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Our knees are one of the largest and most complex joints in our bodies. They are a weight-bearing ‘hinge joint’. This means they can straighten and bend with a usual flex between 0º and 135º. The knee’s main function is to allow movement of the leg and it is absolutely critical for normal walking.
Knee replacement surgery, also known as knee arthroplasty, is a very commonly performed operation. In the USA it accounts for around 4.5% of all operations undertaken. In the UK about 80,000 new knee replacement operations are performed annually.
It is one of the most successful operations in Orthopaedic Surgery with good clinical results in more than 90% of cases. For the majority of patients this knee replacement operation can bring pain relief and the chance of greater mobility in only a matter of a few months.
There are actually three different types: 1) Total knee replacement surgery, where the whole knee is replaced; 2) Partial knee replacement surgery, where only part of the knee is replaced; 3) Bilateral or double knee replacement surgery, where artificial knee replacement is performed on both knees at the same time.
An arthroplasty, knee replacement, will mean taking or cutting away the damaged part of the knee joint and substituting it for an artificial knee replacement.
Knee replacement is on of the most popular and successful orthopaedic surgeries.
For the majority of patients a new knee replacement will mean less pain and stiffness, more opportunities for physical activities and a return to ‘normal’ life. This often has a knock-on effect on the patient’s mental well-being.
The aim of this article is to explain what is knee replacement, provide knee replacement information and answer those questions that arise when new knee replacement surgery is being considered.
Despite its huge success rate, knee replacement surgery is a major operation and its eventual outcome relies heavily on how much work, particularly in exercising, the patient puts in after the surgery. For this reason, doctors may often suggest a range of other therapies such as physiotherapy, medication and/or lifestyle changes before knee arthroplasty is performed as a last resort. So, the question is – do I need a knee replacement? Or indeed – why do I need a knee replacement?
The reasons for knee replacement surgery are varied, but the most usual cause is osteoarthritis. Osteoarthritis is the most common form of arthritis in the UK. It causes pain and swelling in the joints, in particular the knees, hips, spine and small joints in the hand.
There are, however, some other indications for knee replacement. According to the NHS website these include:
How do I know if I need a knee replacement? Having a knee replacement is a big step and reputable surgeons will only make the decision to operate based on the indications above and the following symptoms. These symptoms of needing knee replacement fall into four categories:
Arthritis is a very common condition where inflammation in the joints can lead to severe pain. It is most often thought of as a disease affecting older people, but, in fact, it can strike at any age from childhood onwards. The two most common forms of arthritis are osteoarthritis and rheumatoid arthritis. In the UK, about 10 million people suffer with some form of arthritis and, of these, about 90% suffer with osteoarthritis. Other arthritic conditions which may require knee replacement are gout and ankylosing spondylitis.
Osteoarthritis affects the smooth cartilage lining in one or more joints. This cartilage is a protein substance that acts like a cushion between the bones of the joints. When the cartilage roughens and becomes thinner, this puts extra pressure on the tendons and ligaments. In turn, this may lead to inflammation, swelling in the joint and even bony spurs called osteophytes. When the cartilage loss is severe, bones may rub against each other, changing the shape of the joint and pushing the bones out of their usual position. Although osteoarthritis can affect anybody it is most prevalent after the age of 40 and tends to affect women more than men. There may also be a genetic link. In the USA it is estimated that approximately 50% of osteoarthritic patients eventually require an osteoarthritis knee replacement.
Rheumatoid Arthritis affects over 400,000 people in the UK. It is an autoimmune disease where the patient’s own immune system attacks the cells that line the joints in particular the synovial membrane. Further swelling and a change in the shape of the joint can lead to a break down in the bone and cartilage. Around 20%-30% of patients with rheumatoid arthritis have problems with their knees. Compared to knee replacement for osteoarthritis, the outcomes for knee replacement for rheumatoid arthritis are not so good. However, as with all medical procedures, a successful outcome is dependent on many different factors.
Arthritis is a common indication to knee surgery.
Gout is caused by too much uric acid in the body which can affect a joint causing intense pain, redness and swelling. It is most often associated with the joint in the big toe, however it may, less often, also affect the knee joint.
Ankolysing Spondylitis mainly affects the bones, muscles and ligaments of the spine, however it can lead to pain and swelling in tendons, eyes and large joint like the knees.
Post-traumatic arthritis is caused, as the name suggests, by the wearing out of a joint after a physical injury – most commonly dislocations and fractures.
All of these conditions could lead to knee replacement surgery but, as mentioned earlier, the most common reason for performing knee replacement surgery is osteoarthritis.
Does knee replacement cure arthritis? No, If a patient suffers from arthritis, knee replacement will not cure it. Arthritis is a progressive disease which can be managed to a degree by lifestyle – exercise, diet and medication. Arthritis knee replacement will not cure the disease, nevertheless it does potentially offer greater mobility and eventually less pain in the joint. The patient will still need to manage the arthritis after knee replacement.
Knee replacement surgery is fairly major surgery which will ‘disrupt’ the patient’s life for a few months afterwards. This can include not being able to work and being dependent, at least immediately after the operation, on other people to perform some of the most basic life needs. For these reasons, and, of course, the fact that any surgery carries a very minimal risk to a patient’s life, most doctors will recommend some alternative therapies before suggesting a patient becomes a knee replacement candidate.
These treatments include:
Generally, a candidate for knee replacement will have been expected to have tried the above options before being considered for surgery.
As with any surgery, the physical well-being of the patient and their ability to recover from a major surgical intervention will have to be taken into account. Two other very important considerations are the age of the patient and their weight.
Age of the patient and their weight are two very important considerations in case of knee replacement surgery.
In theory there is no ‘knee replacement age’.The operation can be performed at any age. However, the average age for knee replacement surgery is 60-80 years old. Generally a total knee replacement will last 15-20 years (sometimes up to 25 years even), so, although it is perfectly feasible to have a second procedure after this time, having surgery at the same site can cause extra problems. So, for example, if a patient has knee replacement age 45, there is a strong possibility that further surgery will be necessary at around 65 years of age. This is known as revision total knee replacement surgery, which takes longer than the original procedure and has a lower success rate. Although there is no official minimum age, most surgeons will not consider patients under 40 because of the potential need for multiple revision operations.
For younger patients (age 45-60), a partial knee replacement is often offered. This will last only about 10 years, but because the surgeon cuts away less of the original bone, the revision surgery is a little easier.
With regards to an upper knee replacement age limit – provided a patient is healthy and, in the opinion of the surgeon, will be able to participate fully in the necessary post-operation rehabilitation, then the operation can take place at any age.
Generally, there is no weight too obese to get a knee replacement. Having said that, any type of surgery for an obese patient carries a higher risk than for somebody who is non-obese. The surgeon will always advise an obese patient to lose 5%-10% of their total weight. This can significantly reduce the risks associated with anaesthesia.
Being overweight is one of the trigger factors for joint replacements. For every one pound of extra weight, an extra three pounds is added to the load on the knees. This obviously also applies when the knee is replaced, which means that the life of the artificial knee will be much reduced. Thus, obese patients will always be encouraged to lose some weight both before and after the procedure.
As with any medical operation knee replacement surgery risks and benefits should be given careful consideration.
The biggest benefits of knee replacement surgery must be the freedom from pain and increased mobility. These benefits should not be underestimated. Continual pain can be very debilitating and the inability to sometimes carry out some of the simplest tasks in life can be very depressing. So, these huge benefits can quite substantially improve the patient’s quality of life and improve not only their physical condition but sometimes also their psychological condition. The surgery can open up a whole new chapter in their life.
When it comes to the risks involved, it has to be said that knee replacement surgery has been around for a long, long time and it is one of the most successful operations performed in hospitals. Nevertheless, any surgical procedure, large or small, will always carry a very tiny risk to the patient.
An artificial knee will never be as good as a natural knee. Most people give their artificial knee a 75% rating compared to their natural knee. An artificial knee usually does not have the full 135º flex of a natural knee joint. In addition, many people find it difficult to kneel, either because of the scar at the front of their knee or because the knee feels ‘funny’.
Some of the latest developments in knee replacement surgery aim to correct some of these issues. 3D scanning of the patient’s natural knee, new materials, minimally invasive surgery (keyhole surgery) and computer-assisted navigation systems are all helping to revolutionise surgery in general and specifically knee replacement surgery. 3D printing of knee components is a tantalising prospect, which should ensure that any knee prosthesis is a perfect fit. The next few years may bring even more innovations.
Interestingly, the timing of a knee replacement is quite crucial to its success.
If the operation is done too soon, it is less successful and may mean that a revision knee replacement operation is required in the future which could involve more problems.
If the operation is done too late, it may well mean that the joint has already degenerated too much, and although the procedure can still be performed, the outcome will not be as successful as an operation performed earlier.
If a patient decides they do not want the operation, or indeed, the doctors decide not to operate because the risks are greater than the benefits, then unfortunately the knee joint will continue to deteriorate. This means that the patient will change the way they walk and may become bandy-legged or knock-kneed. Using the knee joints less because of pain means that the muscles around them will weaken. The patient’s weight distribution and gait will change which may well put pressure on and cause problems with other joints in the body – typically in the spine or hips. Arthritis is a progressive disease so it will not improve on its own. The rate of progression, which is usually quite gradual so that is imperceptible on a day-to-day basis, will, of course, vary from person to person.
There are four main types of knee replacement surgery and within these some different surgical techniques.
Ultimately it will usually be the decision of the surgeon as to which of the knee replacement options would best suit a particular patient. During the procedure, parts of the knee joint will be replaced with a knee replacement prosthesis or implant. These protheses vary slightly from manufacturer to manufacturer. Generally, however, knee replacement materials consist of a metal alloy of cobalt-chromium and titanium. This metal prosthesis rests on a cushion of polyethylene which is a strong, durable plastic.
Total knee replacement, also known as TKR, is often described by doctors as total knee arthroplasty.
The knee comprises three different compartments:
The total knee replacement surgical procedure replaces all of these three compartments. A total knee replacement implant consists of four components:
The components are fixed using special bone ‘cement’, or are treated so that the bone is encouraged to grow into and fuse with the replacement parts.
There are many different manufacturers of knee replacements. Probably the four biggest manufacturers are Stryker, Zimmer Bionet, DePuty and Smith & Nephew. As with any product on the market each brand has its own unique selling points and there are obviously some differences between them. In general, surgeons will have their ‘favourite’ total knee implant with a couple of others ‘in reserve’ for situations where their prime choice is not suitable for the patient.
