Knee Replacement

Knee replacement surgery is a major undertaking that should be carefully considered before proceeding. 

Here, Dr. Wickline offers his advice for patients considering knee replacement surgery, just as he would for patients who see him in-office.

If you feel knee replacement is the right path for you and are interested in following Dr. Wickline’s recovery protocols, the Less Swelling Less Pain Total Knee book is available for purchase. These protocols have helped thousands of patients recover from knee replacement surgery with less swelling, less pain, and reduced need for narcotic pain medications. Many people have been able to save money on physical therapy co-pays and have had increased patient satisfaction post-surgery.

What Are the Typical Symptoms of a “Bad Knee”?

The majority of patients who are considering knee replacement surgery have pain in the knee that worsens with activity. Stairs become difficult, and standing in one place or walking long distances causes pain and oftentimes swelling. As symptoms worsen, many patients begin to minimize trips to large grocery stores or shopping malls.

Please note: Some patients who report pain in the knee—usually the front of the knee—actually have NO KNEE ARTHRITIS. Occasionally, a worn out hip socket will produce pain in the front of the knee. A bad hip socket also causes extreme difficulty putting on your sock and shoe and patients report needing to lift the leg to get into a car. Let your surgeon know if this is happening to you. You should obtain an x-ray of your hip to verify that you do not have severe HIP arthritis causing your knee pain. A new knee will obviously not fix a bad hip socket!

What is Knee Arthritis?

Most commonly, knee arthritis refers to osteoarthritis (OA). Osteoarthritis is a degenerative, “wear and tear” disease process during which cartilage wears away in the joint, causing pain and disability. This degenerative change occurs naturally with aging. 

Some patients with knee arthritis may have a different diagnosis like avascular necrosis or rheumatoid arthritis.

Avascular necrosis (AVN) is caused by disruption of blood supply to one or more sections of the knee. Loss of blood supply leads to an area where the bone dies. This causes pain, and frequently the bone collapses in this region and acts very similar to a fracture.

Other patients may have knee pain related to an autoimmune disease called rheumatoid arthritis (RA). This disease frequently has a genetic predisposition, causes destruction in multiple joints throughout the body, and generally requires laboratory testing for diagnosis.  Rheumatoid patients have the same treatment options as osteoarthritis patients, but also may benefit from specialized medications that are prescribed by rheumatology specialists.

See these sources for more information:

• https://www.arthritis.org/
• https://www.helpfightra.org/

Choosing a Joint Replacement Surgeon

Choosing the right surgeon is an important step in your outcome. Studies have suggested that surgeons who have more volume have outcomes that are associated with lower cost, lower dislocation rates, and a general trend towards lower complications.¹ Some studies suggest that your surgeon should perform at least 200 knee replacements per year to get into the lowest complication group.  Ask your doctor how many surgeries he/she performs per year. Asking other patients about their experiences, asking physical therapists, your regular doctor, or operating room nurses are other good ways of determining a higher quality surgeon.  

Fellowship training, which usually entails at least one additional year solely dedicated to joint replacement, is associated with shorter surgical times and less opioids as compared to surgeons who do not have fellowship training.²

Treatment Options to Consider Before Knee Replacement Surgery

If you are suffering from knee arthritis, the following treatment options are available:

