Making decisions about knee replacement as an older person with multiple conditions
Not having knee replacement surgery
Not everyone we talked to went on to have knee replacement surgery. Knee replacement is not always offered at the referral appointment. Sometimes this is because an individual’s health could make the operation too risky or because surgery would not improve their knee problem, for example if it turned out that the knee problems were to do with another joint (like the hip) or muscle damage. Some people who are offered knee replacement may decide to postpone or not have the surgery. Changes in health or life circumstance over time may mean the decision has to be reconsidered. This section covers:
- Reasons for not having knee replacement surgery
- Other treatment options and ways to manage
- Thoughts about the future
Reasons for not having knee replacement surgery
- Higher risks
We talked to a few people who had not been offered knee replacement surgery because the surgeon concluded the risks of surgery were too great. Ruth and Penny had other health conditions which made the risk of infection high. Michael X was diagnosed with kidney cancer while waiting for a surgery date and so his knee replacement was postponed.
Penny could not have knee replacement surgery while having intravenous steroid treatment for vasculitis because she was at higher risk of bleeding and infection (spoken by an actor).
Penny could not have knee replacement surgery while having intravenous steroid treatment for vasculitis because she was at higher risk of bleeding and infection (spoken by an actor).
Right, my knee-, the surgeon wasn't going to do anything about it because I was on steroids.
I said, “Well, why’s that?” and he said, “Well, if it starts to bleed,” he says, “it could have not very good consequences, you might even lose your leg, you might get infection in it.”
I says, “Oh dear me, right, okay,” so I says, “we'll just leave that at the moment then.”
And I've got this condition called vasculitis, which is an inflammation of all the blood vessels in my body, and I'm going regularly for treatment at the hospital.
While waiting for total knee replacement, Liz’s other health problems worsened and she was no longer able to have surgery.
While waiting for total knee replacement, Liz’s other health problems worsened and she was no longer able to have surgery.
Unfortunately, before I've had the chance to get my knee operated, my heart problem’s overtaken me, and I've had three heart attacks and had to have a triple bypass, which has been very successful from the point of view of supplying my heart with blood through the main arteries, but still the smaller vessels aren’t receiving a very good flow of blood, so I'm still left with residual angina, which if left untreated, then develops into another heart attack, so I'm pretty dependent on this-, my spray, my GTN spray. I am improving steadily after the surgery, and slowly getting back to some kind of normality.
Goodness. And so, you were due-, you were eligible to have the knee replacement, but this all happened over the summer, before you could have the operation itself?
Yes, it did, yes.
Am I right in thinking, Liz, that you also had a stroke before the heart attack?
I did, in July, which left me blind in my left eye.
And you don't have your sight back in your left eye?
Yes, I can see a little bit of light, but I can't see objects or direction or anything.
And before you had a stroke and the heart attacks, did you see the surgeon to discuss if surgery was an option for you?
Yes, yeah. But I mean even before this happened, he was rather concerned about my general health.
And was that sort of health overall, or to do with the heart—?
Yeah, as an anaesthetic risk.
Okay.
When I had my right knee done, I had problems getting my blood pressure to come back up. I had terrible problems with passing out, with very low blood pressure. So that was how instead of just being in for 24 hours, I was in for a couple of days longer.
- Not needed
Others were not offered knee replacement because X-rays showed that other joints, such as the hip, were causing pain in the knee. Treatment or surgery for their back or hip was needed instead. Sometimes knee problems were related to muscle damage which would heal with time, rather than a problem with the joint itself.
At Linda Y’s appointment, the surgeon showed her the X-rays and told her that her hip was causing the pain in her knee (read by an actor).
At Linda Y’s appointment, the surgeon showed her the X-rays and told her that her hip was causing the pain in her knee (read by an actor).
When I spoke to the consultant he said, “It’s not your knee, it’s your hip.”
Anyway they did some X-rays, and they showed me the difference and it was unbelievable: the hip on the one side looked as if it was right up, you know, in my body compared to the hip on the other side so and as soon as they’d done the hip, repaired the hip, the actual knee: there was no problems anymore.
And because my knee’s no problem now.
Oh brilliant.
But it gets a bit sore, both knees do, because I've had that-, and walking awkwardly since I've had the hip-, well, not awkward but differently since I've had my hip so the knees do get a bit sore now. But on the whole, I don't have pain in the knee anymore.
Lesley’s surgeon advised that her back was the cause of her knee pain, so further knee surgery was unnecessary.
Lesley’s surgeon advised that her back was the cause of her knee pain, so further knee surgery was unnecessary.
After my appointment at the [hospital] and said that [they] weren’t going to go forward with anything at that stage.
He didn’t feel that I would be of any benefit having a full knee replacement rather than the partial that I’ve got.
But he was very pleasant and I thought ‘well, he’s going to see me again and we’ll see how it goes.' But he said if there was any real major problem between then, that I could go back to him. However, he felt that a lot of my problems come from my back. And I’m sure that is the case.