Triathlon knee replacement
One of the most popular total knee replacement products is the Triathlon total knee replacement manufactured by Stryker. Stryker knee replacements are used in over 100 countries and to date more than 3 million Stryker protheses have been implanted.
The Triathlon knee replacement is a single radius joint. This means that as the joint pivots, the radius (from the centre to the outer edge) remains the same. With a multiradius or multiple radii knee joint the ‘centre’ changes as the joint flexes and therefore the length of the radius changes. A single radius joint puts less stress on the thigh muscle (quadriceps). This muscle is attached to the knee and therefore may become a source of pain and discomfort during the recovery period.
In several studies the Stryker Triathlon knee replacement has also been shown to have superior durability to some other knee implants. The National Joint Registry of England and Wales shows the Triathlon Stryker knee replacement has a much better revision rate than other knee implants after three years. Another medical study in 2018 (Excellent 10-year patient-reported outcomes and survival in a single-radius, cruciate-retaining total knee arthroplasty) states that, ‘The Triathlon TKA continues to show excellent longer-term results with high implant survivorship, low rates of aseptic failure, consistently maintained PROMs and excellent patient satisfaction rates of 88% at 10 years’. (PROMs are Patient Reported Outcome Measures).
The benefits of the Triathlon knee replacement are listed as:
It has also been designed to be compatible with the Mako system. Stryker’s Mako System is robotic-arm assisted technology. Mako uses a virtual 3Dmodel which allows surgeons to create a surgical plan for the patient before the surgery. During surgery, the surgeon implements the plan and adjusts for increased accuracy while using the robotic arm.
As with any surgery, the surgeon/consultant must decide for each patient which would be the most appropriate prosthesis .
Partial knee replacement, as the name suggests, consists of replacing only part of the knee joint mechanism. Sometimes it is known as a half knee replacement and it is a much simpler operation than total knee replacement . In partial knee replacement surgery a considerably smaller incision is made in the knee and less bone is removed. Recovery is quicker and there is more natural movement in the knee post-operation. It is therefore a better option for those people who are more active. Around 25% of people suffering from osteoarthritis are suitable for this surgery, however those with rheumatoid arthritis, which affects the whole knee joint, will need a complete knee replacement. Partial knee replacement surgery, where possible, is particularly beneficial for younger patients. A partial knee arthroplasty means they can stay more active after the operation, and also, a knee replacement revision, which is more likely in a younger patient, will be easier because of the greater amount of bone left.
The partial knee success rate is very high. There are many studies which show that 90% of partial knee replacements remain functioning well ten years after surgery. Those patients surveyed, who have had a total knee replacement on one knee and a partial knee replacement on the other, consistently state the they prefer the partial knee replacement.
Unicompartmental knee replacement is another term for partial knee replacement. It is also sometimes known as unicondylar knee replacement, unicompartmental knee arthroplasty or, indeed, unicondylar knee arthroplasty. All of these terms are associated with partial knee replacements. . The doctor will always need to perform a physical examination of the knee join to establish which part of the knee requires replacement – the lateral, medial or patella-femoral. Most commonly, the medial (inner) joint of the knee wears out the most often. This is sometimes known as anteromedial arthritis. The phrase unicondylar knee replacement is usually used to describe the replacement of this particular part of the knee. Generally the unicompartmental knee replacement and partial knee replacement is less invasive than a total knee replacement.
For most people their surgeon will be the best placed person to decide on the dilemma partial vs full knee replacement . In the majority of cases, the surgeon will elect to use the less invasive partial knee replacement wherever possible. However, this does depend on the state of the knee and, as mentioned earlier, partial knee replacement can only be performed if just one part of the knee is affected. Interestingly, a 2019 article in The Lancet found little difference in the clinical outcomes between the two procedures. However, there is no doubt that partial knee replacements do have some advantages over total knee replacements:
It is estimated, however, that only 5% – 6% of patients with arthritic knees are eligible for partial knee replacement. Revision rates for partial knee replacement also tend to be higher than for total knee replacements.
Most doctors agree that partial knee replacements, where possible, are the best option for younger patients. Although, overall, the life of a partial knee replacement is considerably shorter than a total knee replacement, revision surgery is much easier. For an older, less active patient – maybe 60-70 years- there is a good chance that a total knee replacement will not need to be revised in their lifetime. However, this is probably not the case for younger patients. Above all, of course, a decision must be made according to the state of the knee. Full knee replacement vs partial knee replacement is an important discussion which must take place between the patient and doctor.
Although ceramic hip replacements have been around for a while, the incorporation of ceramic materials into mainstream knee replacements is a relatively new innovation (about 20 years). They are useful for patients who suffer from allergies to metals. Sometimes the component can be all ceramic or sometimes it is ceramic on plastic. Unfortunately, there is little independent medical evidence comparing the various aspects of ceramic components with metal or plastic components. A 2018 article in the medical journal Orthopaedic Proceedings found that ceramic replacements performed as well as the the best-performing all metallic replacements. Many surgeons, though, do believe that the life of a ceramic knee replacement prosthesis is about 5 years longer than those from more traditional materials. The advantages of a ceramic total knee replacement are believed to be:
The type of metals used in metal knee replacements are alloys of cobalt-chromium, titanium, zirconium and nickel (cobalt-chromium is often used in dentistry).
All metal knee replacements are used less often these days. The idea was that they could provide longer-lasting joint replacements for younger active people due to the durability of the metals. The metals can, however, cause inflammation, pain and even organ damage.
The most common type of knee replacement materials now are metal and plastics. This metal-plastic combination is the most frequently used type of knee replacement. Essentially the plastic is a special high-grade wear-resistant plastic which covers the ends of the metal components and provides a smooth surface between them.
As the name suggests a double knee replacement, also known as bilateral knee replacement, is when knee replacement surgery takes place on both knees. This can either be a simultaneous bilateral knee replacement, when both knees are operated on during the same surgery session, or staged bilateral knee replacement, when there is a separate operation for each knee with a time gap between them.
Possibly the most obvious advantage of having both knees replaced at the same time is that there is only one session of surgery and one recovery period. This recovery period however, may be quite difficult as the patient does not have one good leg/knee on which to steady themselves. In this way rehabilitation is more complicated. Recovery time is therefore longer than for a single knee replacement but shorter overall compared to the recovery time for two separate (staged) knee replacements. Generally, time-saving is the biggest advantage. The disadvantages tend to be more associated with increased medical risks. Longer surgery means a prolonged anaesthesia time, risk of greater blood loss and an increased risk of complications. Patients usually have to be in a good physical condition before a surgeon will consider a simultaneous knee replacement.
Staged bilateral knee replacement carries a slightly lower medical risk for each surgery, although it has to be borne in mind that the patient is now having two surgeries instead of just one as in the simultaneous double knee replacement surgery. It can also be a little disheartening after having recovered from one surgery on one knee to be then plunged back into another session of double knee replacement recovery/rehabilitation mode after the second surgery.
As with many other medical decisions the surgeon is usually the best placed person to decide which type of bilateral knee replacement is most advantageous for the patient based on medical records and lifestyle.
The answer to the question – ‘what type of knee replacement implant is best?’ – is highly-dependent on the patient and their expectations. A relatively young patient with a very active lifestyle will have different requirements from that of a more elderly person with a more sedentary lifestyle.
The surgeon, in consultation with the patient, will, firstly, have to decide whether a full knee arthroplasty or a partial knee arthroplasty is required.
Current condition of the knee joint, age of the patient, lifestyle, previous medical history and current health all need to be taken into account when deciding on the best knee replacement implant for the individual.
Probably, the next consideration will be the knee replacement materials. As stated above the most commonly used is plastic on metal and this type of replacement joint has a good track record. However, in certain circumstances, all metal or ceramic joints could be a better choice.
The next consideration is the actual type of joint i.e. how it works. The most commonly used is the fixed-bearing (the tibial insert is fixed to the metal tibial implant) or mobile-bearing implant (the polyethylene insert can rotate short distances within the metal tibial component), single radius joint or multiple radii joint (see the discussion about triathlon knee replacement). Despite various studies investigating the success of each of these there seems to be limited differences when all aspects are taken into account both long-term and short-term.
What is minimally invasive knee replacement? There are various definitions but generally the following criteria are used:
Traditionally a knee replacement requires an incision of 8-12 inches whereas minimally invasive knee replacement requires approx. 3-6 inches. The surgeon normally has to cut through quadriceps muscles, the quad tendon and other soft tissues. In less invasive surgery certain tendons and muscles are pushed out of the way.
In a similar fashion the kneecap is usually turned over 180º whereas in minimally invasive total knee replacement it is simply pushed to one side. In traditional surgery the tibia is dislocated from the femur before the prosthetics are fitted. In minimally invasive knee replacement this will probably not happen
The biggest challenge for the surgeon with minimally invasive knee replacement is their limited vision and access to the joint which makes it much more difficult to ensure an ideal prosthetic fit and alignment.
Advantages of minimally invasive knee replacement surgery are less damage to skin and tissues, less blood loss, less post-operative pain, a smaller scar and sometimes a shorter recovery time. There are, however, some other issues to consider. Firstly, it is a very technically demanding procedure for surgeons. There is a more probable likelihood of a badly-fitted or misaligned prosthesis, skin and soft tissue may be stretched and torn and the whole operation takes longer.
Minimally invasive knee replacement is not a good choice for everybody. Its success also largely depends on the experience of the surgeon. Where the surgeon is less experienced traditional surgery may offer a smaller likelihood of complications.
On average a knee replacement weighs about 1.12lbs (0.50kgs) for men and 0.76lbs (0.34kgs) for women. The weight of the implant is roughly equal to the weight of the bone which is being removed. In this way, the patient should not feel any extra weight around the knee joint. The actual weight is very dependent on the body and knee size of the patient. This is the answer to the question – how much does a total knee replacement weigh? – but obviously a partial knee replacement will weigh less but still commensurate with the parts it is replacing.
Having decided, in consultation with the surgeon, that knee replacement surgery is the best way forward, the next question that comes to mind is – how to prepare for knee replacement surgery?
As with any major surgery, some planning in advance will make it easier in the recovery phase of the operation.
Some patients are given a total knee replacement protocol. This, however, is usually given to the patient after the surgery and includes the rehabilitation plan after the surgery. If the protocol is offered by the surgeon before the surgery, this may be the time to study it and query anything that is not clear.
