Conversations for Confidence: Expert Answers on Knee Surgery

You or a loved one may have lived with knee pain for years and have been just dealing with the symptoms. Surgery may be an option, but there are other ways to manage - and even eliminate - the pain, so you can get back to the activities you love most.

In a recent webinar, Todd Kelley, MD, an orthopedic surgeon at The Christ Hospital Health Network, talks about different types of knee problems, nonsurgical treatments, and what to expect if you choose knee replacement surgery.

Here's what Dr. Kelley wants you to know so you and your loved ones feel confident about your knee care.

How Your Knee Works

The knee is more complex than the hip, which is a ball-and-socket joint. A knee can bend, straighten, rotate, and slide forward and back.

"People think the knee just bends and extends, but there's actually a lot of different motions at play here," says Dr. Kelley. "The mechanics are more complex."

The main components of the knee include:

• Bones: The thighbone (femur), shinbone (tibia), smaller fibula on the outside (bears less weight), and kneecap (patella) are all part of the knee.
• Ligaments: Four main ligaments hold the knee bones together and keep the knee stable. The medial collateral ligament (MCL) on the inside of the knee and the lateral collateral ligament (LCL) on the outside of the knee control side-to-side stability. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) cross in the center of the knee and control forward-and-back motion.
• Muscles and tendons: Muscles and tendons help the knee move. The quadriceps connect to the kneecap through the quadriceps tendon, and the patellar tendon connects the kneecap to the shinbone. When the quads contract, the knee straightens.
• Articular cartilage: This bright, smooth, shiny surface covers the ends of bones and the underside of the kneecap. It wears down when you have arthritis.
• Meniscus: This cartilage is a different, stiffer type called fibrocartilage. It consists of two C-shaped cushions inside the knee. Children and teens typically have blood supply here, so a meniscus tear can often heal. In adults, the blood supply lessens, so degenerative meniscus tears become common with age.

Sudden vs. Gradual Knee Problems

Dr. Kelley typically sorts his knee patients into two groups.

"We have a type of patient who says, 'I was dancing at a wedding this weekend, and I felt a pop, and now I can't bend or straighten my knee.' That's an acute injury, or something that happened that day," he explains.

"On the other hand, someone may come in and say, 'This has been bugging me for two or three years, and it aches when I'm sitting down. I feel this crunching sensation in my knee when I'm walking.' Those are the things we hear when someone's talking about arthritis symptoms."

Acute Injuries

Acute knee injuries happen after a specific event, such as a fall, twist, or pop.

• The knee swells the same day.
• Usually, it's a ligament injury or significant meniscus tear.
• A torn ligament makes the knee feel unstable.
• A torn piece of meniscus can flip and get caught between the bones, blocking the knee from bending or straightening.

Gradual, Long-Term Pain (Arthritis)

Knee pain that has lasted for years is usually knee arthritis.

• You may feel aching when sitting or stiffness in your first few steps after standing.
• When you walk, your knee may crunch or grind and feel like it isn't strong enough on stairs.
• Most people manage this pain for a long time with medicine, rest, and ice before they seek care.

How Imaging Helps

Imaging helps your provider get a closer look at your knee. Typically, an orthopedic surgeon will start with ordering an X-ray or an MRI, depending on the symptoms. An X-ray shows the bone, while an MRI shows the soft tissue, including ligaments, tendons, meniscus, and cartilage.

If you have an acute knee injury, you'll probably need an MRI to look inside the knee. For arthritis patients, you may only need an X-ray, which shows if there's cartilage and a gap between bones, or no cartilage and bone on bone.

"If you see bone on bone, we don't need to get an MRI to look for arthritis because we can see the spatial relationship between the bones," says Dr. Kelley. "And then we can determine a treatment path from there."

Treating ACL and Meniscus Tears

With acute knee injuries, treatment often depends on a patient's goals and age, not just their diagnosis. ACL injuries and meniscus tears are common.

Typically, the first step in treating either injury is the RICE method:

• Rest
• Ice
• Compression
• Elevation

The goal is to reduce swelling. Taking anti-inflammatory medications can help with swelling, too. Sometimes, early physical therapy restores gentle motion.

With ACL tears, athletes and people who need to pivot, twist, and run regularly tend to choose ACL reconstruction surgery. Orthopedic and sports medicine surgeons provide this treatment. Less active adults may just need physical therapy, without surgery. Therapy can help train your muscles around the knee to stabilize the knee in place of the torn or weakened ligament.

For meniscus tears in teenagers, it may be worth doing a surgical repair because the meniscus still has blood supply and can heal. Degenerative meniscus tears in adults 50 and older are a normal part of aging and don't require specific treatment. If the tear blocks motion, a knee scope (arthroscopy) can remove the piece that's in the way.

