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Signs you Need a Knee Replacement
Orthopaedic surgeon David Dalury, MD, discusses top signs of needing a knee replacement, how to prepare yourself for the surgery and what to expect afterward.
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Learn more about David Dalury, MD
David Dalury, MD
Dr. David Dalury is a graduate of Dartmouth Medical School. He did a fellowship at the Harvard Hospitals, where he was trained in total joint replacement surgery. He is a Clinical Professor of Orthopedic Surgery at University of Maryland Medicine and Chief of Orthopaedics at University of Maryland St Joseph Medical Center. He is a member of numerous medical societies and associations and has written extensively for peer-reviewed publications. In addition, Dr. Dalury resides as an active member of The Knee Society, an elite group of orthopaedic surgeons charged with the advancement of care to patients with knee disorders through leadership in education and research. Dr. Dalury is a member of the University of Maryland Joint Network, a group of surgeons known for their advanced expertise and positive outcomes in total hip and knee replacement.Learn more about David Dalury, MD
Transcription:
Signs you Need a Knee Replacement
Scott Webb: Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This episode is sponsored by the University of Maryland Joint Network. UM Joint Network surgeons are experts in total hip and knee replacements. Held to the highest standards of care, UM Joint Network surgeons produce better outcomes for patients compared to national averages, including lower infection rates and faster recovery times. The UM Joint Network, home to Maryland's leading joint replacement surgeons.
And joining me today to discuss knee replacement surgery is Dr. David Dalury. He's a Clinical Professor of Orthopedic Surgery at University of Maryland Medicine and Chief of Orthopedics at University of Maryland St. Joseph Medical Center. So doctor, thanks so much for your time today. We're talking about knee replacements. What are the symptoms, the top signs of needing a knee replacement?
Dr. David Dalury: The most common symptom that would lead someone to think about having their knee replaced is pain. But pain isn't the only symptom that patients is going to experience. Pain is usually aggravated with activity, but there are folks who get pain at rest as well and that usually means that someone has more advanced arthritis in their knee. But yet there are patients who never really experience pain and what they really experience is instability and lack of confidence on uneven surfaces. So the combination of instability, buckling, leg giving way and pain is usually what patients who are leaning towards a knee replacement will experience.
Scott Webb: And I'm assuming that there's acute knee pain or a knee injury and then there's, as you say, when people are experiencing pain or instability sort of unexpectedly, right? There's a kind of a range there for people.
Dr. David Dalury: Oh, absolutely. And in general, patients who get knee replacements are having it done for arthritis. And that's more of a chronic problem. So someone who has an acute sports injury or acute traumatic event, they rarely require a knee replacement. They oftentimes can be treated conservatively, of course. And sometimes they would be candidates for something called an arthroscopy or a clean-out, if you will. But it's the patient who has the chronic symptoms, something that is unrelieved by other treatment modalities, that's the patient who would benefit from a knee replacement.
Scott Webb: Okay, good. And so how common are knee replacements?
Dr. David Dalury: Knee replacements are amazingly common. We've been doing them since the 1970s. But because of increase in patient activities, increase in patient's expectations, increase in previous trauma, arthroscopies, sports injuries and, unfortunately, increase in obesity, the number of knee replacements has increased dramatically in North America with an expectation that the numbers could increase by up to 30% to 40% over the next 10 years.
Scott Webb: Wow. That's pretty amazing, 30% to 40%. And it sounds to me like you do take sort of a conservative approach as much as you can and don't dive right into surgery. How do you do the diagnosis? How do we diagnose somebody who's a good candidate for surgery?
Dr. David Dalury: Well, you're right. You don't want to dive right into a knee replacement. I look at knee replacements as really the end of the road when nothing else has been effective and patient's quality of life has really suffered. Those to me are the benchmark decision points for when someone should have a joint replacement.
But the most common reason that patients get a diagnosis is through a regular x-ray. It's rare that a patient with chronicity of the types of symptoms that we described needs to have an MRI. So in general, a good history, a conversation with your surgeon and a good set of x-rays make a big difference. And I'll say a good set of x-rays because there are certain views or certain types of x-rays that are more valuable to making the diagnosis. And you can miss someone having a significant knee problem if you don't get the right kind of an x-ray. So in general, we encourage patients not to get MRIs, but to be examined, give a good history and get the correct set of x-rays before you get a good diagnosis as to whether or not you're a good candidate for a knee replacement.
