Facing Knee Replacement Surgery? Prepare With These Steps

After nearly a decade of a largely sedentary life on the outskirts of Las Vegas, at 55, I gave my car to my then-teenage daughter and moved to Washington, D.C., for a new job and a return to an urban lifestyle where I hoped a lot of walking would help keep me healthy.

Less than a month later, I hobbled into a doctor's office with a knee so painful I could barely walk. My sudden uptick in physical activity aggravated something I didn't even know I had: Knee osteoarthritis fueled by more than two decades of competitive tennis, including as an NCAA Division I scholarship college player. A cortisone shot got me back on my feet within a couple of days, but an orthopedic surgeon warned me that pain would almost certainly return because both of my knees had lost almost all their shock-absorbing cartilage. I was, in orthopedic parlance, "bone on bone."

For several years, I got by with physical therapy and over-the-counter and prescription pain and anti-inflammatory medications. But during the COVID-19 pandemic, I, along with millions of other Americans, discovered pickleball. I thought the significantly smaller court and legions of 50- and 60-something doubles players made it a more appropriate sport for my stage in life.

But my knees didn't agree, and five months after my 60th birthday, I began preparing for one of the most common orthopedic surgeries in the United States: Total knee replacement. Somewhere between 850,000 and 1 million patients have the procedure annually, and by 2030, as many as 1.28 million knees could be replaced each year, a number expected to double, to 2.6 million, by 2060 according to the Arthritis Foundation. About 60% of patients are women and the surgery largely remains a purview of baby boomers: The mean patient age is 66.8 years, according to the American Joint Replacement Registry

Before going under the knife, I did my homework. I researched and consulted several orthopedic surgeons before selecting the one to do my procedure, read articles and clinical studies, watched YouTube videos about the procedure and did "pre-hab" to strengthen the muscles that support the knee during the rigorous post-surgical rehabilitation.

Even after all of that, I was ill-equipped for what I encountered during the next 18 months.

It's kind of like having a baby: "Everyone thinks they're ready, but they're really not," says James Rickert, a board-certified orthopedist and president of the Society for Patient Centered Orthopedics. "The average provider has a hard time understanding the experience from the patient's point of view."

Samantha Smith is a Dallas-based physical therapist who offers online courses for knee replacement patients and created and moderates a more than 30,000-member Facebook group for those considering the surgery or navigating recovery. In a nod to the surging popularity of the procedure, the number of members in Smith's Facebook group has doubled since last summer.

"It's a crazy surgery and patients kind of get left in the dark sometimes," Smith says. "I've talked to surgeons about how much they proactively share with patients, and they've told me that if patients knew before surgery what they'll likely face, they wouldn't go through with it."

During the procedure, the surgeon saws off small portions of the femur and tibia (thigh and shin bones) to create a smooth surface for prosthetic — usually metal — components that are hammered or sometimes cemented into place. Those components then glide across a smooth plastic disc inserted as a stand-in for the knee's cartilage.

My surgery, which is increasingly the case, took place at an outpatient surgical center and went smoothly. Patients generally must take their first steps before they are discharged, and I was home within a few hours.

The first two to three weeks were painful and grueling because of the intrusiveness of the surgery and the extensive physical therapy exercises patients must do multiple times daily for several months to successfully rehabilitate the knee. But pain medication I took on a regimented, round-the-clock schedule kept my pain mostly under control, and my early progress went according to plan.

But a month into my recovery, I realized I wasn't prepared for the sheer duration of the rehab and how physically and mentally exhausting the procedure and recovery can be.

Pre-surgery, I received the perfunctory warnings about rare, but potentially serious surgical risks such as blood clots and infection, and specific precautions to avoid them. However, I got little guidance about issues many patients confront as they recover.

"The research done is typically on patients' short-term experience: the length of the hospital stay, the complication rate," Rickert says, "or the really long term: How long will this thing [implant] last?

"There's very little research on the actual patient experience in the midterm."

