Making decisions about knee replacement as an older person with multiple conditions
Worries and risks of knee replacement surgery
Making a decision about knee replacement surgery when it is offered involves thinking through many options. People we talked to considered the possible benefits of surgery but also the risks involved. This included risks of the surgery itself, of recovery, and how ‘successful’ the knee replacement would be longer term. The balance of benefits and risks is different for each person. It can draw on the advice of healthcare professionals, including what a surgeon who recommends knee replacement says at the referral appointment, but also a patient’s own views and their past experiences of other surgeries. This summary covers people’s worries or concerns about:
- Risks in relation to other health conditions
- The operation and going into hospital
- Ageing and declining health
- Successful outcome and recovery
The risks of having knee replacement surgery, including having an anaesthetic and expectations for recovery, are usually explained by the surgical team. Before surgery, people signed a consent form whereby they stated they had been informed by a healthcare professional of the possible risks of surgery and were giving consent to go ahead.
Petra decided to concentrate “on the major risks as opposed to the minor risks. The major risk is obviously that it doesn't work or that you die on the operating theatre or something like that.” Jan, Ged and Victoria said that they “try not to think about [the risks of surgery].” Ged said about the risks of blood clots or death that “he didn’t want to think about those sort of things.” He preferred to “be a lot more positive” and said, “I’m quite positive that the people there know what they’re doing and I’ll be alright.”
Risks in relation to other health conditions
When thinking about the risks involved in having knee replacement surgery, most people considered the impact of their other medical conditions. For some, like Mahinder and Mary, who have heart problems, their other health conditions were of great concern. Other times some people we talked to felt their other health conditions were unlikely to be relevant; they expected the surgeon would flag if there were extra risks or would need to do the surgery in an adjusted way (such as with anaesthetic options).
So, but obviously when the pandemic started, I thought look, you know it was a very terrifying situation, so never mind about the knee, we’re all concerned about whether we’re gonna catch this virus. So, I put that to one side. And another thing I just mention why I delayed my knee, is after I had the endocarditis, I remember the doctor telling me when I left, he said to avoid any unnecessary surgical procedures. Yeah, so but my heart is - last time well the doctor had an echocardiogram somewhere, they’re keeping an eye on me. And then they said, “No, your heart’s working fine” And, but although I mentioned it that were, after I had I came out of the hospital, after the endocarditis, one doctor was saying that maybe you could have your heart valve repaired or something like this. And then - but because I was very weak, I said there was no way. And at the moment they were talking about open heart surgery- I don’t want that. I said, “Look, there’s no way I’m going to survive open heart surgery because I’m in a very weak state.” So, I said no. And then I think through my diet and sort of I believe, you know, I’ve kept my [laughs] heart goes up, yeah. The main, main concern if you like to think about the operation is my, the heart murmur - leaky valve, you know mitral valve? So that’s the main concern about having the knee operation. But of course, medical science has moved on. I spoke to my GP and he said, “No, it should be okay.” I should get it, get it done through the NHS and you’ve got all the care and all of the other things. So my only concern is what affect it will have, you know? Some adverse effect on my heart.Mahinder has heart problems and has been trying to avoid “unnecessary” operations. His main concern is the risk from knee replacement surgery on his heart.
Mahinder has heart problems and has been trying to avoid “unnecessary” operations. His main concern is the risk from knee replacement surgery on his heart.
A few people felt it would be unhelpful to focus too much on their other health conditions when thinking about whether to have knee surgery. Petra, who had had six knee surgeries before, tried not to let her previous experiences of having a spike in blood sugar levels and high blood pressure immediately after surgery affect her decision on knee surgery too much because she saw a revision knee replacement as “the only way around this and I’ve got to have it done.” Most people expected that they would be told by the surgeon if their other health conditions and medications were relevant, for example if there were extra risks.
Some people, like Jill and Marjorie, had been worried about aspects of their health. Pre-operative assessments (health checks made before having surgery) were useful for understanding more about whether other health conditions were a risk. Jill had been worried that her diabetes or her heart condition might mean she couldn’t have the operation. Neither were flagged as issues at her pre-operative assessment.
