don’ts, what to expect after surgery, time taken for recovery, degree of pain relief,amount of movement possible at the knee and any patient specific demands should be thoroughly addressed. Total knee replacement in an indicated patient tremendously improves pain relief and also improves function and mobility to a degree that is possible at that age. A good surgery by the surgeon and an expensive implant doesn't always guarantee a good outcome. A lot of patient specific factors like age, weight, activity level and other medical conditions can have a significant say in the outcome and needs to be discussed with the patient to keep expectations realistic.
Pain management after total knee replacement
Total knee replacement is a painful procedure and poor pain management in the post-operative period can cause dis-satisfaction, muscle weakness and joint stiffness. We follow unique state of the art protocols for evaluating and preparing a smooth road map for surgery keeping patients well informed and counselled by a dedicated team of counselors. In my practice, pain management starts much before the surgery using preemptive analgesia (to control pain before surgery to smoothen the transition to surgery). Postoperative pain is well taken care off using patient controlled epidural pumps, nerve blocks and parenteral pain medications to enable faster recovery and expedite rehabilitation.We provide a dedicated supervised home physiotherapy program to enable patients to realize the ultimate benefits of knee replacement surgery.
Who is an ideal patient to undergo knee replacement surgery?
I follow stringent policies and protocols to screen and evaluate patients undergoing knee replacement at multiple levels to ensure successful results following knee replacement surgery. I consider an active person after their 50s suffering from intractable knee pain which is significantly hindering their daily routine making them either avoid their personal and social commitments or force them to take regular medications to overcome pain with x-rays showing advanced cartilage degeneration to be an ideal candidate for knee replacement. Special considerations are given to young patients with rheumatoid, psoriatic and severe post-traumatic or post-infective arthritis who may also benefit from knee replacement surgery with better mobility, pain relief and a superior quality of life.