Scott Webb: Yeah. And good to know that, as you say, a good set of x-rays can do the trick. But of course, you have to have the right views, so the x-ray had to been planned, you know, to be looking for specific things or specific views. So good to know that an MRI isn't necessarily necessary, if you will. My mom had a knee replacement surgery and I know that the recovery was the most difficult part for her both mentally and physically. So what can patients expect after surgery? What's that recovery process like?
Dr. David Dalury: Well, it's remarkably variable. There are patients who say, you know, "Honestly, it wasn't that bad." And there are other patients who say it two to three months of real difficult discomfort, pain, and stiffness. And I often like to tell patients that being well-prepared to understand what to expect afterwards really makes a lot of their recovery that much easier.
So pain is usually the issue that's most challenging for patients. So we work really hard in particular to manage their discomfort with a combination of injections that are done before the knee is closed and a cocktail, if you will, of different oral medications that can be taken afterwards. But I've had patients who said, you know, "I took two or three tablets, thats it." And I have other patients who said, "I really needed a good number of pain medications for up to four to six weeks." And so the variability in terms of pain control is quite substantial.
But patients can put full weight on their leg the day of surgery. They can go up and down stairs. They can walk as comfortably as they can. They can shower the day of surgery because we don't use staples anymore. Left knee patients usually can drive about seven to ten days after surgery. Right knee patients probably shouldn't drive less than two weeks after surgery.
And most knee patients will require physical therapy. Some folks say, "I really want to do this on my own at home," and that's perfectly fine. There are plenty of handouts and videos that are available to help patients through it, but making sure that you regain your motion is important.
Scott Webb: Yeah, people delay surgery for a variety of reasons over the last year. It might've been because of COVID or whatever other reasons. But what happens if people delay surgery and maybe decide not to get that knee replacement when they should?
Dr. David Dalury: I think it's important to recognize that there are no age criteria about, you know, either too young or too old to have your knee replaced. And that's one of the reasons that people say, "Well, I'm either too young or too old," but that's not the case. Again, recognizing that a knee replacement is sort of the end of the road. If you're there at age 40 or in your 90s, as long as you're healthy enough, getting your joint replacement is a good choice for the patient's improvement in quality of life.
But there are some instances where you literally can wait too long. And there are two that come to mind. One is stiffness. The patient who comes in with a significant deformity, whether it be a bow leg or a valgus or knock knee leg, combined with an inability to bend their knee well, those patients generally have more difficulty recovering after surgery. And the other instance is there are rare cases where you can wear away the bone, whether it be the patella on the femur, or sometimes the tibia can wear away when it rubs against the femur. Those instances can jeopardize your ability to get a good result.
As long as the patient does not have significant bone loss, does not have a significant deformity and maintains the range of motion, getting their knee replaced is very much an elective procedure.
Scott Webb: Yeah, it sure is. And it's good to know that you're never too young or too old. And you know, if you're feeling that way, like, "Oh, I'm too young for a knee replacement," well, as you say, if you're there, you're there, right?
Dr. David Dalury: Yep. It's the end of the road. And if you've tried everything else, I mean, I've done knee replacements on 27-year-olds and 98-year-olds, judiciously of course, but the 27-year-olds really had no choice. Her knee looked like she was 70, but it was an old football injury from playing with her brothers. And the 98-year-old lived for seven years after she had her knees done and sent me a Christmas card every year.
Scott Webb: So when we talk about preparing for the surgery, is there anything in particular the patients need to do? Should they try to lose some weight? Should they do anything in preparation for that knee replacement?
Dr. David Dalury: So in general, weight loss is important. The less you weigh, the easier it will be for you to recover and for transferring and going up and down stairs in particular. And so we're pretty strict about making sure that you're within a certain weight gain because the complications are much higher if you were beyond a certain BMI. But in terms of preparing for surgery, the best thing to do is to maintain the motion that you can and to keep your leg as strong as it can be.