Some common issues I wish I had been prepared for included:

• Severely disrupted sleep. In my case for 2.5 months because of pain and an inability to get into a comfortable position.
• Depression fueled by pain, lack of sleep and lengthy recovery. One in five knee replacement patients struggle with depression, while 15% to 20% battle anxiety triggered by the procedure, according to Daniel J. Riddle, professor emeritus of physical therapy, orthopedic surgery and rheumatology at Virginia Commonwealth University in Richmond, Virginia.
• Near-total physical deconditioning because patients are partially incapacitated for the first two to three months and can take a year to 18 months to fully recover.

The satisfaction rate for knee replacement hovers around 80%, a near-record high for elective surgeries, Riddle says. But that still means that 20% — or one in five patients — are unhappy with the results.

"It's really hard to predict who's gonna be that 20% who's not happy," says Nick DiNubile, a Philadelphia-area orthopedic surgeon specializing in sports medicine. "It's harder to find something that's safer, that when it works, it works great. It can be a life-changing procedure, but there are dissatisfied patients. We should be doing things differently: Personalizing our approach, setting realistic expectations and working to circumvent roadblocks patients will likely face."

Riddle, however, says the rise in knee replacements is driven by the allure of a panacea.

"Surgeons can tell patients until they're blue in the face what to expect and how difficult it can be, and patients don't care: they just want a new knee," he says. "There is a challenge in the psychology of long-term recovery."

Two-and-a-half years out from my surgery, many people are surprised that I don't offer an unqualified endorsement of the procedure. The dull arthritic ache is gone and my extension — how straight I can get my knee, an important characteristic for a healthy walking gait — has improved. However, my flexion — how much I can bend the joint — is slightly worse and my knee regularly feels stiff after exertion or changes in the weather.

I would never tell someone not to have the surgery, but I encourage anyone considering it to do their homework and fully understand what they may be getting into.

My replaced knee will never be as good as my original was, but arthritis is a progressively debilitating and irreversible disease, and many swear by the procedure. If I ever must have the other knee replaced, I will rely on the lessons I learned through my first knee replacement and thoroughly research any new developments or breakthroughs.

The experts I interviewed recommended the following, and I found all to be helpful:

Physical therapy, weight loss and exercise can postpone, or even eliminate, the need for surgery. Research presented at the 2023 meeting of the Radiological Society of North America showed that strengthening the quadricep and hamstring muscles enables some patients to avoid knee replacement. Patient educational programs in Europe, Canada and Australia emphasizing strengthening exercises, weight loss and physical activity have helped patients forego the procedure, Riddle says. I've lost about 40 pounds in a quest to avoid or delay having my other knee replaced.

Non-surgical care is underutilized prior to knee arthroplasty, Riddle says. His research focuses on non-surgical alternatives. "I think there are many patients who could delay surgery if they had good, non-surgical care before surgery," he says.

Your physical therapist is as important as your surgeon. Patients often seek the very best surgeons, but give little thought to their physical therapist. "Most surgeons seem to see their role as making sure the implant is in there right, and that it's not shifting around, and then it's up to the PT to get the patient across the finish line," Smith says. "The PT is with the patient for months, two to three times a week. So, I feel a huge responsibility for a patient's successful rehab."

Many for-profit practices require PTs to work with two or three patients simultaneously. I began my rehab in such a practice, but my progress accelerated significantly when I switched to a facility that pairs one therapist with one patient at a time.

Ask tough questions. When talking to surgeons and physical therapists, patients must be their own advocates. "The power dynamic makes it difficult to ask hard questions because you're trusting this person, and you want to convey that you trust them," Rickert says. "But you want to ask the questions you need answered." These may include:

• How long am I going to be laid up?
• How much is it going to hurt? What will you do to help manage my pain?
• What can I expect over time?
• What are some bad things that could happen? What's the worst outcome I could have?
• How poor will my sleep be and what can I do about it?

Consider alternative post-surgical therapies. In my quest to recover, I pursued several established, complementary therapies that helped, including lymphatic massage, extra-corporeal shockwave therapy, aqua therapy and cupping.