FOR some individuals, the decision to undergo elective total knee replacement is relatively clear-cut — you may have unrelenting pain and stiffness that limit everyday activities and interfere with sleep, your symptoms don’t respond to drugs or other treatment, and you have a low risk for surgical complications — in which case, you may have an ideal candidate for the procedure, says the Special Spring/Summer issue of the Scientific American — healthafter 50.

For the ideal candidate, knee replacement will effectively — and safely — relieve your pain and restore function and mobility, such as being able to use stairs, walk short distances, get out of bed and put on your socks without distress, adds the health letter.

However, sometimes, while the desire to once and for all relieve nagging knee pain may be tempting, it may be difficult to know when it’s appropriate to have surgery — “but are your symptoms severe enough to warrant surgery, and have you done everything short of replacement to improve your symptoms?”

Also, knee replacement surgery is not without risks, such as:

a) Serious complications such as blood clots and infections occur in up to 5 percent of patients;

b) Recovery can be long and sometimes painful; and

c) Up to 15 percent of patients are unhappy with their outcome after knee replacement.

Richard Iorio, M.D., an orthopedic surgeon and professor at NYU Langone’s Hospital for Joint Disease in New York, says, “If you’re currently in severe pain from advanced osteoarthritis of the knee, total knee replacement is most likely the appropriate solution as long as you’ve exhausted all possible pain relief treatments. But you and your doctor need to carefully consider a number of factors before deciding whether you’re a good candidate for the procedure.”

Two related studies that focus on assessing candidates for total knee replacement suggest that as many as one-third of total knee replacement patients may not be ideal candidates for the procedure.

Total knee replacement to relieve pain in patients with arthritis is considered one of the most successful procedures in all of medicine — roughly 719,000 total knee replacements are performed annually in the United States, according to the Centers for Disease Control and Prevention — and the number is expected to grow.

Being a complex hinge joint, the knee has the ability to flex, extend, glide and rotate.

Any part of the knee can be damaged from injury or disease such as osteoarthritis, resulting in pain and disability.

To relieve pain and restore function, an orthopedic surgeon performs a total knee replacement — this involves removing the cartilage inside the joint and replacing it with an artificial component to provide a smooth, gliding surface.

Aside from infection and blood clots, potential complications of total knee replacement include stroke and heart attack, joint instability, stiffness, pain and overall failure of the implant — fortunately, precautions can be taken to reduce the risk of adverse effects.

There are no established U.S. recommendations to help guide orthopedic surgeons in their selection process for knee surgery when they assess an individual’s degree of pain, stiffness and physical function from arthritis.

Unfortunately, current practice guidelines involve only oral drugs, injections, weight loss and a reduction in activities — such interventions aren’t disease altering and leave patients frustrated with these alternatives to knee replacement surgery, says the health letter.

A key area of current research is developing measures to determine whether patients are disabled enough to undergo knee replacement:

The study authors say developing up-to-date, evidence-based criteria for surgical management of knee osteoarthritis could help orthopedic surgeons better identify the candidates who’ll clearly benefit from knee replacement.

Ultimately, the decision to replace your knee to relieve disease is one that should be made between you and your orthopedic surgeon — with or without guidelines.

Dr. Iorio offers this advice: “The decision to undergo knee replacement surgery should be made only after your surgeon performs a comprehensive orthopedic evaluation — which includes an imaging test to assess knee damage — after which he or she should discuss with you in detail the pros and cons of the surgery.”

He adds, “...knee replacement surgery is something that needs to be decided upon not only by your surgeon but by you as well.”

Dr. Iorio says that generally, you’re a good candidate if you have:

• Severe knee pain that is disabling interferes with daily activities and is not relieved by drugs or other nonsurgical interventions

• Pain worsened by weight-bearing activity

• Moderate to severe pain during rest or sleep that’s not improved by drugs

• Significant stiffness in the knee that persists after movement starts, often with morning stiffness that improves somewhat over the course of the day

• Significant instability in the knee, which leads to buckling

• Chronic inflammation and swelling of the knee

• Knee deformity (knock-knees or bowlegs) that continues to worsen

On the other hand, you should think twice about undergoing total knee replacement if any of the following apply to you:

• You haven’t yet exhausted all nonsurgical methods to relieve knee distress, including nonsteroidal anti-inflammatory drugs, exercise, weight loss and injections

• Your knee only bothers you during certain activities

• You have a severe peripheral nerve disorder or blood vessel disease

• You have a heart or lung disorder that puts you at high risk of surgical complications

“Knee replacement sooner instead of later is often the best option when arthritis pain and loss of function become debilitating and drugs no longer help,” says Dr. Iorio — putting off surgery can complicate the procedure because more bone and cartilage may be worn away and deformity may progress.

Also, being disabled by arthritis pain for an extended period can weaken your muscles and make rehabilitation more difficult.

Always remember that the experience of your orthopedic surgeon is a key consideration of your knee surgery’s success — if possible, choose a board-certified orthopedic surgeon who performs 30 to 50 total knee replacements a year.

Studies show that surgeons who do the most operations each year tend to have the highest success rates and the lowest complication rates.

Hospitals that perform high numbers of total knee surgeries tend to have the best track records.

Knee replacements generally last at least 10 years, and newer ones may endure 20 or 25 years or longer.

Though recovery can be long and sometimes painful, most patients report being very or completely satisfied with the results, concludes the health letter.

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