I like to tell my patients that, "Your knee replacement is finished" when they're in the recovery room, "It's brand new. And the only thing that's getting better, so to speak, are your muscles. And the only way they get better is if you're comfortable enough or strong enough to bend them." So coming to the OR with good motion and good strength really makes a big difference.
Scott Webb: Yeah, you can see how that would be a good thing. And of course, if you've got a brand new knee, but everything else related to the knee, around the knee is not in the best shape and hasn't been kept active. That's probably not a good thing, right?
Dr. David Dalury: Yes, that's absolutely true. And the function of the knee is different from the knee itself. A knee itself really has no function other than to provide support stability and a pain-free surface. But the actual function of the limb is muscular. So working on your balance, working on your strength, working on your independence is really where you're going to get the most benefit after your knee replacement.
Scott Webb: And as we get close to wrapping up here, are there any complications that we haven't talked about already that people might experience post-surgery?
Dr. David Dalury: So in general, the risk of a complication after this type of surgery is in the 1% to 2% category. And the ways to prevent that are to make sure that your general health is as good as it can be; that your diabetes, if you're a diabetic, is under control; that your weight is within an acceptable range and that's generally with a BMI of less than 40; that you've done the best that you can to maintain your range of motion and your strength. If you do all those kinds of things and you follow the directions post-operatively, that 1% to 2% complication rate is a well-established rate of a potential complication for a procedure that should provide patients 90% to 95% relief of pain and should last them for 20 to 25 years.
Scott Webb: Yeah. When you talk about a risk reward, 1% to 2%, that's not so bad. And to last, you know, into the 20 plus year range, that's pretty great. And as we wrap up here, anything else you want to tell people about knee replacement, when they should consider it, why it's important not to delay, what are your takeaways?
Dr. David Dalury: Well, there's a lot of misinformation about knee replacements out there. I have many people tell me, "Well, they only last eight years or 20% of patients are unhappy or have complications afterwards." That's just not true. The risk of a complication is in the 1 to 2% complication rate and the durability of these knees is in the 20, sometimes as high as the 30-year mark.
And so the best advice I give my patients is try everything else first. Think about medications, injections, therapy, braces, et cetera. But if your quality of life is suffering and you've tried everything else, knee replacements are remarkably predictable, durable, and safe.
Scott Webb: I couldn't say it any better myself. This has been really informative today. And as you say, there is a lot of misinformation. Hopefully, we've been able to kind of fight some of that back for people when they click play here. So doctor, thanks so much for your time. You stay well.
Dr. David Dalury: Thank you very much.
Scott Webb: And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.
Signs you Need a Knee Replacement
Scott Webb: Welcome to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We put knowledge and care within reach, so you have everything you need to live your life to the fullest. This episode is sponsored by the University of Maryland Joint Network. UM Joint Network surgeons are experts in total hip and knee replacements. Held to the highest standards of care, UM Joint Network surgeons produce better outcomes for patients compared to national averages, including lower infection rates and faster recovery times. The UM Joint Network, home to Maryland's leading joint replacement surgeons.
And joining me today to discuss knee replacement surgery is Dr. David Dalury. He's a Clinical Professor of Orthopedic Surgery at University of Maryland Medicine and Chief of Orthopedics at University of Maryland St. Joseph Medical Center. So doctor, thanks so much for your time today. We're talking about knee replacements. What are the symptoms, the top signs of needing a knee replacement?
Dr. David Dalury: The most common symptom that would lead someone to think about having their knee replaced is pain. But pain isn't the only symptom that patients is going to experience. Pain is usually aggravated with activity, but there are folks who get pain at rest as well and that usually means that someone has more advanced arthritis in their knee. But yet there are patients who never really experience pain and what they really experience is instability and lack of confidence on uneven surfaces. So the combination of instability, buckling, leg giving way and pain is usually what patients who are leaning towards a knee replacement will experience.
Scott Webb: And I'm assuming that there's acute knee pain or a knee injury and then there's, as you say, when people are experiencing pain or instability sort of unexpectedly, right? There's a kind of a range there for people.