1. Live with the symptoms.
2. Lifestyle modifications, including activity changes and particularly weight loss. Your knee sees anywhere from 2.3x to 8x times your body weight with every step, so a 10 pound weight loss is a 23 to 80 pound weight loss for your knee!
3. Low impact physical therapy or aquatic therapy. An arthritic knee DOES want to see some gentle exercise daily. Many patients report that using a bike is reasonably well-tolerated.
4. Medications. Acetaminophen, also known as Tylenol, can be used to help with symptoms. It has a low side effect profile for the vast majority of patients. NSAID medications are frequently are cited as being somewhat more effective in terms of pain relief due to their additional anti-inflammatory properties. These medicines, while very effective, can put a hole in the lining of the stomach, raise your blood pressure, and irritate the kidneys. Be careful!  In the past, doctors prescribed narcotics for this diagnosis. This led to significant abuse and addiction. Narcotics are not recommended for this diagnosis.
5. Many patients may benefit from intra-articular injections. Standard cortisone, slow-release cortisone, and hyaluronic acid (HA) are used to help reduce knee arthritis pain. HA injections (also known as viscosupplementation) are not currently recommended by the national orthopedic consensus workgroup from the AAOS.
6. Rheumatoid arthritis patients should consult with a rheumatologist prior to any surgery to determine if one of the new medications can dramatically improve their symptoms. In the last three decades, these new medicines have saved thousands of patients from needing surgery!
7. Nerve treatments. There are multiple nerves around the knee that can be deadened to help relieve pain. Pain management specialists may have some experience with this. There are two US companies that have treatment protocols: Avanos (Coolief^TM) and Pacira (Iovera^TM).
8. Osteotomy. This is a procedure that involves cutting the tibia (shin bone) or the femur (thigh bone) and changing the overall angle of the leg. This takes pressure off the arthritic side of the knee and transfers it to a non-arthritic side. It is generally reserved for younger patients and likely should only be performed by surgeons with lots of experience. It is not routinely used in the United States.  
9. Partial knee replacement. This is a procedure that involves replacing typically one part of the knee. The knee can be divided into three parts: The inside (medial compartment), the outside (lateral compartment) and the kneecap/kneecap groove area (anterior or patellofemoral compartment).  
10. Knee replacement is generally the final answer to end-stage arthritis. This involves replacing the cartilage on the end of the femur and the top of the tibia and frequently the undersurface of the patella. This is the most common surgical treatment for knee arthritis.

Choosing a Joint Replacement Surgeon

Choosing the right surgeon is an important step in your outcome. Studies have suggested that surgeons who have more volume have outcomes that are associated with lower cost, lower dislocation rates, and a general trend towards lower complications.  Some studies suggest that your surgeon should perform at least 200 knee replacements per year to get into the lowest complication group.  Ask your doctor how many surgeries he/she performs per year. Asking other patients about their experiences, asking physical therapists, your regular doctor, or operating room nurses are other good ways of determining a higher quality surgeon.  

Fellowship training, which usually entails at least one additional year solely dedicated to joint replacement, is associated with shorter surgical times and less opioids as compared to surgeons who do not have fellowship training.

Swelling After Knee Replacement Surgery

Swelling – the first and most common culprit for postoperative pain.

This is perhaps the most important topic you need to understand to recover from your knee replacement surgery more quickly and have fewer complications

Have you ever twisted your ankle as a kid playing soccer, tennis, or volleyball? Most of us have.

Most of us have learned through these experiences that we should not walk a mile the next day or the next week, and it frequently doesn’t seem normal for a couple of months or more. You’ve learned to stay off it, limit how much weight you put on it. 

If you sprained your ankle badly today, would you do a 90-minute walk tomorrow on that same ankle? Obviously not.

This is no different for how you need to behave after knee replacement. However, I have many patients say “I have finally made the difficult decision to move forward with surgery now, so I want to heal as fast as possible by doing extra exercises before and after surgery.” I can tell you that this mindset almost always backfires. Think about the ankle sprain and the question you just answered. You know that you need to control the swelling to get that ankle pain to decrease and get back to your active lifestyle.

Therefore, I need you to follow my plan with no additional strengthening or extra walking the first two weeks post-op. If you do, you’ll very likely reach post-op milestones weeks or months before other patients following outdated protocols. You will also likely have less pain than what other patients have to endure. I have already published proof of this so please see our website for peer reviewed articles.

If you have a watch that monitors your steps, our data shows that more than 750 steps per day in the first week seems to be associated with more pain, greater need for pain pills, and more difficulty getting back to normal activity. This is important to me (and personal). My wife has been treated for cancer and has a high risk for permanent swelling/lymphoedema. 

Any major surgery on the lower leg can cause permanent swelling (secondary lymphoedema). Most surgeons assume there is no way to improve post-op swelling. I disagree. I want to decrease the post op swelling and the risk of permanent lower leg swelling. I’ve teamed up with Dr Mark Merlin, a vascular surgeon who nearly lost his leg in a bad trauma. He is one of the world’s leading researchers on lymphoedema and is a consultant for NASA, as astronauts get lymphoedema-like symptoms in space.

About the Less Swelling Less Pain Total Knee Book

The Less Swelling Less Pain Total Knee guide is designed to navigate you through everything you need to know before and after your knee replacement surgery to optimize for your recovery. These are the same protocols that Dr. Wickline shares with his own patients ahead of knee replacement surgery.

In this book, you will learn what to expect leading up to, during, and after your hip replacement, including:

• How to prepare for recovery
• Optimizing your nutrition ahead of surgery
• A step-by-step plan for your recovery
• And much more