Well, I think my weight for surgery, that’s a little bit of an issue with me. I mean, I most probably will get told that tomorrow. So, I am, as I said earlier on, I am really trying to get some weight down and get some weight off, because of the anaesthetic. Because the heavier you are, you know, it’s more anaesthetic they have to give you. And I’m 73 now and I need to, if they told me, you know, tomorrow, they can’t operate until I lost say another two stone or something like that, I would lose the two stone to get it done. And that’d be it and, you know? But I don’t know, I mean, I’ve seen people waiting with me when you go in and they’re bigger than I am. But it’s also perhaps they’re not there for a knee. Perhaps they’re there for a hip or something? But I do know weight’s a problem definitely with surgery so, that’s something I should’ve addressed a long time ago, really. But there we go. When we spoke in June we spoke a bit about weight gain, and you’d done an awful lot at that point actually to lose a bit of weight. I wondered did that come up with the assessment appointment or when you were getting ready? No, no it didn’t. I don’t, I said to him that I struggle with my weight, I usually tell the doctors that - well I do. And I did lose about 8 or 9 pounds, something like that just under about. So I’m very heavy anyway, but I did lose about - it was just over the half a stone I think. My daughter told me to - she’s a nurse - and I did really try, but I, no, that really didn’t come up to it at all. Come into anything. Unless they were being polite. But I wasn’t, I know I’m overweight, but I don’t remember anything mentioned, being mentioned about my weight.Marjorie had been worried that being overweight would increase her risk when having an anaesthetic but it was not mentioned as a concern at her referral appointment.
Marjorie had been worried that being overweight would increase her risk when having an anaesthetic but it was not mentioned as a concern at her referral appointment.
The operation and going into hospital
Having other medical conditions could add extra considerations when having knee replacement surgery and being in hospital. Tina had been told by her surgeon that her mitral valve heart condition and medications “slightly increase the risk, [on top of] the normal risk, that there is with any operation” and she needed to have the operation in a hospital where there was an intensive care department as a precaution.
[Sigh] well it’s more the COPD, if, if I have to go for this operation, oh, please don’t lay me flat [laughs]. That, that worries me very much and I’m a bit scared because I’ve never had an operation before. So, it’s more or less just, just my breathing I think, and I’m just frightened because at the moment you can’t have anybody with you. Yeah, at my age, I’m a bit scared. Yeah. I’d be on my own and I have not sort of had an operation in that sense. I had a D&C donkey’s years ago. It was a different thing altogether. You know, and that’s the only time, except having the girls, yeah. I think that might be it. And if I have to lay flat, but I keep being told you’ll get an epidural. Because of your breathing, because you have COPD. And following on from that, there were some quite serious complications, not because of the knee operation, but when I went through the follow-up appointment with [knee surgeon], I think he allowed me half an hour, and we spent about seven minutes talking about my knee, and 23 minutes talking about the fact that I had a sudden serious drop in my sodium level and ended up in hospital for five weeks. And the low sodium was obviously because of that experience where they monitored it pretty closely this time, and yes, I did go through a period when it did drop quite low, but nowhere near as low as it did on the previous occasion.Linda X, who had COPD, had never had an operation before and she was worried that lying flat would make it harder to breathe.
Linda X, who had COPD, had never had an operation before and she was worried that lying flat would make it harder to breathe.
Pete had low sodium levels after a previous knee replacement surgery. His sodium levels were closely monitored for his second knee replacement surgery.
Pete had low sodium levels after a previous knee replacement surgery. His sodium levels were closely monitored for his second knee replacement surgery.
- Having an anaesthetic
The risks of having a general anaesthetic can be greater for people over 70 who have other health conditions. Worries about having a general anaesthetic were common amongst the people we talked to.