Lastly, it is very important to remain as active as possible as we will see in the next section
Why is it important to do pre surgery exercises for knee replacement? Firstly, it is important that the legs are as strong as possible. Initially there will be a greater reliance on the ‘good’ leg and as time progresses rehabilitation will be much easier if the muscles in the ‘knee replacement’ leg are strong to help support the weaker knee. In addition, the patient will need to rely more on the strength in the upper torso – arms, stomach, shoulders etc.
Before knee replacement surgery it is important that the legs are as strong as possible.
The surgeon will be able to suggest good pre op knee replacement exercises, but here are some exercises which have been shown to be helpful:
1. Exercises that strengthen the quadriceps (the muscles attached to the knee joint):
2) Exercises that strengthen the muscles in the hip and buttocks, which will provide more stability when walking and moving:
3) Knee bending – this helps to maintain mobility prior to surgery:
4) Chair pushup – immediately after the surgery walking aids (such as frames or crutches) will be needed. This exercise will strengthen the triceps in the arms:
5) Stomach Kickbacks – this exercise strengthens the hamstrings and the gluteal muscles. We use these muscles to go from sitting to standing and, for example, to get in and out of cars:
6) Standing on one leg – this is excellent for maintaining balance and therefore reducing the risk of falls:
For those not used to exercising it is better to start slowly and gradually work up. For example, each of these exercises can be done 5 times aiming for 3 sets. Gradually try to increase the frequency little by little to 20 times for 3 sets. The rehabilitation period after the surgery will be greatly improved and probably shortened as well.
Patients are usually admitted to hospital either on the day of surgery or sometimes the day before. Occasionally, but not often, the operation can be performed by using an epidural. An epidural is a spinal injection which numbs the lower half of the body. More frequently, however, for a knee replacement operation the surgery is performed under general anaesthetic. The surgeon will make the decision as to which is the most appropriate.
The total knee arthroplasty surgical procedure involves making a vertical incision in the knee of up to 10” (approx. 22.5 kms) long. This will vary a fair amount depending on whether the surgeon considers minimally invasive surgery is appropriate. In this case the incision will be much shorter. This incision will reveal the kneecap or patella. This will need to be turned or moved out of the way so that the surgeon has access to the knee joint.
The surgeon will make the decision as to which is the most appropriate anaesthetic in your case.
In the total knee arthroplasty surgical procedure the surgeon will usually first start work on the thighbone or femur. Damaged bone and cartilage will be cut away and the end resurfaced in preparation for the fitting of the new metal component which is usually cemented to the bone.
In a similar way the ‘top’ of the tibia or shinbone will also need to be prepared and resurfaced. When it is ready the bottom part of the implant – the tibial tray – is attached to the tibia using bone cement. After this the surgeon will snap in a polyethylene (medical grade plastic) tray to act as a cushion between the two metal components.
Sometimes the kneecap will need to be adjusted or flattened to ensure a good fit. When this is necessary a small plastic component may also be fitted on the patella.
Before completing the knee replacement operation, the surgeon will flex and bend the joint to ensure that it is moving as it should and then stitch or staple the incision.
As with any surgery, knee replacement surgery time will vary from one patient to another. The total knee replacement operation time is usually 1-3 hours. Partial knee replacement will sometimes take a little less time.
Externally: from the outside the knee should look no different after the knee replacement procedure, apart from the scar from the incision. As with any surgical scar this will fade over time. Initially there will also be some swelling but this again is common after any operation and will disappear over time.
Internally: on the inside, naturally, the knee will look a little different with its new prosthetic.
There will always be some pain associated with any major operation, although hospital staff will try to minimise this with painkillers, which, immediately after surgery, are often given intravenously. Knee replacement surgery is no different in this respect – the skin around the knee will have been cut and ‘damage’ done to the bones. There will therefore be quite a lot bruising after knee replacement. Many people would argue that a knee arthroplasty ranks as one of the most painful operations – a lot of bone and tissue will have been removed so the remaining soft tissue must stretch more. Is knee replacement major surgery? Yes, in many respects it is.
These are general guidelines concerning pain but they may vary. Everybody’s pain experience, body reactions to trauma and pain threshold is slightly different.
Hospitals will always endeavour to get patients home after any surgery as quickly as possible. Financial considerations aside, people tend to feel better in their own homes and, provided recovery is going as planned post-surgery there is no real reason why the patient should stay in hospital.
You should stay in hospital 2-3 days after surgery.
So, how long in hospital for knee replacement? Various elements will have an influence on the length of stay required post-operation, including the patients overall health, age, recovery from anaesthesia and how straightforward the surgery was. Most hospitals count on between 1-5 days with the average hospital stay at 2-3 days. For those who have a partial knee replacement the hospital stay can be shorter. There are even some hospitals who perform knee arthroplasty surgery as an outpatients’ procedure and send patients home the same day, however this is very rare, especially on the UK.
Correct post op knee replacement aftercare is crucial for the overall success of the surgery. Let’s first deal with the very common question often posed by patients – Do I need someone to stay with me after knee replacement? For those people who live alone, life will be especially difficult without some sort of help from friends, family or neighbours. Immediately after discharge from hospital, mobility will be extremely limited so even the ‘simplest’ of tasks will cause problems.
In the UK, there are many commercial companies who will provide aftercare support at a cost. When considering this option always check references and, where possible, try to get first hand recommendations. In some cases, the local social services team will provide help free of charge. This will depend on certain circumstances and the hospital will be able to arrange this if the patient is eligible.
As with any operation medical staff will be keen to get the patient out of bed and walking as soon as possible, mainly to prevent post-surgery blood clots forming. When it comes to knee replacement surgery it is even more important that the patient attempts to walk. Remember all those pre-surgery exercises to strengthen the muscles?
Generally the patient will be helped to stand within 12-24 hours of the operation. Doctors and physiotherapists will expect the patient to walk using a walking frame or crutches. How long do I need to use crutches after knee replacement? Probably they will be needed for up to about a week after the surgery. At this point, the patient will be encouraged to walk unaided.
Everybody’s recovery time is slightly different, however this is an average timeline when it comes to walking on the new knee.
Day
Action
Day One
Sit on the edge of the bed with help from the physiotherapist. Get out of bed, stand up and step around to sit in a chair.
Days 1-2
Start walking with the aid of crutches or a walking frame and helped by a physiotherapist.
Days 2-3
Walk with the aid of crutches or a walking frame but without another person’s help.
Days 3-4
Progression to walking with 2 sticks and go up and down stairs with the help of the physiotherapist.
Days 4-7
Patient will be able to walk short distances with the aid of sticks.
Weeks 1-3
Patient can walk and stand unaided and for up to 10 minutes.
Weeks 4-6
Patient should be able to walk further progressing to 30 minutes per day, and, depending on the nature of their job, may be able to return to work.
From about 12 weeks the patient should be able to participate in some other sports like cycling and swimming, although walking is always excellent exercise for general health.
Sleeping after knee replacement may be a little difficult at first. However, the body needs sleep to recover from the trauma of the operation, so if you are unable to sleep after total knee replacement, it could impact the recovery time. The two main problems will be pain and finding a suitable sleeping position.
There are a couple of things that may be able to alleviate some of the pain. Firstly, if you are on painkillers try to take one dose about one hour before going to bed. This will ensure the maximum pain relief as you are falling asleep. Another trick is to place a towel around the knee and then position an ice pack on the knee for about 15-20 minutes, before bed. This will numb the area. Always take the ice pack off before going to bed. The other issue is trying to find good sleeping positions after knee replacement surgery.
It is important to find a good sleeping position after knee replacement surgery.
Sleeping on your back: This is the best position for sleeping in immediately after knee replacement surgery. This position means there is less pressure on the knee. It will also help if you sleep under lightweight covers to put as little weight as possible on the knee. The knee, where the arthroplasty has taken place, should remain as straight as possible in order to maintain an adequate blood flow to the site of the surgery. Putting a pillow under the knee and calf will cushion the knee from pressure as well as helping to keep the leg straight. However, do not place the pillow under the foot as this will put stress on the knees and, thus, increase the pain.
Sleeping on your side: This is not recommended initially, but, if this is the preferred sleeping position, it may be possible as the knee starts to heal. The knee which as been recently operated on must ALWAYS be ‘on top’. When it is ‘on the bottom’ too much pressure will be put on the surgery site and it will be very painful. Putting a pillow between the knees will provide a cushioning effect. Sleeping on the side may be painful at first because the knee is not straight.
Sleeping on your stomach: Sleeping on the stomach puts direct pressure on the surgery site and can be very painful. Patients are strongly advised not to lie in this position. After the internal/external wounds have healed, usually between 3-6 weeks, it may be possible to sleep on your stomach providing it does not cause any pain.
Knee support post-surgery: Some patients use a ‘wedge’ pillow after total knee replacement surgery. This helps to elevate the leg while at the same time either keeping the knee straight or at an optimal angle. These pillows come in a variety of shapes and sizes. Medical staff will be able to suggest the best type in each situation.
Knee replacement surgery recovery begins almost immediately after the operation. Initially the wound from the surgery will be covered with a large dressing. Sometimes there will be a tube extending from the wound to drain any blood from the site and prevent it gathering inside the knee and potentially leading to an infection. As mentioned previously, recovery after knee replacement begins with moving and walking with the help of a physiotherapist as soon as possible and usually patients go home after about three days.
How long does it take to recover from a knee replacement? Full total knee replacement recovery time takes a while. It can take up to three months for the pain and swelling to subside and even up to a year for the leg swelling to fully disappear. Recovery from knee replacement will continue for up to two years after the surgery, while the scar tissue continues to heal and muscles are restored through exercise.
However, a patient can resume normal leisure activities after six weeks. So, the knee replacement recovery time average, in terms of getting back to ‘normal life’, is not so long.
As with any operation the body’s total recovery time will depend on the age, fitness and general health of the patient.
Research in 2020, comparing two groups of patients (under 80 years old and over 80 years old) showed that total knee replacement is a very safe procedure for the elderly. There were minimally more severe complications, a longer length of stay in hospital and smaller gains in the functioning of the new knee when compared to the younger patients. However, it should be pointed out that these differences were relatively minimal. There is no doubt that as people age, the body’s recovery time is extended.
So, knee replacement recovery time for the elderly will take longer than for younger patients. Arthritis Research UK states that patients may feel very tired when they return home and muscles and tissues may feel very sore. It is important therefore that the elderly are patient.