Dr. David Dalury: Oh, absolutely. And in general, patients who get knee replacements are having it done for arthritis. And that's more of a chronic problem. So someone who has an acute sports injury or acute traumatic event, they rarely require a knee replacement. They oftentimes can be treated conservatively, of course. And sometimes they would be candidates for something called an arthroscopy or a clean-out, if you will. But it's the patient who has the chronic symptoms, something that is unrelieved by other treatment modalities, that's the patient who would benefit from a knee replacement.
Scott Webb: Okay, good. And so how common are knee replacements?
Dr. David Dalury: Knee replacements are amazingly common. We've been doing them since the 1970s. But because of increase in patient activities, increase in patient's expectations, increase in previous trauma, arthroscopies, sports injuries and, unfortunately, increase in obesity, the number of knee replacements has increased dramatically in North America with an expectation that the numbers could increase by up to 30% to 40% over the next 10 years.
Scott Webb: Wow. That's pretty amazing, 30% to 40%. And it sounds to me like you do take sort of a conservative approach as much as you can and don't dive right into surgery. How do you do the diagnosis? How do we diagnose somebody who's a good candidate for surgery?
Dr. David Dalury: Well, you're right. You don't want to dive right into a knee replacement. I look at knee replacements as really the end of the road when nothing else has been effective and patient's quality of life has really suffered. Those to me are the benchmark decision points for when someone should have a joint replacement.
But the most common reason that patients get a diagnosis is through a regular x-ray. It's rare that a patient with chronicity of the types of symptoms that we described needs to have an MRI. So in general, a good history, a conversation with your surgeon and a good set of x-rays make a big difference. And I'll say a good set of x-rays because there are certain views or certain types of x-rays that are more valuable to making the diagnosis. And you can miss someone having a significant knee problem if you don't get the right kind of an x-ray. So in general, we encourage patients not to get MRIs, but to be examined, give a good history and get the correct set of x-rays before you get a good diagnosis as to whether or not you're a good candidate for a knee replacement.
Scott Webb: Yeah. And good to know that, as you say, a good set of x-rays can do the trick. But of course, you have to have the right views, so the x-ray had to been planned, you know, to be looking for specific things or specific views. So good to know that an MRI isn't necessarily necessary, if you will. My mom had a knee replacement surgery and I know that the recovery was the most difficult part for her both mentally and physically. So what can patients expect after surgery? What's that recovery process like?
Dr. David Dalury: Well, it's remarkably variable. There are patients who say, you know, "Honestly, it wasn't that bad." And there are other patients who say it two to three months of real difficult discomfort, pain, and stiffness. And I often like to tell patients that being well-prepared to understand what to expect afterwards really makes a lot of their recovery that much easier.
So pain is usually the issue that's most challenging for patients. So we work really hard in particular to manage their discomfort with a combination of injections that are done before the knee is closed and a cocktail, if you will, of different oral medications that can be taken afterwards. But I've had patients who said, you know, "I took two or three tablets, thats it." And I have other patients who said, "I really needed a good number of pain medications for up to four to six weeks." And so the variability in terms of pain control is quite substantial.
But patients can put full weight on their leg the day of surgery. They can go up and down stairs. They can walk as comfortably as they can. They can shower the day of surgery because we don't use staples anymore. Left knee patients usually can drive about seven to ten days after surgery. Right knee patients probably shouldn't drive less than two weeks after surgery.
And most knee patients will require physical therapy. Some folks say, "I really want to do this on my own at home," and that's perfectly fine. There are plenty of handouts and videos that are available to help patients through it, but making sure that you regain your motion is important.
Scott Webb: Yeah, people delay surgery for a variety of reasons over the last year. It might've been because of COVID or whatever other reasons. But what happens if people delay surgery and maybe decide not to get that knee replacement when they should?
Dr. David Dalury: I think it's important to recognize that there are no age criteria about, you know, either too young or too old to have your knee replaced. And that's one of the reasons that people say, "Well, I'm either too young or too old," but that's not the case. Again, recognizing that a knee replacement is sort of the end of the road. If you're there at age 40 or in your 90s, as long as you're healthy enough, getting your joint replacement is a good choice for the patient's improvement in quality of life.
