What to ask before choosing surgery

What to bring with you

Carry a medicine list, earlier reports, and short notes on past knee care. Add the daily tasks that now cause trouble. Your surgeon needs more than an X-ray to understand the knee. What the surgeon sees while checking swelling, movement, strength, and sore spots also matters.

What to ask about likely relief

Ask what walking, sleep, and stair use may be like after recovery. Find out what may still hurt or stay limited. Average results won't say what will happen to you. Ask how many people like you improve, stay about the same, or get worse, and what the surgeon bases those numbers on.

What to ask about risks

Replacement can bring infection, blood clots, stiffness, another hospital stay after you go home, or another operation later. It may also improve daily movement for some people whose knees are badly worn. Both facts belong in the talk. Ask about your own risk, and ask again if the reply isn't clear.

What to ask about recovery

Ask how long you'll need help at home after surgery. Find out when driving may be safe again. Your age, heart health, blood sugar, weight, and help at home may change recovery. If the surgeon wants to delay surgery, ask what needs to improve during that wait.

When to make the choice

Choose only after you understand likely relief, recovery, and risk. Ask plainly what waiting may cost you. If walking and sleep keep getting worse, don't let delay become the decision by default. Nobody can remove every doubt, but you can insist on clear reasons.

Sources

1. 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.

2. A systematic review of prospective studies in unselected osteoarthritis patients found that the proportion reporting an unfavourable long-term pain outcome ranged from about 7% to 23% after hip replacement and 10% to 34% after knee replacement; in the best-quality studies, 9% or more after hip and about 20% after knee replacement.

   Beswick AD, Wylde V, Gooberman-Hill R, et al. — What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients.. BMJ Open, 2012. DOI: 10.1136/bmjopen-2011-000435.

3. 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.

4. 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.

5. 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.