Total knee replacement recovery time for the elderly is about twelve weeks. Probably a walker or crutches will be required for up to three weeks. In four to six weeks the swelling should subside significantly and there will be a greater movement in the joint.
It is particularly important that the elderly work closely with a physiotherapist, who will also give advice on gentle exercises to perform alone at home. Remember that the knee replacement recovery time will be longer but it will happen.
Let’s try to summarise the knee replacement recovery timeline. It is important to remember that this is an ‘average’ knee replacement rehab timeline for the first 12 weeks, sometimes recovery may be a little quicker, sometimes a little slower.
Time Period
PATIENTS USUALLY CAN:
Sit at the side of the bed and walk a few steps helped by a physiotherapist and walking aid (e.g. crutches, walking frame). A passive motion machine may also be used. This device moves the knee slowly and minimises the buildup of scar tissue and can alleviate stiffness in the joints. The patient will experience pain, swelling and bruising .
Day Two
Stand up, sit, change locations and use the toilet. Walk for a slightly longer time and climb a few stairs with assistance. If the dressings on the knee are waterproof, the patient can take a shower.
Day Three
Stand, dress, shower and use the toilet with no help. With help, climb up and down a flight of stairs. Go on longer walks relying on walking aids less. For some patients this may be the day they can go home.
BY WEEK 3
In the first week, although possibly still painful, bend the knee 90º and later extend it straight out after about 10 days. Walk either unaided or if necessary with just a stick. Walk or stand for longer than 10 minutes.
WEEKS 4-6
Walk even further, probably totally unaided. Cook, clean and perform everyday household chores. Return to work if it is a sedentary job. Possibly start driving. Travelling is allowed e.g. in a bus, train, car etc.
So what happens 6 weeks after total knee replacement? Basically life is becoming much easier, the new knee is much more flexible and much less painful. The site of the surgery is healing. The patient can probably walk even further. Sometimes patients notice that their knee may ‘click’ or ‘clunk’. This happens because of some minor motion between the thigh bone prosthesis and the plastic component. As the knee strengthens, the components will stabilise and it will become less noticeable and/or disappear completely.
What happens 8 weeks post-op total knee replacement and beyond? The initial phase of healing is usually complete about eight weeks after the surgery. The patient can start to participate in recreational exercise like walking, swimming, cycling, dancing and golf. However, high impact activities like jogging, jumping and skiing are still discouraged. It is advisable to continue with the stretching and strengthening exercises. Keeping the muscles strong and supple will lessen the friction between the surfaces of the prosthesis which will help to extend the life of the new knee.
In 2014 an independent survey stated that about one-third of patients reported that their knee did not feel ‘normal’. More recent research has shown that this figure is now a little lower at around 20-25%, possibly due to new techniques and new types of prostheses. However, it is clear that for a minority of patients the knee replacement will always feel ‘different’. Having said that, of course ‘different’ will probably eventually become ‘normal’.
Nevertheless, for the majority of patients there does come a time when the new knee replacement will feel ‘normal’. This is estimated to be between 1-2 years, but can be even longer for some people.
Certain actions may always feel slightly uncomfortable. 60-80% of patients reported that they feel uncomfortable when kneeling. Up until now research cannot find a definitive reason for this.
After a knee replacement operation there will be many questions that need to be answered by the doctors and medical staff. Although the general answers to many of these knee replacement questions can be found below, it is important to discuss them further with the medical staff who are familiar with the specifics of the situation. As mentioned before, not everybody’s knee replacement recovery timeline is the same.
In this day and age one of the first questions will almost certainly be – when can I start driving again after knee replacement surgery Generally, most patients can start driving again after about 6-8 weeks, but it is important to check with the doctor or physiotherapist. The criteria are that the patient can bend their knee to get in and out of the car and, obviously, control the car.
In the UK, where a driver has been told by their doctor to not drive for more than 3 months there are certain procedures that need to take place. Most patients will be back to driving before this time, but there are always some exceptional circumstances.
If, after more than 3 months after surgery, the patient has been advised against driving after knee replacement, DVLA will have to be informed. There is a £1,000 fine if DVLA are not informed about a medical condition that affects driving. The full details can be found at the website listed at the end of this article.
The degree of bend after knee replacement also known as ‘flexion’ or ‘range of motion’ (ROM), is one of the key components in a successful rehabilitation programme after knee replacement surgery.
It is generally accepted that the following ranges of motion are required:
Degree of Bend/Flexion
Activity
65º
Walking
70º
Lifting an object from the floor
85º
Climbing steps/stairs
95º
Sitting and standing comfortably
105º
Tying shoelaces
115º +
Squatting or sitting cross-legged
So, how much bend after knee replacement is expected on the recovery timeline. Typical ‘milestones’ are:
Research shows that up to 7% of patients can’t bend knee after knee replacement, often because they have developed stiffness after surgery. The best way to avoid stiffness is to continue to improve the flexibility of the knee. Building ROM takes a consistent and persistent effort. The best way is to ask the physiotherapist to measure the flexion each week and set a goal for the following week for an increase.
The kneeling position is used in many daily activities as well as in certain occupations and leisure activities e.g. gardening. In addition, it is also an intermediate position when we get up from the floor, especially in older adults.
Can you kneel on a knee replacement? – the short answer is – Yes! There is no medical reason why patients should not be able to kneel on their new prosthesis. According to the American Academy of Orthopaedic Surgeons, kneeling is not harmful to your knee after a total knee replacement, although it may be uncomfortable.
Recent research shows that about 65% of people can kneel without a problem 18-24 months after surgery. The limited research on this topic seems to suggest that there may be a difference between the perceived ability and actual ability to kneel. For some people there is a fear of harming the prosthesis.
Kneeling after knee replacement will become easier over time, nevertheless most people do have the sensation that the knee is artificial and does not feel ‘normal’.
Cycling after knee replacement is a great form of exercise that most patients can participate in. It is worth, however, just checking with the doctor or physiotherapist that it is OK. Most patients can begin one to two weeks after surgery by riding on a stationary bike. Initially, cycling will allow a full passive ROM i.e. the maximum degree of bending and straightening of the knee. It is important, however, to not put too much stress on the knee. The following tips will help:
The seat height should be adjusted so that when sat with the knee straight down, resting on the lowest point of the pedal, the knee is slightly bent. Initially, pedal in reverse slowly. Don’t worry if, at first, it is not possible to pedal all the way around – this is normal. Just pedal around until the knee bends as far as it can. Pedal slowly. With the knee bent as far as possible, hold this position for a few seconds and then continue pedalling in reverse. Slowly let the knee straighten and continue pedalling in reverse until the knee is bent as far as possible again. Do not pedal in a forward motion until it is comfortable to cycle in a reverse motion. Your knee will require a minimum of 90º flexion to achieve this.
The knee ROM will improve quite quickly using this method. Do not be alarmed if it is easier to pedal in reverse than in a forward motion, this is quite a common occurrence with knee replacements. Sometimes the physiotherapist will decide to increase the resistance on the bike so the knees have to work a little harder.
Road cycling after knee replacement can begin after about four to six weeks of stationary bike use. Although cycling is excellent exercise to strengthen the knee after knee replacement surgery, it should be used in conjunction with other exercises to ensure that all aspects of recovery of the knee are addressed.
Running after knee replacement is a slightly controversial subject. Most doctors, physiotherapists would advise that running (or jogging) is not recommended. The advice from Arthritis UK is: ‘General advice after a total knee replacement is to avoid high-impact exercise such as running and jumping. These activities will increase wear of the artificial jolt surfaces.’
The American Academy of Orthopaedic Surgeons (AAOS) does not recommend jogging or running after a total knee replacement because it is high-impact. The NHS is less specific, however it also suggests that it is best to avoid extreme movements where there is a risk of falling.
All of this means that it is perfectly possible to go running after knee replacement surgery, however the risk is that the joint will wear out much quicker and therefore revision surgery will be required sooner than normal. Stories abound on the Internet of people who are, even running, after knee replacement, marathons.
The problem is that there has been little scientific research into the effect of running on a knee prosthesis. A 2020 survey (which included both total knee replacement, partial knee replacement and hip replacement patients) published by the International Congress for Joint Reconstruction noted that 12% of runners were able to return to running within one year of surgery, however it should be noted that hip replacement patients were more likely to run than knee replacement patients. Unfortunately, the percentage for each (knee replacement and hip replacement patients) is unknown. About 67% or runners were satisfied with their post-surgery running, while about 33% were not. 31% of the runners stand that they felt pain when running. From those who had been runners before their surgery and had begun running again after surgery – 6% had a higher revision rate than those who had not begun running again after surgery – 5%. It must be remembered that this survey was carried out with patients who had had either total (51%) or partial knee replacement (4%) or hip replacement (45%) so it is difficult to distinguish the specifics relating to total/partial knee replacement.
Most medical staff will continue to go with the ‘legend’ that running after knee replacement is not a good idea, however there is no real concrete research available to either prove or disprove this theory. Having said that it would seem logical that the more wear and tear on a joint (be it natural or artificial) the quicker it will start to wear down.
Skiing after knee replacement surgery is a similar scenario to running. Many knee replacement patients, and particularly those who were skiers prior to the surgery, will often be able to ski again. Skiing, however, falls into the same category of high-impact sports as running, and, therefore, the main issue is about the effect that it has on the longevity of the prosthesis.
Thomas P. Scmalzried MD in Orthopedics Today summed it up nicely when he said: ‘ There has always been a philosophy that the patient and the surgeon want the joint replacement to last as long as possible – hopefully, for the duration of the patient’s life. But that is in contrast to the philosophy about patients having joint replacement surgery to enjoy a better quality of life and there are certain physical activities that increase their quality of life. There is a big controversy about advisability as compared with capability’.
The Knee Society divides various sports activities into three categories: firstly those which are appropriate activities for knee replacement patients, secondly those which are suitable but carry a greater risk and thirdly, those that should be avoided. Interestingly, downhill skiing appears in the second category alongside such activities: scuba diving, in-line skating, ice skating, softball, volleyball, speed walking, horseback riding, hunting and low-impact aerobics.
As with running, there is no real scientific evidence either for or against snow skiing after knee replacement surgery. Previously, it was probably true to say that with the older versions of polyethylene used in protheses – ‘the more it was used, the more it wore down’. However, research on the current, more modern version of polyethylene is sadly lacking.
The best advice for any patient is to discuss the matter of practising an sports with the medical team.