Since it was common for people to have concerns about having a general anaesthetic, an epidural (a local anaesthetic in the spine) instead of a general anaesthetic was often seen as a better option. Dave Y, who had heart and lung problems, felt a “little bit wary” of the risk of having a general anaesthetic but, with an epidural, had “no qualms of having it at all”. Some people, like Jan and Pete, were told they would have an epidural, or were advised against having a general anaesthetic by their surgeon because of their other medical conditions. Jan thought this would be better as it would be easier to recover from the operation. Pete was advised not to have a general anaesthetic for his second knee replacement surgery because of his history of heart and vascular problems, and the medications he takes.
Despite it being perceived as less risky than a general anaesthetic, an epidural still caused worry for some. The thought of being awake for the operation could be very off-putting. Clive was ‘petrified’ of having his knee surgery by epidural more than when he had his heart surgery under general anaesthetic, but he felt he needed to have the operation because “it is the one thing that will keep me going.”
Not everyone had concerns about the anaesthetic. Michael’s previous good experience of anaesthetic made him feel confident, and the surgeon was not worried about his other health conditions.
- Stroke and disability
Concern also existed for some people that having knee replacement surgery and an anaesthetic might lead to them being disabled in some way. Eleanor said “it scares the hell out of you” when she was told that one of the risks of having an epidural was being paralysed as a result of nerve damage. For Mary, having a stroke was her biggest fear. Dave X said he thought more about the dangers of having high blood pressure after his wife’s friend had a stroke.
- Blood clots and bleeding loss
Liz, Derek and Ged were anxious about blood clotting risk. Ged tried to keep a positive frame of mind about it.
Professor Andrew Price explains the risks and plan for those taking blood thinning medication before surgery.
Professor Andrew Price explains the risks and plan for those taking blood thinning medication before surgery.
Anybody who's having a joint replacement, there's a period of pre-assessment where your individual circumstances are looked at very closely by the secondary care or the hospital. So you're under the care of a consultant but the pre-assessment team will look at you and assess aspects of your health not directly related to your knee arthritis which need to be addressed.
Now one of these is whether patients takes medication to thin the blood, or clotting medication as it's kind of referred to. And some examples of that would be patients who've had a previous blood clot in the leg or deep vein thrombosis or pulmonary embolism. Those patients may be on long term medication to thin the blood.
Similarly, patients who've had a problem with their heart and, say, who've had stents. So these are small cardiac operations to allow better blood flow to the heart. And people who have stents are protected with blood thinning medication.
So let's assume that, say, there's a, there's quite a proportion of-, there's quite a big proportion of people who are being pre-assessed who are going to have a knee replacement, say, who are on blood thinning medication. So the risk, if you stay on your blood thinning medication, is that at the time of your surgery, you would bleed in a way that would be dangerous for you. So in the pre-assessment process, there's some very specific planning for the individual about stopping the blood thinning medication and replacing it with other medications after the surgery to reduce the risk that we're balancing. So there's the balance of you being someone who is going to clot versus someone who's going to bleed too much. So we assess you, stop your blood thinning medication, put you on to other treatments while you're in hospital, and then restart your blood thinning medication in a few days after, usually a few days after, the operation.
During that time, there are some very specific things that happen. Each patient has a specific assessment just before your surgery to make sure that we've got this plan correct and it's tailored to your own needs. And postoperatively again, at the time you're discharged back to your home or wherever you're going, that there'll be a specific plan for how to restart your blood thinning medication so that there's no confusion about how that works.
Of course there are risks involved in surgery. So even with these plans, some people have blood clots and some people will bleed. Hopefully we're trying to minimise both of those issues. And in my experience, they are actually managed to a very acceptable risk compared to say how things were 10, 20 years ago.
So it's all about patient focused care: stop your blood thinning medication, use an alternative treatment while you're having your surgery, and then restart as an appropriate time making sure the patient really understands how to do that, and that your general practitioner is aware so that they can always step in and help.
Victoria tried not to think about the risk of a blood clot and expected to be given a blood thinning injection to protect her. Toby had Von Willebrand disease, which meant he had severe bleeding after an injury or surgery. This was an important consideration for his knee replacement operation. Some people thought they might need to stop taking blood thinner medication before their knee surgery to reduce the risk of blood loss problems, and were given instructions around this.
