Do I Really Need Knee Surgery?

Introduction:

During nearly four decades in the practice of orthopedic surgery, one of the most important questions people have brought to my attention is this:

"Do I really need surgery?"

The importance of this question does not lie solely in the possibility that the answer might be no. It derives mainly from the fact that this question — when asked directly, early, and with an attitude of honest curiosity — invariably leads to a discussion which engenders a closer bond of collaboration, understanding, and shared decision-making between the person asking it and the provider receiving it.

If you are hesitant to ask some version of this question of a provider who has given you a recommendation for knee surgery, please understand that posing it is not primarily a challenge to your provider's competence. It is, in fact, among the most responsible questions you can ask under these circumstances. And in my professional experience, it almost always leads to a beneficial improvement in collaboration and mutual understanding — for everyone involved.

Here is a summary of the foundational sources of information which must be present in the knowledge base of any provider attempting to formulate a proper answer — one firmly ensconced in Logic and Virtue — to the question:

"Do I really need knee surgery?"

A Complete and Accurate Diagnosis

This is the end-product of a thorough evaluation which:

— Gives proper attention to the details of your personal and family history. That history has direct implications for what laboratory testing may be warranted, and for what else — beyond the knee itself — may need to be examined physically or subjected to diagnostic imaging.

— Includes a physical examination of the other components of your locomotive chain — hips, ankles, feet, lower back, as appropriate — because knee pain can be the manifestation of a downstream effect caused by a problem originating elsewhere in the body.

— Includes appropriate scrutiny of the information presented by proper diagnostic imaging — the right modalities, inclusive of all necessary body parts, interpreted in the right context.

— Considers the implications revealed by laboratory testing, where indicated by personal or family history. Such testing can reveal systemic, metabolic, or inflammatory conditions which, once identified and properly addressed, may render surgery unnecessary.

A Discussion of Therapeutic Alternatives

This encompasses experience with prior treatment and careful consideration of what additional alternatives may yet be reasonably viable.

Most people who presented to my practice having already received a knee replacement recommendation from another provider shared one thing in common: they were unaware that additional alternative treatment strategies might exist for them.

The absence of such a discussion from their prior experience reflects the opacity of the currently prevailing medical system — which, by design, does not make adequate space for it. In my considered opinion, a thorough discussion of possible additional alternatives should be an experience available to everyone facing a recommendation for knee replacement surgery. Without exception.

A Conversation About Personal Goals

This is about personal hopes, dreams, and aspirations — and about the personal vision of life beyond the treatment process. It explores a question which is deceptively simple and profoundly important:

"What do you actually want your life to look like — after all is said and done?"

A 75-year-old who simply desires to walk comfortably without pain demands less of a treatment process and outcome than a 55-year-old who wants to return to competitive tennis. Less aggressive treatment tactics may make perfect sense for one person — while a more aggressive plan may be entirely appropriate for another. A surgical recommendation made without this type of conversation is, at best, incomplete. At worst, it is inappropriate.

If any of the above sources of knowledge have been absent in constructing the complete picture which accurately describes your personal presentation — you now have a framework which allows you and your provider to "paint by number," ensuring that the full and elegant Mona Lisa of your uniquely personal clinical picture emerges before any irreversible decision is made.

ASK THE KNEE COACH

"My knee is always worse when the weather turns damp. Is that real, or am I imagining it?"

You are not imagining it.

The relationship between weather changes and arthritic pain is soundly based in physics. The mechanism responsible is known as Boyle's Law — when external barometric pressure drops, as it characteristically does ahead of rainy weather, fluids expand.

In a healthy joint, that expansion is inconsequential. In an arthritic joint, where the tissues in and around the joint have a significantly higher water content, even a modest downward shift in barometric pressure can provoke a meaningful increase in pain and stiffness. Your arthritic knee, in a very real sense, acts as a barometer.

What can you do about it? Keeping arthritic joints warm, moving them gently during weather changes, and the judicious use of anti-inflammatory medication are all reasonable starting points. Knowing that a difficult day is likely coming when the forecast calls for rain gives you the opportunity to plan around it — rather than being caught off-guard by it.

And there is a longer-term implication worth noting: the less inflammation present in the joint, the less dramatically weather changes will register. Managing inflammation is not only about day-to-day comfort. It is also about reducing your knee's sensitivity to the things you cannot control — including the weather.

Dr. Bonesmith

Michael J. Maynard, MD

Logic and Virtue in Orthopedics