What are the best ways to ensure the shortest but most beneficial recovery period after total knee replacement? Here are a few knee replacement surgery recovery tips:
and some DO NOTS:
Knee replacement recovery exercises are potentially even more important than the pre-surgery exercises. However, for those patients who performed the exercises prior to their operation, the physio after knee replacement will be much easier as the muscles will already be strengthened. The knee replacement recovery exercises are almost as important as the surgery in creating a good, flexible knee joint. The exercises will commence almost immediately after the artificial knee replacement usually under the guidance of a physiotherapist. This physiotherapist will also teach the patient exercises which can be done at home in order to strengthen the knee. This knee replacement physiotherapy needs to continue for a minimum of about 12 weeks. The aim of the exercise programme is to help reduce swelling, increase the ROM of the knee and generally strengthen it.
Knee replacement recovery exercises are same important important as the pre-surgery exercises.
The physiotherapist is in the best position to advise on specific post knee replacement exercises, however below are some general exercises that are most often used in knee replacement rehabilitation.
A good exercise to combat swelling is Ankle Pumps and Circles: whilst in a lying position. with the legs straight pull the feet up towards you and then push them away in a gentle pumping action. Rotate the feet clockwise and anticlockwise from the ankle joint. It is best to aim for 10 repetitions of each exercise. However, the ankle pumps should also be performed 10 times every hour during the day.
Good exercises to improve range of motion:
Good exercises to improve strength – most of these exercises can be done lying on a bed:
Note: Ankle Pumps (see above) are also good strengthening exercises.
It is difficult to pinpoint specific exercises to avoid after knee replacement, however there are certain movements which are not recommended. So, any exercise which includes these movements should be on your ‘banned’ list!
Post-surgery
There is no doubt that knee replacement surgery is a painful procedure, and obviously the first few days after the operation will probably be the worse. Skin and bone will have been cut so severe pain after knee replacement surgery is only to be expected. However, medical staff will help to manage the pain with painkillers during your hospital stay. Partial knee replacement pain will not be quite so bad as the surgery is a little less invasive. . At Discharge
At discharge, the medical staff will discuss with the patient the best form of pain control. This could be over-the-counter painkillers or stronger prescription drugs. These may be needed for up to about six weeks after the operation.
Three months after surgery
Swelling and bruising, which cause some pain, may be present up to 3 months after surgery but, for the majority of patients, there will be considerably less pain than prior to the surgery. If there is still severe pain after knee replacement after three months, this could be chronic pain. This is pain persisting for three months or longer. It affects roughly 20% of patients after knee arthroplasty surgery. This needs to be discussed with the doctor who will decide on the best curse of treatment in each individual case.
Six months after surgery
For some patients the pain will still linger. Sometimes the swelling can take up to a year to subside and this, obviously, is one reason for pain. It can take up to two years for the knee to recover. However, if you are still experiencing debilitating knee replacement pain then it is important to discuss the matter with your doctor. It is essential that the reason for the residual pain is found so the correct remedial steps can be taken.
Pain at night
Many patients complain that they have pain worse at night after knee replacement and, in fact the most common cause of sleep disruption is pain. It has been reported that over 50% of patients wake up with pain after joint treatment. Again this is something that should be discussed with your doctor as everybody’s needs will be different. However, using ice packs just before bed, planning the schedule for painkillers so that they are taken about 60 minutes before bedtime and finding a comfortable sleeping position will all help with the night pain after knee replacement surgery.
Non-invasive treatments:
When none of the above appear to make any difference to the level of pain, occasionally more drastic measures may have to be taken. Corticosteroid injections may be used. These are often fairly effective but their impact on the pain after knee replacement surgery is relatively short-lived – about one to six months
Genicular nerve block/neurotomy is a relatively new technique used to treat severe knee pain (either replacement or natural) that has not responded to other treatments. Basically it blocks the ‘pain messages’ that are sent to the brain and is more or less permanent. It is not, however, always instant and may take up to three weeks after the initial treatment to take effect. In exceptional cases, there may be a need for revision surgery, but this is rare.
Apart from the obvious pain from the site of the knee replacement operation, some patients report pain in other parts of their body. Firstly, there is the issue of ‘referred pain’. It is not really known why, but sometimes we experience pain away from the site where the pain is ‘happening’. The precise reason for this is still really unknown, but it is thought that when the nervous system carries a signal to the brain that there is a ‘pain stimulus ’ in one part of the body, the brain then responds by sending the signal that the person experiencing pain. Sometimes, because of how the nerves are wired, the brain sends the pain signal to a different part of the body. This ‘referred’ pain can occur in any ‘pain’ scenario and occasionally can occur after knee replacement therapy.
Secondly, most patients, prior to the surgery have been in a lot of pain with their knee. This almost certainly means that the patient, unconsciously, has changed the way that they walk and/or hold themselves, in order to compensate for the bad knee. With the new knee prosthesis, this gives the body the opportunity to pull itself back into alignment. Unfortunately this will mean e.g. hip pain after knee replacement as the hip joint realigns itself.
Back pain after knee replacement may also be caused by a re-alignment, however a survey in 2013 shows that it was more prevalent among younger, female patients. It was also associated with depression , which is not an uncommon occurrence after surgery. In addition, if a patient suffered from back pain prior to total knee replacement surgery, then a new knee will not relieve the back pain.
Thigh pain after knee replacement is common just after the surgery, especially at the front of the thighs. It is caused, because the quadriceps tendon, just above the kneecap, is often cut and then sutured back again during the operation.
Calf pain after knee replacement is often not severe and is just caused by muscle soreness because of the change in walking style. However, if the whole leg is red and swollen and the calf is particularly tender, this could be a blood clot which can occur after any operation. If this is case, it is important to see a doctor immediately.
Ankle pain after knee replacement and/or foot pain after knee replacement may occur soon after surgery and later due to the change in alignment of the leg. Occasionally, the rotation of the femoral and tibial components changes the rotation of the shin-bone and this can, subsequently, affect the ankle/foot. This may manifest itself in foot or ankle pain and the feeling that your shoes are wearing in a different way. Consult the doctor if you believe this is a problem.
Felling pain is normal after the knee replacement surgery. Usually it can be relieved with the pain-killers.
This article has already mentioned the problem of stiffness after total knee replacement a few times. Probably the most common question is: How long does stiffness last after total knee replacement? Some knee stiffness after knee replacement surgery is normal and provided the patient sticks to the exercise regime this stiffness should dissipate over time. Ice packs will also help, particularly when the stiffness is caused by swelling. There should be a marked difference after three months, however slight stiffness can persist for months or even years, especially after activity or exercise.
On rare occasions, and where severe stiffness occurs over a long period of time, the patient may have stiff knee syndrome or arthrofibrosis. This could be classed as one of the total knee replacement complications. It is caused by a build-up of scar tissue in the knee which starts to limit the range of motion of the knee. If the surgeon does diagnose arthrofibrosis, he/she may initially attempt to manipulate the knee to break up the tissue, usually with the patient under anaesthesia. Where this does not work, surgery will be required.
A certain amount of swelling after knee replacement – indeed after most operations is normal. It is actually the first stage of the healing process, which is called the inflammatory phase. The body sends thousands of cells to the affected body part and the influx of these cells causes the swelling. In the case of swelling after knee replacement, it can be fairly easily controlled by doing one or more of the following:
The simple answer to the question: How long does swelling last after knee replacement surgery? – is ‘it depends’. Every operation is slightly different and every body is different in the way it responds to the surgery. Typically, swelling will last for up to two to three weeks after surgery, although it will probably gradually lessen over this time. Fo some patients, however the swelling may last for between three and six months. If you feel that the swelling is particularly uncomfortable and lasting a long time it is best to discuss it with the doctor.
The amount of time it will take to feel no pain is different for everyone. For obvious reasons the worst time for pain is immediately after the surgery. Usually, the pain reduces within three to five weeks. After six weeks, when the patient has more mobility, the pain becomes less but is replaced with stiffness and soreness which can be uncomfortable. All of this, of course, depends on the patients commitment to the pain management regimen given by the doctor and the physical therapy/exercises.
How long do you have pain after knee replacement surgery? A difficult question as it will vary for everybody. As the intensity of the physiotherapy increases over time, the patient will be stretching muscles and joints which maybe have not been used for a long time – this can be a source of soreness. It is not unusual for patients to experience some sort of pain for up to one year. If the patient feels that the pain is more intense than it should be, or has lasted for much longer than expected, it is worth talking to the doctor to check that there are no exceptional reasons.
Knee replacement pain after one year sometimes does happen. Various medical studies have shown that from 16% to 44% of patients suffer from chronic knee replacement pain. It is sometimes difficult to diagnose the exact cause of pain as it can accompany almost any other complication. When the pain is accompanied by swelling, this is often a sign of infection or a mechanical problem with the joint. Research which examined data from 2010 to 2015 found that about 1% of patients suffer infection after a total knee replacement operation. Mechanical problems can include a faulty prosthesis, or a misalignment.
A medical research article (Chronic Pain after Total Knee Arthroplasty) published in 2018 stated: ‘Despite a good outcome for many patients, approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Chronic pain after TKA is associated with functional limitations, pain-related distress, depression, poorer general health and social isolation.’
It is also worth remembering that for many people the reason for the knee replacement surgery was osteoarthritis. By replacing the knee, the osteoarthritis will not disappear, so this can also cause some pain. If there is knee replacement pain after one year, it should be investigated by the doctor to ensure that it has not been caused by any obvious reasons.
Pain can occur some years after the knee replacement. Sometimes it is caused by sources within the knee such as: knee instability, aseptic loosening (a loose knee replacement), infection, or a loss of bone. Other times it is not directly caused by the replacement knee itself. Problems in the spine, the hips, the ankles and the feet could lead to the knee pain problem. Occasionally this may even beg the question of whether, in fact, the knee was the problem in the first place.
There is anecdotal evidence of patients receiving a knee arthroplasty, only for surgeons to find out later that, although the initial pain was in the knee, it was actually caused by a problem somewhere else in the skeletal system. Even such problems as cardiovascular diseases, bursitis and tendonitis can cause pain within the knee. The section on knee replacement complications and problems gives more information on some of these issues and how they may be resolved. It is essential, however, that real long-term pain is investigated by a doctor. It appears that it may take some time to investigate, but it is very important particularly if there is something wrong mechanically with the replacement knee.
The restrictions after knee replacement can be divided into short-term and long-term.
