With the help of cortisone injections, physical therapy, anti-inflammatories, and hyaluronic acid injections every six months to help cushion and lubricate my joints, I was able to get up and about, but I had lost nearly all of the shock-absorbing cartilage in both knees; in arthritic-knee jargon, I was “bone on bone.”
A few months after my 60th birthday, I began preparing for one of the most common elective orthopedic surgeries in the United States: total knee replacement (also called total knee arthroplasty).
According to a 2023 survey, between 850,000 and 1 million patients undergo total knee replacement surgery annually, and that number is expected to rise to at least 1.2 million by 2040. About 60% of patients are women, and the procedure is primarily the domain of the baby boomer generation, with the average patient age being 67.4 years, according to the American Joint Replacement Registry. But younger generations are also increasingly undergoing the procedure.
Before my surgery, I did my research: I consulted with five doctors before choosing an orthopedic surgeon, read numerous articles and clinical studies, joined a Facebook support group for “knee replacement warriors,” watched YouTube videos with advice from surgeons and physical therapists, and did some “prehab” to strengthen my leg muscles in preparation for the rigorous rehabilitation after surgery.
But what I experienced after the surgery showed me I was totally unprepared.
In a total knee replacement, surgeons remove damaged cartilage and arthritic areas from the femur and tibia and replace them with usually metal components that act as surfaces for the joints. These components slide over smooth plastic discs that are inserted to replace the knee’s cartilage, according to the American Academy of Orthopaedic Surgeons. The surgeon also often repairs the surface behind the kneecap and attaches a plastic cover or “button” before putting the kneecap back in place and closing the surgical incisions.
The procedure has been described as “brutal” by many patients.
Surgeons sometimes downplay the difficulties of surgery, says James Likert, a board-certified orthopedic surgeon and president of the Society for Patient-Centered Orthopedic Surgery. “I think it’s easy for health care providers to sell surgery as a cure-all,” he says. “It’s easy to highlight the benefits, and it’s easy to downplay the risks.”
“It’s a big operation, and patients are sometimes left in the dark,” says Dallas-based physical therapist Samantha Smith, who offers online courses for knee-replacement patients and created and manages a Facebook group for more than 19,600 knee-replacement patients, of which I’m a member. “I’ve had conversations with surgeons about how proactively they are sharing information with patients,” she says. “They’ve said that if patients knew what they were likely to be getting before surgery, they wouldn’t have the surgery.”
Other surgeons say it’s the most effective way to treat stubborn arthritis..
Studies have shown that satisfaction rates for knee replacement surgery hover around 80 percent, near the highest ever for an elective procedure, said Daniel J. Riddle, a physical therapist and professor at Virginia Commonwealth University in Richmond.
“It’s hard to find a safer procedure, and when it works, the results are fantastic,” said Nick DiNubile, a Philadelphia-area orthopedic surgeon who specializes in sports medicine. He said it can be a “life-changing procedure,” but that some patients may be left unsatisfied because “expectations are not met.”
“We need to dig deeper into the complaint,” DiNubile says. “Is it pain? Is it loss of function? Once we understand the complaint, we can develop a treatment plan to address the deficiency.”
The surgery I underwent in September 2022 was a textbook procedure. I received the same light anesthesia or sedation that most patients undergoing a colonoscopy receive, and a spinal nerve block for pain relief. The surgeon relied on “robotic assistance,” a computer that provided real-time data. Studies show that this technology minimizes incision length and soft tissue damage, guiding surgeons to make more precise bone incisions and place implants that are best suited to a patient’s specific anatomy.
Within two hours of my surgery, my husband walked me out to the car. (Most patients have to take their first steps within two hours of surgery, but mine could be done at the outpatient surgery center.) When I got home, I had a light dinner, walked up the stairs, and went to sleep in my bed.
The first 2-3 weeks were painful and difficult due to the severity of the surgery and the extensive physical therapy exercises patients perform multiple times each day. However, my pain management plan was working well and the initial progress was as planned. At my appointment two weeks later, the surgeon asked where my prescribed walker/cane was and laughed when I replied, “I always forget.”
