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Total Knee Arthroplasty

Patients can best make decisions about their health care when they are fully informed. “Informed consent” describes the process through which patients give health care providers written permission to provide health care services, after being fully informed about those services. In order to give informed consent before total knee arthroplasty, you must be educated about your diagnosis, your treatment options, the details surrounding the procedure, the expected post-operative recovery time, the important risks of surgery, typical benefits of surgery, and any available alternatives to surgical treatment. I will discuss each of these points with you in the office. Since there is an abundance of information to digest, however, this written summary is provided for your convenience.

Diagnosis

Total knee arthroplasty is used to treat a variety of knee disorders. The one central feature that links all of these disorders, however, is damaged cartilage. The vast majority of patients undergoing total knee arthroplasty will have one of the following conditions:

Osteoarthritis: Osteoarthritis (OA) is the most common form of arthritis affecting the knee. Also called degenerative joint disease, or degenerative arthritis, OA is characterized by progressive deterioration and thinning of the cartilage inside your knee. Cartilage is the smooth coating over the ends of the bones where two bones meet to form a joint. Like Teflon on a frying pan, cartilage provides an ultra-smooth coating over the bone to allow smooth gliding of the joint. Normal cartilage is about a quarter of an inch thick. In OA the cartilage becomes progressively thinner until the underlying bone becomes exposed (“bone-on-bone” arthritis). This ultimately leads to joint stiffness, roughness of motion (called “crepitance”) and pain. An additional important source of pain is from reaction of the lining membrane of the knee (“synovial tissue”), which becomes inflamed like a blood-shot eye in response to the arthritis. This membrane produces fluid when it is inflamed, which causes knee swelling.

The cause of OA is unknown, although increased wear-and-tear, biochemical factors, and genetic factors are thought to play a role. The disease may affect one or multiple joints, but often involves the hands, spine, hips, and knees.

Rheumatoid Arthritis: Rheumatoid arthritis (RA) is one of several forms of “inflammatory” arthritis. In RA, the synovial tissue becomes severely inflamed and enlarged, producing enzymes and other factors in the joint fluid that ultimately begins to destroy the cartilage. RA is usually treated by a rheumatologist using a variety of strong medications to control the inflammation. If the disease cannot be well-controlled over the long term, cartilage damage and joint destruction may follow, necessitating total joint replacement. Because of improved medical treatment of this disease, fewer patients with RA are coming to total joint replacement.

Post-Traumatic Arthritis: This develops after sustaining a fracture through the knee joint. When a fracture extends into the knee and disrupts the cartilage, the risk of development of subsequent arthritis is increased. The arthritis may develop months or years after the fracture has healed. The pattern of joint and cartilage destruction is similar to that seen in osteoarthritis.

Alternative Treatments

Surgical alternatives to total knee arthroplasty include unicompartmental knee arthroplasty (partial knee replacement) and tibial osteotomy (see “Surgery” under heading “Treatment Options” above). Only select patients are candidates for these procedures. Once you have exhausted conservative treatment measures, including medications, joint injections, and physical therapy, AND if it has been determined that you are an appropriate candidate for total knee arthroplasty, then the only alternative to surgery is to continue living with the arthritis as you are doing. In general it is advisable to wait as long as you can before proceeding with TKA, for two important reasons.

1. although serious complications are rare, TKA is associated with important risks; and
2. the older you are when you have a TKA, the better the chance that it may last you your lifetime and eliminate the need for revision surgery, which is riskier and is associated with poorer results.