Firstly, let’s take a look at total knee replacement precautions short-term:
Restrictions
Getting dressed/undressed
Sitting
Using stairs
And what about total knee replacement precautions long-term? Much will depend on how quickly and how well the patient recovers from the knee replacement surgery. The doctor and/or physiotherapist can give the patient suggestions specifically for that person. Here are some general restrictions:
Restriction
High-impact sports
Particularly where pulling, jerking and/or twisting of the knee is required.
Turning
Take small steps when turning. Do not pivot on the knee.
Sudden movements
Do not make sudden jerky movements with the knee.
Lifting
Do not carry more than 20lbs or about 9kg. This will put undue stress on the knee.
There are no real mandatory constraints when it comes to work restrictions after total knee replacement. For those with sedentary/office-type jobs, a return to work can take place usually about eight weeks after the operation. However, it is worth remembering that sitting down for long periods of time is also not good for the knee, so frequent short walks around the office and some leg exercises while sitting, will help to improve circulation and improve the total recovery time.
For more physically active jobs, it really depends on how the patient feels. Usually it is about 12 weeks before a patient can return to a physically active job, but before then they will have to decide if they feel able to meet the physical demands of the work. There may be problems for people working in the building industry – builders, plumbers, roofers etc. also shelf stackers, warehouse staff, horticulturists among many others. As mentioned earlier kneeling can be a problem for some people so this may be a difficulty in certain occupations. The patient must decide when/if they can return to work.
https://clinichunter.com/hip-replacement-surgery/doctors/After knee replacement 90% of people see real improvements in their quality of life, but it does not happen immediately. Recovery does take time so it’s best to have realistic expectations.
For most people it will take about three months to return to normal activities and six months to a year or more to make a full recovery and regain full strength.
The replacement knee will not bend quite as far as the original knee which will make some activities more difficult. However, staying active helps maintain strength, flexibility, and endurance in the long term. Exercise will help to strengthen the bone, create a strong bond between the bone and the prosthesis and thus reduce further bone damage and osteoporosis.
Being overweight puts pressure on the knee and increases the risk of inflammation. It can also cause damage to an artificial knee by putting extra stress on the joint and thus causing the prosthesis to break or wear out sooner. For this reason overweight and obese patients are advised to lose some weight both prior to and post surgery.
The majority of knee replacements will last anything up to 25 years and, for most patients, life after knee replacement means a reduction in pain and stiffness and increased mobility. Nevertheless, to get the best from the new knee it is important that patients exercise regularly, maintain a healthy weight and attend all their hospital/doctor check-ups.
A total knee replacement cannot return the legs to a pre-arthritic state as they will not be as strong or have the same range of motion as a healthy natural knee. However, most patients will be able to participate in activities which were not possible prior to surgery. Many patients also report that the physical benefits affect their mental state as well. They are generally able to enjoy their life more.
After knee replacement 90% of people see real improvements in their quality of life.
For any ‘cut’ to the skin a scar will form as the healing process takes place. Usually a partial knee replacement scar is about 4”-6” long and a total knee replacement scar about 8”-10” long. The surgeon will make a vertical incision. The healing process varies from person to person, so the size, colour and texture of the scar will vary.
Any surgical incision goes through a three-step process of healing.
The body’s natural response to an injury or surgery is to produce scar tissue. It’s the body’s natural response to healing itself. Scar tissue is formed when new collagen fibres are produced to repair the damage to the skin. However, in some patients the body produces too much scar tissue, and, for some reason, this is particularly common in the knee. This excess scar tissue or arthrofibrosis can limit the range of motion of the knee and become quite painful. Performing range of motion exercises as soon as possible after surgery and gentle massaging of the scar (from two weeks after surgery) may help to prevent arthrofibrosis.
If, however, the scar tissue has already built up – how to get rid of scar tissue after knee replacement surgery? There are three possible solutions:
Can you damage a knee replacement? – yes, of course. This is why it is so important to look after it well and avoid sudden movements and high-impact sports. Possibly one of the main causes of damage is falling on the knee. This can be a particular hazard just after surgery when loss of strength, range of motion and balance may lead to an increased risk. This is why it is so important that the patient being to build their strength in their legs through exercise as soon as possible.
In the first few weeks after the operation it is advisable to keep something e.g. a walker, spare chair etc close at hand which can be used to steady yourself in the event you lose your balance. A bathroom/shower can be an especially dangerous place with its wet tiles and even sitting and standing up from the toilet may present problems. Grab rails in the bathroom are a good idea.
In 2018 a study discovered that, from a group of 134 people who had undergone a knee replacement, 17.2% had fallen at least once during the six months after the surgery. About two-thirds of these falls had happened when the patient was walking.
Other causes of a damaged knee replacement may be continual sudden or high-impact stress on the knee or, after some years, just general wear and tear. Many knee replacements will last up to 25 years, however it depends on how they are used.
Once a prosthesis is damaged, probably the only solution is revision surgery in order to fit a new prosthesis.
Flying after knee replacement is not a major problem, but there are a few important things to remember. Let’s take a look at some questions to do with flying: How long after knee replacement can I fly?
Most doctors will advise patients to only travel on short haul flights (e.g. 3-4 hours) at least six weeks after surgery (although in some cases, where special precautions are taken this may be shorter). For long haul fights ( 4 hours +) it is advisable to wait three months. Why is this? The main reason is that post-surgery patients are more likely to develop deep vein thrombosis (DVT) which can be deadly. Wearing compression socks during the flight will help. Patients are also asked not to fly two weeks before the surgery for much the same reasons.
Where possible, it is advisable to try to book an aisle seat, which will offer the opportunity to stretch the legs out every so often. It is important to stretch occasionally during the flight and walk up ad down the aisle to boost circulation.
When flying after knee replacement surgery, it is highly likely that the prosthesis will set off the airport detectors, as all implants have some metal components. Airport security staff are used to such situations. Some hospitals/clinics offer their patients special cards confirming that they have had a joint replacement. It is worth carrying this with you, if you have one, or indeed, just a letter from the doctor confirming that you have had a knee replacement. It may also be an idea to wear loose fitting trousers so, if necessary, the security officers can see the scar. By all means, inform the security officer before going through the screening and they should offer a private screening with a hand-held detector and a pat-down inspection. Note that having a knee replacement will not be taken as an excuse to not be screened, security still have to do their job!
A knee replacement operation is a very common procedure and most people have no complications. Nonetheless, similar to any operation, there are some risks in addition to the benefits. A survey in the USA found that fewer than 2% of patients suffer severe knee replacement complications.
It should be emphasised that total knee replacement complications immediately after surgery are rare. What about later? Post knee replacement problems after some time are also rare but can occur from time to time. Let’s take a look at the main complications.
Knee replacement problems after 3 years: for a small minority of people there may still be some residual pain from the surgery, however ‘new’ pain should be investigated as it could be that the prosthesis has become loose. The other possibility, of course, is that the prosthesis has become damaged in some way due to a fall.
Knee replacement problems after 5 years: any issues at this stage will be similar to knee replacement problems after 3 years.
Knee replacement problems after 10 years: there is a small chance that for some people the knee replacement will start to wear out. This is not common as most protheses will last up to 25 years, but when the knee has not been looked after properly it can start to fail as early as 10 years after the initial surgery.
A knee replacement operation is a very common procedure and most people have no complications.
Some other rarer but more serious complications are listed below in further detail.
A loose knee replacement is, perhaps, one of the most serious complications. There may be several causes for this including infection, faulty design, a defect in the product or just general wear and tear. Some lawsuits in the USA have cited failure of the cement used to connect the prosthesis to the bone as a reason for a loose total knee replacement. It can also happen when the bone around the implant deteriorates.
A slightly different issue, but often with the same outcome is the problem of instability caused by loose ligaments after total knee replacement. In this scenario the new knee is perfectly OK but the soft tissue structures surrounding the knee cannot provide the stability for it. Sometimes this is caused because the ligaments stretch out after surgery. Often the solution to these issues is revision surgery.
Symptoms of a Loose Knee Replacement
What do symptoms of a loose knee replacement feel like?
Knee replacement dislocation is a major complication, however it rarely happens. A medical article in 2018 found that the frequency of dislocation of knee replacement is only 1.87% per 1,000 operations and, in fact, only 0.93% for first knee replacement surgeries. The incidence is slightly higher for revision surgery. On average the dislocation occurred about 2½ years after the operation, but obviously it can happen at any time.
Similarly, to a loose knee replacement, symptoms will be severe pain, swelling, instability, ‘popping’ noises and movement limitations, however there will usually be a visual deformity of the knee. The most common treatment for knee replacement dislocation is revision surgery.
A slightly different complication is patellar dislocation after total knee replacement. In the same way as with a natural knee the kneecap (or patellar) may become dislocated. When the total knee replacement surgery takes place, the surgeon, after making the initial incision, pushes the kneecap to one side so that he/she has access to the knee joint. One reason for patellar dislocation after total knee replacement is that the kneecap may not have been sited correctly after surgery. Trauma to the kneecap may also result in dislocation. Often surgery is required to correct the problem.
Often ‘clicking’ and ‘clunking’ of a knee replacement is nothing to worry about. Immediately after the surgery, the swelling will ‘cushion’ the knee, but as time goes on many patients start to hear clicking noises. Most of these noises are caused by metal and plastic components rubbing up against each other. These components are held in place by the body’s muscles, tendons and connective tissues like collagen and elastin. Knee strengthening exercises will also help strengthen the muscles and tendons and help the connective tissues grow around the knee replacement, thus reducing the noises. On average, this will take about three months after surgery. However, remember that each patient’s recovery time is different, so knee replacement clicking after surgery may last for a longer or shorter period of time.
The one time when total knee replacement clicking may be a problem is when it suddenly starts some time after surgery and is accompanied by pain and swelling. It may be a sign that the knee replacement is loose. A doctor should be consulted.
An infection after knee replacement is rare and only happens in about 1% of cases, however it can be a serious complication. There are actually two types of infections – superficial and deep knee infections.
Superficial infection: After total knee replacement an infection may occur around the site of the surgery. It will usually occur immediately or shortly after the operation and can be treated with antibiotics. Nevertheless, it is important that it is treated immediately. If it is left it can lead to a far more dangerous deep knee infection.
Deep Knee infection: An infection can also develop around the prosthesis, and this known a deep, major, delayed-onset or late-onset infection. This type of infection after knee replacement can happen weeks or even years after the initial surgery, although 60-70% of these infections occur in the first two years after surgery. The problem is that an artificial knee cannot fight bacteria easily. A natural knee will be helped by the body’s own immune system but this does not happen with a plastic/metal artificial knee. Bacteria from anywhere in the body can travel to the knee replacement, accumulate there, multiply and cause an infection. This bacteria can enter the body from a small cut or even dental treatment. (In fact some surgeons will recommend taking antibiotics prior to any major dental work). For a deep knee infection after knee replacement, the usual treatment is further surgery.
