Knee Replacement By Dr. Brian Culp

WHEN IS THE RIGHT TIME FOR A KNEE REPLACEMENT

People with knee arthritis often come into the office with a common question. When is the right
time to have my joint replaced? Although the answer to that varies from person to person, my
answer is usually the same. When you have tried everything else and it is bad enough that it is
getting in the way of living your life." Knee replacement surgery can be an extremely effective tool to manage debilitating arthritis. It is, however, still a surgery, and with all surgeries there are risks, so we always exhaust every conservative option, and we attempt to manage those risks before ever moving forward.

The most common complaints I get in the office include joint swelling, pain in the knee,
tightness, balance issues, clicking and popping, weakness, and loss of range of motion, so these
are all hallmarks of progressive arthritis of the knee, and these should be evaluated by an appropriate orthopedic surgeon to determine the right steps for you. Joint arthritis should always be managed in a stepwise fashion starting with conservative treatments first. These include the following:

1. Exercise. Exercise is great for the knee joint and cannot only improve your function but
decrease your pain. This can be done on your own with directed exercises or alternatively under the guidance of a skilled physical therapist. As arthritis progresses, it can cause stiffness of the joint leading to loss of range of motion. Pain can cause you to guard and use your muscles less fluidly resulting in weakness. Breakdown of the joint can also lead to stability issues resulting in the sensation that one may fall. Optimizing range of motion, strength, and balance can ultimately improve the feeling of your knee and delay the need for a joint replacement in the setting of knee arthritis.

2. Weight Loss. One of the most reliable strategies to improve the pain in your knee and decrease the progression of arthritis is weight loss. Every pound of body weight that you carry is equivalent to 4 pounds of force on the joint. What does that mean? That means that 10 pounds of weight loss is like taking a 40 pound weight off your leg. That being said, weight loss can be very challenging in the setting of arthritis. With a painful joint, it can be very difficult to find a way to exercise. The best strategies include: low-impact exercise such as walking, swimming, and bicycling. It can also be helpful to solicit the help of a registered dietician or nutrition specialist in determining the correct foods to eat. Decreasing the overall number of calories consumed on a daily basis can be a fast track to weight loss. The fastest way to do this; avoid drinking your calories. Consuming more water and tea and avoiding sugared or artificially-sweetened drinks can allow the pounds to fly off. Finally, in extreme circumstances, a bariatric surgical intervention may be required to decrease the amount of daily caloric intake and to facilitate weight loss.

3. Medication. A number of medicines can also be used to safely manage swelling and pain. We often recommend that over-the-counter medications be tried first. These include Tylenol (acetaminophen), as well as nonsteroidal anti-inflammatories (NSAIDs). These include ibuprofen, Advil, Motrin, and Aleve. These drugs can be taken safely to decrease the overall amount of joint pain one is dealing with and also facilitate better function. Prolonged use should be monitored under the care of a physician. Discuss this with your doctor before taking for more than one month's time. Narcotics and illicit drugs are very rarely the answer. While these drugs have the ability to manage acute pain, they are poor medications at managing chronic pain. We recommend strongly against taking opiate pain medications to control your osteoarthritis.

4. Injections. Injections can be a wonderful tool at decreasing joint pain and improving your day-to-day life. There are different types of injections that are often employed in the setting of arthritis, with different functions and durations of use. The first-line treatment is often a steroid (cortisone) shot. Intraarticular corticosteroid injections can decrease the swelling of the joint, as well as improve pain and function. While these are not a permanent solution, these can have a lasting effect for many people, especially in the setting of mild arthritis. Viscosupplement injections (hyaluronic acid) – while these come by a number of names, including gel shots (chicken fat), lubricant shots, viscosupplementation injections can be a great tool to decrease their joint pain. While not a solution for everyone, these shots can be very effective and can be taken every six months to improve the overall function in the joint and decrease pain. Discuss this with your doctor. Platelet-rich plasma and stem cell injections have become a new viable option for treatment. While these are still in investigation, they do show some promising effects in joint pain and may ultimately be used as a mainstream form of treatment. Currently, however, insurance companies do not cover this form of injectable medication and may be an out-of-pocket cost for the individual. The merits of these injections should be discussed with your physician and weighed in light of the individual's degree of arthritis and age.

Surgery is the last option. When conservative options have been tried and exhausted and the pain and loss of function is affecting your quality of life, surgery may be the last option on your plate. The main things to do prior to having surgery are to get healthy. Losing body weight not helps decrease the pain of the joint but also it speeds your recovery and improves the longevity of a joint replacement. Also, managing your chronic conditions like blood pressure issues, diabetes, and unhealthy habits such as smoking should be optimized prior to choosing an elective surgery, as this may decrease your chance of complications and once again improve your overall outcome.

When it is ultimately time to consider a joint replacement, a partial or total knee replacement may be right for you. This should be decided in conjunction with your x-rays with your treating orthopedic surgeon. In general, we use minimally-invasive techniques, avoiding damage to the muscles of the knee joint. Additional technologies are utilized in the appropriate scenarios, including custom-made knee instrumentation, navigation, and robotic surgery. While not necessary for all surgeries, this can be helpful in complex scenarios and unique cases. Finally, joint replacement has come far enough that this can be performed as an outpatient procedure. Young and healthy individuals with moderate-to-severe knee arthritis may be an eligible candidate to have their joint replacement performed and go home the same day. Please talk to your doctor about any questions regarding your knee arthritis.

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