- Risk of infection
There is a small risk of wound infection after knee replacement surgery. Certain health conditions or some medications can increase this risk.
Sue was concerned that her varicose eczema might put her at risk of infection. She developed cellulitis when she had her hip replacement. For others, like Hermione and George, knowing someone who had developed an infection after knee replacement surgery added to their worry. Maureen had an infection after a previous surgery but thought it unlikely that it would happen again, so she was not worried.
- Covid-19 pandemic
We talked to some people during the Covid-19 pandemic before a vaccine had been developed. For these people, concern about the risk of catching Covid and becoming very ill because of their age or other medical conditions, had affected how they felt about being in hospital. Mary, who has atrial fibrillation, declined an appointment to discuss knee surgery at the start of the Covid-19 pandemic lockdown.
Delays and backlogs in surgery waiting times resulted in some people we talked to waiting a long time for their knee surgery. This meant having a long time struggling with knee problems, which could reinforce the need for the surgery for some people but also add to their concerns. Linda X felt more hesitant about having knee replacement after having a long time to think about it.
- Upsetting memories of being in hospital
For some people, including Emily and Stuart, being in hospital brought back distressing memories of being there with loved ones in the past. This added to their concerns about having the knee replacement surgery. Previous bad experiences of surgery or a difficult recovery could also add to these worries, as it did for Tina. Linda X had never had an operation before and was scared of being alone in hospital.
Ageing and declining health
Some people felt their health and fitness had declined a lot while waiting for knee surgery. Karen worried that she was not as fit as when she previously had knee replacement surgery due to Covid-19 lockdowns and mobility issues. Others, including Jan and Karen worried that they were getting older while waiting a long time for surgery, combined with their other health conditions.
Well, I’m not so worried about Covid now because I’ve had all my booster- and if you have it, well, I know with COPD it can be bad anyway, I know that, but I am a bit worried because being older and we don’t bounce back so good from things, you know, as you get older. But no, I’ve got my determined head on I’m going to be okay, and I’m going to get back to normal, and that is it.Victoria was “a bit worried” about being older and that she won’t “bounce back so good” but she is determined to “get back to normal”.
Victoria was “a bit worried” about being older and that she won’t “bounce back so good” but she is determined to “get back to normal”.
Successful outcome and recovery
For those considering knee replacement surgery, the hope was that it would be a good outcome and help reduce or remove the problems they had been experiencing. However, many people understood that this is not a guarantee. Some people, including Barry, George, Derek and Janet were worried that the replaced knee may not be as good as they hoped. Michael X is aware he may still have a bit of knee pain after his knee replacement surgery. Karen wondered about the long-term strength and reliability of the bone the replacement would connect to.
My only, I won’t say concern, is I know from my other knee it’s very difficult to kneel on an artificial knee. It’s very pain, well quite painful, I presume because you’ve got metal and it’s not just flesh and bone which you were born to kneel with, you know it’s, it’s different. And when you really notice that is when you’re kneeling down. Well, I’ve always been able to kneel on, have one good knee to kneel on - now I won’t have any natural knee, or knees to kneel on, which make a difference when you want to get down to sort out the bottom cupboard of your kitchen cabinet and things like that. But I will manage, I will sit on the floor, and do what I have to do down there. So, it won’t be an insurmountable problem, but I know that that will, I’m pretty sure that will be the case. So, but apart from that, well even with that, that’s a small price to pay, to have a knee that doesn’t hurt at all, and that you can bend and do what you like with.After having her right knee replaced, Mary can no longer kneel on it so she expects the same will happen for her left knee replacement.
After having her right knee replaced, Mary can no longer kneel on it so she expects the same will happen for her left knee replacement.
Some people were concerned that they might need to have repeat operations if it was not successful, or that their knee problems would be worse than before they had surgery.
Lynda felt “a little apprehensive” about what recovery from knee replacement might be like as she had been told it would take longer and be more painful than when she had her hip replaced.
You can see more here about experiences of making a decision and experiences and views on the outcomes of knee surgery for the people we talked to.
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