The components which comprise a total or partial knee replacement should very closely match the bone which it is replacing. Knee replacements come in all different sizes and the surgeon will take very precise measurements prior to the operation to ensure the prosthesis is a good fit. There is the possibility that a surgeon may implant the wrong size knee replacement and not be aware of the error, however this is a most unusual situation.
Occasionally, the situation arises where the surgeon removes too little bone and this can lead to ‘overstuffing’ of the patella-femoral joint. This means that the there is an increase in thickness of this joint. Research on the impact of overstuffing on the success of the knee replacement is unclear, however, should it have an impact on the comfort of the patient, it needs to be corrected.
Symptoms of Wrong Size Knee Replacement
When the knee replacement components are overstuffed, the knee will feel tight and it will be difficult to regain motion in the knee joint. If too little of the femur or tibia has been removed, the patient will have problems straightening their knee. Any additional thickness or ‘overhang’ of the knee replacement will irritate the surrounding tissue and lead to pain.
Nerve damage after knee replacement surgery happens at two levels. Firstly, as with many medical operations, the surgeon must cut and stretch the skin and this can damage nerves in and around the knee joint. This may lead to a tingling or numbness. May of these nerves will regenerate themselves but it can take up to a year as they grow very slowly. There is never a guarantee that all the nerves will grow back and these sensations will linger in some places. It is estimated that around half of patients feel some numbness after one year, but this symptom is bothersome to less than 10% of these people. Abnormal sensations around the knee does not normally lead to problems with the functioning of the knee replacement.
In some procedures the anaesthetist will administer a peripheral nerve block. When given with a general anaesthetic it is designed to help alleviate the nerve pain after knee replacement. It will provide pain relief for up to 18 hours and will reduce the need for heavy painkillers immediately after the surgery. Nerve damage may occur due to this procedure but most nerve injuries are temporary and recover within about three months. Between 92% and 97% of patients recover within four to six weeks and 99% of patients have recovered within a year. Permanent knee replacement nerve damage after peripheral nerve block is extremely rare.
The role of metal allergies in total knee replacement remains a controversial subject. In general, abut 10%-15% of the population have problems with metal allergies. In the vast majority of cases this is connected with nickel, but can also be caused by cobalt, chromium, beryllium and, very rarely, tantalum, titanium and vanadium. Interestingly, less than 2% of patients have reported knee replacement meal allergy symptoms.
It is imperative that patients advise the doctor prior to the surgery, if they believe they have a metal allergy. Usually a patch test will be conducted to ascertain the exact dermatological allergy. However there does appear to be little correlation between a ‘skin’ reaction to a metal allergy and the reaction of a total knee replacement.
Nickel allergy knee replacement symptoms, or indeed symptoms of any metal allergy, are usually dermatitis or synovitis. Dermatitis, a skin rash similar to eczema, can usually be successfully managed with topical steroid creams. Synovitis is a condition that affects the lining of the knee joint. It may be caused by trauma to the knee or by many different other conditions. Usually tests have to take place to exclude all of these other reasons, before knee replacement metal allergy is suspected.
The best treatment for nickel allergy and knee replacement is still under investigation. Providing the symptoms can be controlled, there will be no or little effect on the functioning of the new knee. The other option is revision surgery using ceramic (zirconium) or titanium prostheses. Using these implants is still regarded as experimental although initial reports are promising.
Even more rare is knee replacement cement allergy. In the exceptional cases where this occurs, it is usually a fairly immediate reaction which occurs while the patient is still in hospital.
Research has shown that knee replacements are not usually effective in the early stages of arthritis. A much better outcome is achieved when the arthritis is more advanced. The surgeon/doctor must decide when is the optimum time for the surgery individually with each patient.
Possible disadvantages of knee replacement surgery include:
The main disadvantage of knee replacement is possibility it should be changed in 10-25 years.
Total knee replacement surgery has been carried out in its present form for over thirty years. The Royal Berkshire Hospital reports the knee replacement success rate UK as 80% of patients reporting a satisfactory result, free from pain, which lasts ten years or more. 20% of patients either agree that their knee is much less painful but they are disappointed with the function of the knee replacement or they suffer a complication so the benefit of the new prosthesis is much reduced or they are worse off than before. From a purely medical point of view, 95% of total knee replacements are considered a success.
The partial knee replacement success rate is even higher. 90% of partial knee replacements still function well after ten years. In addition, in those patients who have had a total knee knee replacement in one leg and a partial knee replacement in the other leg, they consistently prefer the partial knee replacement. For a partial knee replacement, the hospital stay is usually shorter; there is a quicker recovery period and fewer complications. It should be remembered, however, that partial knee replacements do not usually last as long as a total knee replacement so revision surgery may be needed sooner.
Knee replacement success rate is 80%.
Knee replacement revision surgery is needed when the original total or partial knee replacement is no longer functioning as it should do. This may be due to a loosening of the parts of the original prosthesis, a dislocation, pain, stiffness or severe infection. A revision total knee arthroplasty is more complex athan the original operation, is more susceptible to complications and has a shorter lifespan than the original replacement.
Knee replacement revision symptoms include: less stability and reduced functioning of the knee, an increase in pain, a bone fracture or a failure of the prosthesis.
In a revision knee replacement the surgeon has to remove the original prosthesis which will have probably grown into the existing bone. Once the original has been removed there will be less bone remaining, so, sometimes, a bone graft is necessary. All in all the surgery normally takes much longer than for the initial knee replacement. Occasionally only one component of the prosthesis will be replaced.
The total knee replacement revision recovery time is very similar to that for the first operation. It is very important that the patient starts to stand and walk as soon as possible. Interestingly, the personal total recovery time of a patient for an initial knee replacement is no reflection on that of knee replacement revision surgery, which can be longer or shorter than the original.
As with any surgery there is a very small risk of complications and the lifespan of a knee replacement revision is usually shorter that the original knee replacement.
Although knee replacements are highly successful, it is major surgery and the patient will be ‘out of acton’ for at least a few months. So, are there any alternatives to knee replacement? The answer is – yes, there are. In fact, there are some quite basic things which will, if not prevent the surgery totally, at the very least, delay it. These things include losing weight (if you are overweight), doing muscle strengthening exercises and exercises to increase flexibility. All of these will help to stabilise the joint and allow the person to become more active. These are known as lifestyle changes and will help a great deal with or without knee replacement surgery.
Another short-term alternative to knee replacement for osteoarthritis are cortisone or hyaluronic acid injections which lubricate the knee joint and help relieve the pain of arthritis. The length of time these effects last varies greatly from person to person and is partly dependent on the state of the knee joint, however, most publications state ‘from 6 weeks to 6 months’.
When the above measures are not enough to restore a reasonable level of functionality to the knee joint, there are some other knee replacement alternatives.
Knee cartilage regeneration (sometimes known as cartilage repair) is part of the relatively new branch of medicine known as ‘regenerative medicine’. In a nutshell, this branch of medicine uses stem cells and tissue engineering to ‘fix’ tissues which cannot repair themselves. It is still in the early stages of development but initial results are favourable.
There are a few knee cartilage regeneration techniques, however the most successful ones are: ACI (Autologous chondrocyte implantation) and biological allograft transplantation.
The ACI technique involves taking cartilage cells out of the knee joint, growing and expanding them in a laboratory and then implanting them back into the knee during a second surgery about 8-12 weeks later. This technique has good to excellent results, however it is a very expensive technique requiring two surgeries.
The biological allograft transplantation uses a synthetic tissue of hyaluronic acid or collagen to cover the area where the collagen has been lost from. Often this technique is combined with ‘microfracture’. This is where tiny holes are made in the bone so the rich blood supply from inside the bone soaks through into the artificial graft (synthetic tissue). The patient’s own bone marrow cells which have soaked into the graft will multiply and slowly turn into a new hyaline- like cartilage. This technique has similar results to ACI and is more cost-effective, especially as only one round of surgery is necessary. Recovery time for both these techniques is similar to total knee replacement.
Aside from laboratory grown cartilage and synthetic tissue, the medical profession seems to agree that cartilage has practically zero regenerative potential in adulthood, but despite this websites can be found listing knee cartilage regenerate home remedies. There is no doubt that these food and supplement may help to strengthen the cartilage which exists but there is no medical evidence to support the claim that they regenerate cartilage.
Radiofrequency ablation (RFA) for knee pain is a technique which is rapidly gaining in popularity. It is a non-surgical and minimally invasive technique. It uses heat to ablate or damage the nerve fibres which transmit the pain signals to the brain. So, it does not actually treat the knee joint itself, but rather the way in which the patient experiences the pain from the knee.
In radiofrequency ablation for knee pain small needles are inserted into the appropriate location in the knee, and once the area has been numbed or anaesthetised, the temperature of the needles is raised for about 60-90 seconds. There may be some initial discomfort and some soreness after the procedure. The patient can resume normal activities after 24 hours. The pain-relieving effect usually lasts from six months to two years. Eventually the nerves will grow back, but there is no reason why the radio frequency ablation knee pain technique cannot be used again.
The word osteotomy means ‘cutting of the bone’. With arthritis the cartilage in the knee joint gradually wears away. When it wears away equally on both sides this is not such a problem, but often it wears away one side more than the other so the knee joint becomes ‘crooked’. With a knee osteotomy the bone, usually but not only, the tibia, is cut, opened and fixed in place with a metal plate, screws and a bone graft. Thus, the knee joint is ‘straightened’.
Again this osteotomy knee surgery does not cure the arthritis, however it does tend to give very good results in terms of decreasing pain and increasing the knee function. It also delays the time when the patient may eventually end up needing knee replacement surgery. It is a useful alternative for those patients who are still too young for a knee arthroplasty.
Knee resurfacing is another expression for a partial knee replacement. This is where only one part or compartment of the knee is replaced. The areas of bone involved are resurfaced by the surgeon and a partial knee replacement put in place. For more details on the knee resurfacing procedure see our section on partial knee replacement. Knee joint resurfacing can only be used where up to two of the three compartments which make up the knee joint are affected.