What Arthritis Really Means

Arthritis means inflammation ("-itis") of a joint ("arth"). The term generically describes wear and tear as cartilage thins and breaks down over time.

You can think of a healthy knee like driving on a brand-new, smooth road. An arthritic knee is what the road looks like 50 years later: full of ridges, divots, and potholes. As you drive on that road, you feel the grinding and crunching. Occasionally, the knee "catches" or gives out, the way a car jolts over a pothole.

Arthritis of the knee isn't something to "push through," but rather a condition to actively manage.

"I never want a patient to come in and say, 'Oh, it's arthritis. I'll just deal with it,'" says Dr. Kelley. "It's not about pushing through it. It's not just dealing with it. It's, 'How can we help you manage those symptoms so you can still function and have a good quality of life?'"

Nonsurgical Treatment for Knee Arthritis

Dr. Kelley explains that he and his colleagues' base recommendations for nonoperative treatment options on national guidelines from the American Academy of Orthopaedic Surgeons (AAOS). The AAOS comes up with guidelines based on available research and literature.

Recommended Treatments for Arthritis

Here are nonsurgical knee pain treatment recommendations for someone with knee arthritis:

• Patient education: The first recommendation is to help patients understand their condition and treatment options.
• Physical therapy: Physical therapy can't regrow cartilage, but it can help strengthen the muscles around the knee. It also teaches your brain how to use these muscles to protect the joint.
• Canes and braces: These devices take pressure off the knee and support it.
• Topical anti-inflammatory creams: You can get many of these over-the-counter creams, such as Diclofenac, from a pharmacy.
• Weight loss: Weight loss isn't a requirement for treating knee pain, but it can make a big difference. Each step you take puts about three times your body weight through the knee (about eight times for runners). So, losing ten pounds removes roughly 30 pounds of force with every step.
• Over-the-counter medications: Acetaminophen and anti-inflammatories, such as ibuprofen or naproxen, work differently, so you can take them together or alternate between them. It's a good idea to check with your primary care provider first, since anti-inflammatories can affect blood pressure, the heart, the kidneys, and the stomach.
• Steroid (cortisone) injections: A strong anti-inflammatory injection into the knee joint spreads throughout the joint, temporarily relieving pain. Because the cortisone spreads, you don't have to inject it exactly where the knee hurts.

Not Recommended Treatments for Arthritis

The AAOS does not support using the following to treat knee arthritis:

• Shoe wedges: These shoe devices try to change the knee's angle.
• Narcotics: The body builds tolerance to pain medication, requiring higher doses. Narcotics may relieve some pain but don't address arthritis inflammation.
• Gel (hyaluronic acid) injections: These injections are not pain medicine but a synthetic joint lubricant. Results are unpredictable. Recent research found outcomes from a gel injection were similar to a placebo, so guidelines advise against them. Dr. Kelley notes, though, that some of his patients do find relief. If gel injections work, it can be reasonable to continue using them.
• Arthroscopic "clean-out" for arthritis: A knee scope can't fix bone-on-bone arthritis. It only helps when a torn meniscus is mechanically blocking motion.

What's Lacking Evidence

Some treatments don't have enough consistent evidence to support using them for knee arthritis, including:

• Glucosamine and chondroitin supplements
• Massage
• Some physical therapy electrical stimulation units and lasers
• Platelet-rich plasma (PRP), which involves injecting a concentrate of a patient's own blood into the joint to see if it helps with inflammation

Knowing When It's Time for Knee Replacement

The right time to get a knee replacement is when nonoperative treatments aren't controlling or managing symptoms and keeping you comfortable enough to function.

That may be when you're no longer going to restaurants because your knee hurts. Or you're not going to a Bengals game because the stadium stairs will hurt your knees too much. Or you're dreading a family vacation because of knee pain.

The decision is personal. Everyone's pain tolerance and priorities are different, and most patients say they simply "know it's time."

Take Dr. Kelley's dad, who stayed active by going to the gym, swimming daily, walking, and attending his grandkids' games, despite arthritis. He finally chose to have a knee replacement because mowing the lawn became too hard.

"I'm not going to be able to say for you, 'This is when you should decide,'" says Dr. Kelley. "Because I couldn't even tell my dad that. It's very individual when you decide to do it."

However, there are instances when you may not want to wait too long for surgery. If the knee becomes more crooked (bowlegged or knock-kneed) or stiffer, surgery gets harder. Once knee cartilage is gone, the bone starts to wear. Correcting a severely crooked knee requires more extensive work on the surrounding soft tissue and ligaments, and recovery is more difficult.