- Postponing knee replacement surgery
A few people had been offered knee replacement surgery but decided not to have it at the moment. Bridget is in her late 80s and wanted to continue with steroid injections instead of surgery. She was worried about having an anaesthetic with her other health conditions, and felt the injections were keeping the situation manageable. Emily and Dave X felt they could not manage surgery while providing care and support to an ill spouse.
The surgeon told Dave X that he could have both knees replaced. He wants to postpone having surgery at the moment to look after his wife with her health problems.
The surgeon told Dave X that he could have both knees replaced. He wants to postpone having surgery at the moment to look after his wife with her health problems.
No, it was, I mean he’s very nice, a very nice man and, you know, as I say he was quite hopeful that my knees could go on, you know, quite a while if I was lucky, I suppose. And, I do have to put up with the, you know, with the pain of them, you know, more so when I’ve had a busy day or something like that, you know. But you’ve always, you know, gotta weigh that up against, you know, six weeks laid up after an operation and [wife’s] situation, I [sigh], you know, I would be really reluctant to have to go in hospital and with [wife] gets these bad times in the night, you know.
Wouldn’t be something I’d relish, you know.
Of course. And so, what is the situation at the moment in terms of are you waiting to hear back about a date for surgery or-?
No, no, well the ball’s in my court to request it if I get to the point where I think I can’t put up with this anymore.
Okay.
You know. But as long as I can reasonably keep working which I do and like I say I’ve gone back to play table tennis and well then obviously when I do stuff, I ride my bike, you know, they hurt and that’s it, but then I know that. You know, its choices have to be made, you know.
And that’s, that’s sort of my choice, certainly at the moment, you know.
What with, you know, [wife]’s situation with her night times and you know, I’d be, well I wouldn’t be too reluctant about going in to have it done regarding the Covid because I think they must have got that all planned out fairly well, but obviously it’s difficult times and it’s everything all together, you know, I, it would be really difficult for me to say, “Yes, can I have my knees done?” you know.
I’d have to sort of, I think they’d have to be, deteriorate to the point where they were giving out or locking or something, and then I would have to.
Take the plunge somehow or other, you know.
But until then I’ll probably, if they stay as they are, which they’ve been the same now for oh I’d say they’ve been at this level now for two or three years probably. And I’ve managed to deal with it and do everything I wanna do. And that seems to me to be the best option at the moment.
The most influential factors would be the length of time you’re off doing anything after the surgery because my wife can’t drive.
And also [wife]’s situation in the night time which, with her nightmares, I’d be just worried sick for her, you know. If I wasn’t there, you know.
So, it’s that as well. And it’s a combination of the two, you know, because it would be extremely difficult for us if I was laid up for six weeks twice, you know, with [wife] not being able to drive.
After a difficult recovery from her previous knee replacement and her husband’s illness, Emily decided to delay having knee replacement surgery.
After a difficult recovery from her previous knee replacement and her husband’s illness, Emily decided to delay having knee replacement surgery.
How quickly into the appointment did you know that surgery was an option for you and that it was going to be offered?
Oh, I knew years ago I needed it. They told me before [my husband] was poorly that I would need it and I just looked at them and I said, “I know I need it, but I’m not coming until I’m absolutely destitute.”
And he said, “Why?” and I said, “Because, have you ever had a knee replacement?” And of course he said, “No.” It was a young man, and I said, “Well, it hurts like hell before you have it but after you have it, it’s 100 times worse.”
And it really is, the pain is unbearable. I would rather have nine hip replacements than another knee replacement; I’m just dreading it.I really am. To be perfectly honest with you. The pain was horrific, absolutely horrific. And it took almost 18 months before I felt normal again.
Gosh, yeah.
It really took a long time. I don’t know why, it just did. Yeah, it was a real bugger. And I kept putting it off and putting it off and then of course, in 2018 we discovered that [my husband] had melanoma. And I mean my knee was, I was in, I was hurting then, obviously I’d been hurting all along, and I thought ‘well I can’t do anything now because I don’t know which way [my husband] is gonna go and I’ve got to be able to look after him to some degree and he can’t be running around looking after me if I’ve had, got my knee done’.
So yeah, so [my knee] was put on hold and I waited until after the dust settled here in the house and get myself back on an even keel, and I contacted my doctor last year. And now they’re getting the ball rolling.
After discussing the options with the surgeon, Bridget decided to continue with steroid injections instead of having knee replacement surgery. She didn’t want to take any “unnecessary risks.”
After discussing the options with the surgeon, Bridget decided to continue with steroid injections instead of having knee replacement surgery. She didn’t want to take any “unnecessary risks.”
Well, my son came with me, and [the doctor] went through all the options and said that at the current time anaesthetics were much better and that he thought if my knees got seriously bad, the risk wouldn’t be that great. Although, there always is a risk with anaesthetics, and especially with people with other conditions, so at the time I said, “Well, could I have it still-, could I keep up with the injection?” And he was okay with that, so that’s as far as it went.