But there are some instances where you literally can wait too long. And there are two that come to mind. One is stiffness. The patient who comes in with a significant deformity, whether it be a bow leg or a valgus or knock knee leg, combined with an inability to bend their knee well, those patients generally have more difficulty recovering after surgery. And the other instance is there are rare cases where you can wear away the bone, whether it be the patella on the femur, or sometimes the tibia can wear away when it rubs against the femur. Those instances can jeopardize your ability to get a good result.
As long as the patient does not have significant bone loss, does not have a significant deformity and maintains the range of motion, getting their knee replaced is very much an elective procedure.
Scott Webb: Yeah, it sure is. And it's good to know that you're never too young or too old. And you know, if you're feeling that way, like, "Oh, I'm too young for a knee replacement," well, as you say, if you're there, you're there, right?
Dr. David Dalury: Yep. It's the end of the road. And if you've tried everything else, I mean, I've done knee replacements on 27-year-olds and 98-year-olds, judiciously of course, but the 27-year-olds really had no choice. Her knee looked like she was 70, but it was an old football injury from playing with her brothers. And the 98-year-old lived for seven years after she had her knees done and sent me a Christmas card every year.
Scott Webb: So when we talk about preparing for the surgery, is there anything in particular the patients need to do? Should they try to lose some weight? Should they do anything in preparation for that knee replacement?
Dr. David Dalury: So in general, weight loss is important. The less you weigh, the easier it will be for you to recover and for transferring and going up and down stairs in particular. And so we're pretty strict about making sure that you're within a certain weight gain because the complications are much higher if you were beyond a certain BMI. But in terms of preparing for surgery, the best thing to do is to maintain the motion that you can and to keep your leg as strong as it can be.
I like to tell my patients that, "Your knee replacement is finished" when they're in the recovery room, "It's brand new. And the only thing that's getting better, so to speak, are your muscles. And the only way they get better is if you're comfortable enough or strong enough to bend them." So coming to the OR with good motion and good strength really makes a big difference.
Scott Webb: Yeah, you can see how that would be a good thing. And of course, if you've got a brand new knee, but everything else related to the knee, around the knee is not in the best shape and hasn't been kept active. That's probably not a good thing, right?
Dr. David Dalury: Yes, that's absolutely true. And the function of the knee is different from the knee itself. A knee itself really has no function other than to provide support stability and a pain-free surface. But the actual function of the limb is muscular. So working on your balance, working on your strength, working on your independence is really where you're going to get the most benefit after your knee replacement.
Scott Webb: And as we get close to wrapping up here, are there any complications that we haven't talked about already that people might experience post-surgery?
Dr. David Dalury: So in general, the risk of a complication after this type of surgery is in the 1% to 2% category. And the ways to prevent that are to make sure that your general health is as good as it can be; that your diabetes, if you're a diabetic, is under control; that your weight is within an acceptable range and that's generally with a BMI of less than 40; that you've done the best that you can to maintain your range of motion and your strength. If you do all those kinds of things and you follow the directions post-operatively, that 1% to 2% complication rate is a well-established rate of a potential complication for a procedure that should provide patients 90% to 95% relief of pain and should last them for 20 to 25 years.
Scott Webb: Yeah. When you talk about a risk reward, 1% to 2%, that's not so bad. And to last, you know, into the 20 plus year range, that's pretty great. And as we wrap up here, anything else you want to tell people about knee replacement, when they should consider it, why it's important not to delay, what are your takeaways?
Dr. David Dalury: Well, there's a lot of misinformation about knee replacements out there. I have many people tell me, "Well, they only last eight years or 20% of patients are unhappy or have complications afterwards." That's just not true. The risk of a complication is in the 1 to 2% complication rate and the durability of these knees is in the 20, sometimes as high as the 30-year mark.
And so the best advice I give my patients is try everything else first. Think about medications, injections, therapy, braces, et cetera. But if your quality of life is suffering and you've tried everything else, knee replacements are remarkably predictable, durable, and safe.
Scott Webb: I couldn't say it any better myself. This has been really informative today. And as you say, there is a lot of misinformation. Hopefully, we've been able to kind of fight some of that back for people when they click play here. So doctor, thanks so much for your time. You stay well.
Dr. David Dalury: Thank you very much.
Scott Webb: And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.