Additionally, muscles have a memory. After years and years of stiffness, the knee tends to want to return to its old, limited motion, even after replacement. The longer you wait for surgery, the stronger that original muscle memory is.

What Happens During Knee Replacement Surgery

The basic steps Dr. Kelley follows during knee replacement surgery include:

1. Dr. Kelley makes an incision along the front of the knee, slightly toward the inside, so patients who like to kneel aren't kneeling on a scar in the future.
2. He goes through the capsule and moves the kneecap out of the way, so he can see the end of the thighbone and the top of the shinbone.
3. He prepares the ends of the bone to hold the implant, which involves shaving and cutting off the bottom of the thighbone, cutting the top off the tibia, and removing the meniscus. The side ligaments stay. Dr. Kelley tries to preserve the PCL, but removes the ACL in most patients as the implant does the work for the ACL.
4. He places the implant, which has metal and plastic components for smooth movement.

Robotic-Assisted Knee Replacement

Dr. Kelley often uses robotic assistance for knee replacement procedures. With robotic technology, the surgeon maps the patient's bones, alignment, and ligament tension, and the system helps create an individualized plan for implant size, shape, and position.

You can think of it like going to a shoe store where all the sizes and shapes are on a wall across from you in the operating room - Dr. Kelley estimates about 3,000 different options to fit each patient.

Then the surgeon can position the implant virtually in half-millimeter and half-degree increments before they cut any bone. They guide the saw to execute the plan and can adjust during the procedure if needed.

"The robot's not doing the surgery," Dr. Kelley clarifies. "The robot is assisting."

Surgeons use different techniques, but Dr. Kelley prefers the robotic approach. He loves how individualized it makes the procedure. After all, an 80-year-old patient's knee is not going to move the same as the knee of a 50-year-old patient with stiffness. Their angles and deformity might be very different, and the robotic approach allows him to adjust based on their individual anatomy.

Recovery After Knee Replacement

Recovery after a knee replacement is often harder than recovery from a hip replacement. It's tough, but Dr. Kelley says that doesn't mean you're doomed to severe pain during recovery.

How to Prepare for a Smoother Recovery

Dr. Kelley and his team try to keep people as comfortable as possible during recovery, and it all starts before surgery. Preoperative exercises and motions strengthen the knee. The stronger your knee is going into surgery, the better the outcome.

A multimodal pain management plan begins before surgery, so medications are already working during and after the procedure.

Anesthesia and Pain Control

The team prefers spinal anesthesia to general anesthesia. Spinal anesthesia numbs the legs, and IV sedation keeps you asleep during the procedure. Because the body doesn't register pain during surgery, you often need less pain medication afterward.

You also receive pain medicine injections into the tissue around the knee before the surgeon closes the incision.

With general anesthesia, though your brain's asleep, your body still reacts to the pain. You may need more pain medication, including narcotics, during surgery, in recovery, and at home - often for days or longer.

Going Home the Same Day

Most knee replacement patients go home the same day as their procedure. Dr. Kelley estimates fewer than 1 percent stay overnight, usually for medical monitoring if they have a heart rhythm issue or another condition.

"People heal better at home," he says. "They eat better at home. They take their own medicines at home. They sleep better at home. You recover much better at home than staying any time in the hospital."

Recovery Timeline

Here is a general recovery timeline for knee replacement surgery:

• Days two through five: The first few days are the toughest for pain and swelling. Dr. Kelley says this is when patients are most likely to be cursing his name. But pain usually improves each week, and you're sent home with an ice machine to help with the swelling. The more you get up to walk and move, the better you'll recover.
• Around two weeks: Most patients switch from using a walker to a cane. They also begin outpatient physical therapy, working with a physical therapist at a location close to home. If you're off narcotics and feel comfortable and confident driving, you can drive again.
• Three to six weeks: Most people stop using the cane and return to restaurants and grocery shopping. Light chipping and putting on the golf course and easy back-and-forth pickleball are okay activities.
• Three months: Most people reach their maximum recovery, though improvement continues for up to a year.

Why Choose The Christ Hospital Health Network for Knee Care

The Christ Hospital Health Network's multidisciplinary group of orthopedic surgeons, advanced practice providers (APPs), and physical therapists cares for patients with knee pain from an injury to arthritis. Whether you need nonsurgical treatment or joint replacement, your care follows national, evidence-based guidelines and is individualized to your goals.

Same-day appointments and consultations are available, plus walk-in and after-hours clinic options for acute injuries. With seven convenient locations across Greater Cincinnati and Northern Kentucky, patients can get the help they need close to home.

To schedule an appointment with a knee replacement specialist, call 513-447-6838 or complete this form to request a callback.

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