Stem cell therapy instead of knee replacement is a relatively new treatment which comes under the umbrella of ‘regenerative medicine’. A stem cell is a ‘basic’ cell which has not yet become fully developed. There is evidence that stem cell treatments trigger damaged tissues to repair themselves. Despite some private clinics offering a stem cell alternative to knee replacement, research in this treatment for osteoarthritis is limited.
Usually blood is taken from the arm, the stem cells are concentrated and then injected back into the knee. At the time of writing initial results are somewhat mixed as to the efficacy of this treatment and stem cell knee replacement is not recommended by any of the major health services/medical organisations.
Positive lifestyle changes could help your knee to stay healthy with or without knee replacement surgery.
Obviously, a knee replacement cost is nil when the patient has the surgery through the national health service for the country (at least in Europe). However, a private knee replacement can cost a lot of money, especially when surgery, hospital stay and physiotherapy is taken into account.
The private knee replacement cost in the UK varies between clinics but is usually somewhere between £12,000 and £14,000. This probably includes a 3-4 day hospital stay but not the necessary physiotherapy required after the surgery. There will probably also be additional costs for diagnostics and pre-operation consultations. For those who have private health insurance these costs will usually be met by the insurance company but for those without private insurance, the cost of knee replacement UK is extremely high.
A partial knee replacement cost UK is not that much cheaper. The average cost for the UK is just over £11,000 and again this is unlikely to include pre-surgery diagnostics/consultations and post-surgery consultations/physiotherapy.
Naturally, in the UK, NHS knee replacement is available free of charge to those who are eligible for it. This will include all diagnostics, consultation and physiotherapy. It is a very commonly performed operation.
The NHS has its own waiting time target of delivering treatment within 18 weeks of the patient being approved. Unfortunately, with the ongoing COVID epidemic, waiting times have continually been extended and operations routinely cancelled. Even with the lessening pressure on hospital beds, it will be some time before the NHS knee replacement waiting time returns to its pre-COVID situation.
The NHS criteria for knee replacement make it quite clear that knee replacement surgery will only be offered when physiotherapy or steroid injections have not reduced the pain or improved the mobility.
The criteria for knee replacement NHS, according to its website is as follows:
For those eligible for NHS treatment (i.e. any resident of the UK) the NHS knee replacement cost is nil.
NHS knee replacement is available free of charge to those who are eligible for it.
For those who do not wish to pay for private treatment in the UK, but, on the other hand, do not wish to join the NHS long waiting list, there is an alternative. Knee replacement surgery abroad is a viable option. Medical records can be shared online so that a face-to-face consultation prior to the surgery is not required. If necessary, however, communication platforms like Skype, facilitate an ‘online meet’. Both total knee replacement and partial knee replacement abroad can be arranged. What’s also important, patients can get secured for their medical trip, which makes their travel and stay abroad much safer. Clinic Hunter & AXA Partners have created a travel insurance for medical procedures abroad dedicated solely to medical tourists.
There is a scheme currently operating whereby planned medical procedures which are conducted by the national health service of an EU country may be refunded by the NHS, however this does not apply to private clinics. For the most up-to-date information on this scheme, it is essential to refer to the latest NHS pages.
Generally, treatment abroad is done on a private basis. The knee replacement cost in Europe will vary between countries and between clinics. However, savings can often be made of up to 50%. Often a stay of about 14 days will be required. The surgeon will need to check that the operation has been successful, physiotherapy started and, of course, there is the embargo on flying immediately after the operation. Even with the additional cost of flights and hotel accommodation, it is considerably cheaper than private surgery in the UK. It is also worth bearing in mind that the NHS treatment will be the ‘cheapest version’, whereas many private clinics have superior equipment and facilities.
Here are some typical approximate prices (£s) in European countries where costs are lower than the UK:
Country
Cost of surgery
Cost of surgery + flights+ accommodation
Belgium
9800
1200
Croatia
7000
8000
Denmark
10700
12400
Hungary
3700
4300
Lithuania
Poland
4000
4600
Spain
10200
10500
Turkey
4700
5400
The cost of a knee replacement can vary enormously depending on the level of complexity of the operation. The type of surgery (open, laparoscopic), type of implant, patient’s overall health and/or chronic diseases and the duration of hospital stay will all have a significant effect on the final price. Sometimes costs may be reduced by having diagnostic tests like x-rays and MRI scans done in the UK.
Advice after knee replacement surgery is to wait three month after surgery to fly long haul – more than about 4 hours. For this reason, European destinations are the best choice for this type of surgery due to their relative proximity to the UK.
It is difficult to definitively state the best country for knee replacement surgery. In 2019 the top three places for countries with the highest number of knee replacements per 100,000 of population went to Switzerland, Finland and Austria. However, the cost of private surgery in these countries is even higher than in the UK. In addition, a higher number of knee replacements does not necessarily equate to the best country for the surgery. There are many excellent clinics around Europe which can offer an excellent service for knee replacement surgery including the best knee replacement surgeons at a very affordable cost. It is important, though, that the patient finds out as much as possible about the clinic before committing to such major surgery. Our consultants can discuss your requirements in detail and give advice on the most suitable clinic specifically for your needs. They have in-depth knowledge about each clinic and are experienced in finding the best match for each patient.
Poland has long since thrown off the shackles of its communist past, with the only remnant from that era being its relatively low cost of living compared to many other European countries. A low cost of living, however, does not equate to a poor private medical sector. Private clinics in Poland are thriving. They are equipped with the latest technology and surgeons are trained to the highest standard. The latest navigational equipment allows the surgeon to install the knee implant with the highest precision, which will result in better knee mobility.
In 2017, over 60,000 knee replacement operations were performed in Polish hospitals and clinics. The best clinics are given accreditation by the Polish Health Ministry. Many also have certification from the following organisations – ISO (International Organisation for Standardisation), ESQH (The European Society for Quality in Healthcare) and TAS (The Treatment Abroad Scheme). The success rate of knee replacement surgery in Poland is up to 98%.
Poland ticks many of the boxes when it comes to knee replacement abroad. The knee replacement cost Poland is much lower than in the UK ( as is the cost of living, hotels, food etc), it is a relatively short plane ride from the UK (approx 2.5 hours from London), English is widely spoken both within the clinics and in general life and it has some of the best-equipped clinics and most highly trained surgeons. Our consultants can provide specific details on the clinics we represent together with testimonies from other patients.
Turkey is another country where medical tourism is flourishing. In 2015, 34,000 knee replacements were performed in Turkey but this number is continually increasing. According to the International Medical Travel Journal (IMTJ), Turkey holds the third position in the list of countries most often visited for private medical treatment. About one third of patients treated in medical centres in Turkey are from abroad.
The cost of medical treatment in Turkey is very low compared to UK prices and like Poland, Turkey can offer modern treatment methods in state of the art clinics and hospitals. Some clinics in Turkey have been awarded the JCI (Joint Commission International) certificate, which is the highest quality standard for joint replacement. Flights from London to Istanbul are just under 4 hours and the flight costs are very reasonable. All medical staff speak English. Our consultants can provide specific details of clinics in Turkey which would best suit the needs of the individual patient.
There are, of course, many other countries where knee replacement can be performed at a lower cost than in the UK. Knee replacement cost in India is not as cheap as one might expect, when the cost of a long haul flight is factored into the cost. Most estimates, including flights and hotel accommodation are about £11,00 -£14,000 which is not such a great saving on UK costs. Obviously, for those patients who may have friends and relatives in India and therefore can save on accommodation costs, there will be more of a cost saving. Another issue with India is the length of flight from the UK (e.g. London to Delhi is over 8 hours). Doctors will usually advise a wait of 3 months after surgery before flying long haul.
Knee replacement in Spain is another possibility, although the savings are not as great as for some other European countries. A large number of clinics in Spain specialise in orthopaedic procedures and it is only a short haul flight from the UK.
The cost of knee replacement in Thailand appears to be initially much lower than in the UK. Partial knee replacement costs start at around £7,000 (although flight and accommodation costs need to be added to this price). Thailand has some excellent doctors and clinics, however, like India, the flight home may be a problem as it is even further than India. Additionally, in the unlikely event that any corrections are required at a later stage, Europe is much easier (and cheaper) to fly to than Asia.
The Internet provides a great opportunity to find out lots of information first hand about knee replacements. A knee replacement forum such as the Versus Arthritis Online Community, The Arthritis Forum and the Patient website to name but a few, are very informative. Links to these websites can be found at the end of this article.
Knee replacement blogs are also an excellent source of information. They are usually written first hand by somebody who has had the surgery. One thing worth remembering, however, is that bad news is often regarded as much more interesting than good news. Thus, the Internet will always provide a disproportionately high level of ‘horror stories’ compared to examples where the surgery went well.
Many of the NHS hospital websites have very informative reviews and information leaflets about knee replacement surgery available on the Internet e.g. The Royal Berkshire Hospital, West Suffolk Foundation Trust, the Royal Orthopaedic Hospital and many many others.
Total or partial knee replacement is a major operation with a fairly long recovery time. it can, however, give a new lease of life to those people whose activities are limited by serious joint pain and lack of mobility due to osteoarthritis. Doctors, in the first instance, will suggest less invasive ways of correcting the problem through lifestyle changes and physiotherapy. Where knee arthroplasty becomes the only solution, timing is of the utmost importance. If the surgery is performed too early or too late this will have a negative impact on the success of the operation. A knee replacement will not have the same flexibility as a natural knee and will often feel ‘different’. High-impact physical activity is discouraged after a knee replacement. Initial recovery time is up to 12 weeks, while a total recovery may take up to 2 years.
For those patients wanting the higher standard of service that private medical care provides, or who simply cannot wait until surgery is available on the NHS, having a knee replacement overseas is a good option. Places like Poland and Turkey are good choices because of their proximity to the UK and their excellent levels of medical facilities and personnel. Cost savings can be made when compared to UK private medical care.
Places like Poland and Turkey are good choices for private low cost knee raplacement. Contact us for details!
In the UK Anne was a professionally qualified trainer with many years of experience in the training industry. She mainly worked in the travel, tourism and leisure industries (including Thomas Cook and British Airways) as well as in other sectors.
Since moving to Poland twelve years ago, Anne has become involved in other business sectors – teaching English as a foreign language and translating documents from Polish into English. She specialises particularly, in medical translations and works closely with dentists, cardiologists and neurologists in translating and preparing articles for publication. She has also trained as a practitioner in the field of neuro-linguistic programming and is a qualified hypnotherapist.
Any spare time is spent renovating the house in Poland which Anne bought some years ago.
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