And at that appointment when you sort of had decided-, when the surgeon said that you could have the surgery, but you decided not to, how did you sort of feel about that decision at the time?
Relieved.
Do you mind me asking a bit more about why: what was the sort of sense of relief?
I'm 86, and I don't want to take any risks that are unnecessary, and I thought it was an unnecessary risk.
My knees are actually not too bad. I can walk a fair dist-, not a fair distance, a couple of hundred yards, but my knees do get painful, but it isn’t really the knee joint, I don't think, as much as the sort of surrounding area.
Is that the-, sort of the muscles and the tissues?
I think it’s more the tissues.
I don't really-, I can't really pin it down; I have asked about it. But, you know, I get arthritis and rheumatism and all the rest of it, so it’s hard to know at my age what’s hurting, where, exactly.
Janet was having further investigations to identify the source of her knee pain. While waiting for the results, she said her focus had been on supporting her family’s health concerns.
Other treatment options and ways to manage
When knee replacement is not an option, some people had been recommended other treatments or referred for other tests.
- Steroid injections
Hermione, Bridget and Janet had been offered steroid injections as an alternative to surgery. Janet’s knee pain considerably improved after a steroid injection in her hip. Michael X had a recent steroid injection in his thumb joint. He was advised to only have up to three steroid injections a year, which meant he had to wait before having one in his knee joint. Barbara’s steroid injection in her knee had taken away the pain. The relief only lasted a fortnight so she decided it was not worth having another one.
- Exercise
When knee replacement was not an option, exercise continued to be an important way of managing knee function. Janet attended a fitness class and keeps walking. Michael X works part time as a gardener and is continuing to exercise his knee.
- Pain management
Approaches to longer term management of pain were increasing pain medication or use of nerve stimulation therapy.
Ann’s knee pain is caused by soft tissue injury and not due to osteoarthritis which the surgeon said would heal on its own in time. She has started using a pain relief patch.
Ann’s knee pain is caused by soft tissue injury and not due to osteoarthritis which the surgeon said would heal on its own in time. She has started using a pain relief patch.
And when I saw him, he just said, “Oh well it’s soft tissue injury and, and there’s nothing much that we can do. It’s just a question of it healing on its own.”
And I went, “Oh great.” “And it’s going to take a year."
Meanwhile the pain doesn’t stop. But I have got a patch. It’s a lignocaine patch which helps numb the nerves. He didn’t mention anything about surgical intervention. He just said, “Soft tissue’s gonna take a year.” In other words, it’s a slow process and you’ve just got to have patience.
Yeah, and it sounds like it was through your friend that you knew about the pain relief patches.
Yeah.
It wasn’t sort of suggested?
Yes, it was, it was just, I was having, I went to have coffee with her and she said, “Oh my carer’s been on leave, can I ask you to put this patch on my back?” So, I said, “Yeah, no problem.” And so, I put it on her back and I said, “What is this?” And she brought me the pamphlet and I read it and I thought, “Oh, this could do with me.”
And so, I sent a message to the surgery, and she didn’t even discuss it with me, she just prescribed it, and I’ve been on it ever since. I think I’m onto my fourth box now.
Thoughts about the future
Some people thought that if their knee pain or symptoms worsened then they would reconsider options for knee replacement surgery. Janet had not been offered knee replacement surgery and was waiting for scan results on her spine. Depending on the results, and if her pain worsens or she is unable to sleep again, she might pay to have a second opinion privately. Barbara was unsure which direction to take next after being advised against knee surgery. She has decided to try using her walker more and taking it one day at a time.
Dave X tried “to resist” taking painkillers for his knee. He didn’t want to become reliant on them and take them on top of his angina and blood pressure medication.
Dave X tried “to resist” taking painkillers for his knee. He didn’t want to become reliant on them and take them on top of his angina and blood pressure medication.
Do you take painkillers either for the pains you’ve got in your feet or the knee pains that you get?
No, I try to resist it as absolutely as much as I can. There’s only been an odd couple of occasions where I’ve took painkillers. But yeah, I don’t wanna be starting that really.
But they, as I said before they just hurt, they don’t touch wood, they don’t give out or lock or anything nasty like that. They just hurt.
I don’t take painkillers for them. No, I, you know, I take enough tablets for my angina and all that I don’t take, I can’t be taking, you know, painkillers for my knees as well, you know. Not unless, like I say, unless it got absolutely excruciating, in which case, I’d want the surgery then, you know.
Oh yeah, obviously pain relief, you know, but to be honest if I had to be on pain relief all the time for my knees, I’d rather have the surgery I think if it got to that point.
I wouldn’t be keen, I wouldn’t be keen on taking you know, permanent pain relief for my knees. You know, I’d rather have the surgery if it got to that point.
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