Short-term warnings but little medium-term advice
About three weeks into my recovery, I realized I had not prepared myself for what was to come over the next few months.
Before the surgery, I received standard warnings about rare but serious surgical risks, such as blood clots and infection, and specific precautions to avoid them, but I received little guidance about the problems many patients face as they continue to recover.
“The studies that have been done are typically about the short-term patient experience, length of stay, complication rates, or really long-term, like, how long does ‘this implant’ last,” Likert says. “There’s very little research on the actual patient experience over the medium term.”
I suffered from sleep problems for about two months. Many patients suffer from sleep problems for weeks or even months due to pain and inability to find a comfortable position.
Another common problem is depression, exacerbated by pain, lack of sleep, and a long recovery period that limits mobility and independence. One in five knee replacement patients suffer from depression, and 15 to 20 percent struggle with anxiety caused by the surgery, says Riddle. I wasn’t clinically depressed, but I did experience high levels of anxiety as my surgery date approached, and as my rehabilitation stalled, my anxiety continued to rise.
Like many patients, I was partially disabled for the first 2-3 months and often exhausted with almost complete loss of mobility. Surgeons and physiotherapists advised that it would take 12-18 months to fully recover. My mantra became “I’m so tired of being so tired.”
My physical therapy was challenging because of a poorly understood neural response called “protective muscle guarding” that I suffered from during my rehabilitation. This occurs when the brain “locks” the muscles in my leg in an attempt to protect my injured knee, preventing the physical therapy movements. To overcome defensive muscle guarding and get my muscles to cooperate with the physical therapy, I tried several proven treatments, including lymphatic massage, extracorporeal shock wave therapy, aquatherapy, and cupping.
Seventeen months after surgery, I no longer have the occasional dull pain from arthritis in my knee. I’m back on the pickleball court and generally sleeping better. My knee extension (the ability to fully straighten my knee, important for healthy walking) has improved, but my balance and flexion (how far I can bend my knee) have gotten a little worse.
Many people are surprised when I give my less-than-glowing review of knee replacement surgery: My rehab and recovery was much longer and more difficult than I expected.
I don’t know how I would have managed this without an understanding and supportive employer, a desk job, and comprehensive private insurance. I have paid approximately $7,000 out of pocket related to surgery, coinsurance, deductibles, copays, medical equipment, and other types of treatment to overcome my muscle tightness.
I am currently taking steps to avoid or delay replacement surgery for my other knee. I have lost approximately 35 pounds. Weight loss, specific exercises and other physical activity have helped patients avoid surgery, according to patient education programs in the UK, Canada and Australia, Liddle said. A study presented at the Radiological Society of North America 2023 Meeting showed that “strengthening the quadriceps in relation to the hamstrings may be beneficial.”
But if I had to replace my other knee, I’d choose my physical therapist as carefully as I chose my surgeon. “The surgeon performs the surgery, makes sure the implant is inserted correctly, and leaves the patient in the care of the physical therapist,” Smith says. “The physical therapist spends months with the patient, coming in two to three times a week.” Many for-profit clinics require physical therapists to work with two or three patients at a time. My recovery sped up after I transferred to Johns Hopkins, which uses a one-physical therapist, one-patient model per appointment.
Having experienced it once, I will be better prepared for the challenges that surgery will bring and I will be better able to advocate for myself by asking detailed questions of my surgeon and physical therapist about changes in treatment and advances in surgery since my original knee replacement.
I also intend to better advocate for myself by asking tough questions of my surgeon and physical therapist about pain management, poor prognosis, sleep issues and other downsides to the recovery process.
Although your knee will never return to the condition it was before arthritis after knee replacement surgery, which is a debilitating and irreversible disease, if I had to have another knee replacement, I believe my recovery would be less physically and mentally exhausting given what I learned from the first surgery, the one-on-one physical therapy, and the relaxed expectations.
