Knee replacement surgery is increasing exponentially, much more than other joint operations,” says Stuart Edwards, a consultant orthopaedic surgeon based at the Mater Private hospital in Cork and at Aut Even hospital in Kilkenny.
“It’s an epidemic in a way and will put a lot of strain on healthcare systems globally, particularly in America and Europe, in the future. An American research paper has shown that knee operations will increase by 600% over the next 20 years, for example.”
The most common age for women to have this operation is in their mid-60s and it is similar for men but age can range from the 30s to the early 90s, Mr Edwards states, and carrying extra weight can be a big cause.
“Carrying extra weight gives a higher incidence of developing osteoarthritis.”
He cites how even one pound of extra weight can increase the pressure on your knees.
“I tell patients that, in the knee, one pound in body weight equates to six to eight pounds in force across the knee if you do a deep squat, for example. Losing just one pound then will mean a half a stone off your knee in force. It’s really quite remarkable the difference weightloss makes.”
However, genetic influences and trauma (injury in accident) can also be reasons why people need knee replacement operations. Knee replacement surgery is slightly more prevalent in women, he says.
“That’s because there is a slightly higher predisposition in women to what we call primary arthritis, but it affects both males and females.”
Mr Edwards has been carrying out knee replacement operations for nine years, fitting almost 1,500 replacement knees during that time.
WHEN DO YOU NEED ONE?
At what stage should a person consider a knee replacement?
“The general rule is if you are symptomatic with pain in the knee for six weeks or have significant swelling or noise in the knee for more than six weeks you should get advice from your GP,” he says.
“If basic conservative treatment doesn’t help, seek an early referral to a specialist. The overall message is that you don’t have to suffer in pain or in silence.”
He points out, however, that just because you may seek a specialist opinion doesn’t mean that you will definitely be advised to have an operation.
“It’s all about shared decision making. We formulate a plan and you don’t necessarily have to have anything done there and then. There are other options to try first.”
FARMERS LEAVE IT LATE
Many people present late for knee replacement operations, he says, and farmers are late-presenters 99% of time in his experience.
“They don’t want to get anything done until they literally can’t keep going on the farm. So, unfortunately, you can see quite significant disease with farmers who let it go too far.
“This can cause difficulty with the primary operation because the arthritis has worn away so much bone.”
TREATMENT OPTIONS
What are the treatments options?
“If the knee is pre-arthritic you can offer those patients four treatment options, from conservative treatment to surgery,” he says.
1. Conservative treatment includes:• Weight reduction.• Taking anti-inflammatory medication.• Using a stick or walking aid.• Taking a glucosamine* supplement.• Physiotherapy. • Braces.2. Injection therapy is the second option: “Injections of cortisone, steroid or hyaluronic acid are offered. Hyaluronic acid is like WD40 for the knee and it can work fairly effectively for a person who doesn’t want to pursue a new knee. Where the symptoms aren’t quite bad enough (for an operation) it may keep the person ticking over for a few years until such time as they say they’ve had enough of their own knee and want a replacement.”3. Arthroscopy keyhole surgery is the third treatment option: “This is for people who have cartilage tears in their knee but the consensus is that it is of limited value for an established arthritic knee. If there is only a bit of wear and tear it can be useful.”4. Knee replacement surgery: “You can have partial and full knee replacements. Of those who come to my clinic, 90% are too far gone for a partial replacement. So, in my experience, most have the full operation.”Are knee replacement operations less successful than hip replacement ones?
“There is a perception that this is the case but there are subtle differences between the two.
“With a hip replacement there is less pain after the surgery and less physiotherapy is needed, but there is much more restriction. After a hip replacement operation you can’t bend over to tie your shoelaces, for example, and you’ve got to have a raised toilet seat and sleep on your back for a while.
“With a knee replacement operation there is a lot more physiotherapy involved and usually more pain, but there are less restrictions. The success rate with knee replacements is approximately 85-90% and with a hip replacement it is 90-95%.”
A lot is down to the patient, he adds.
“You have to put the work in. I tell patients: ‘There is one person that makes a knee replacement work and that’s the patient.’”
The preparatory counselling before the operation is also very important, he states.
“I call it counselling but it is part of the consent process of understanding what’s involved. It’s about getting to know the patient’s expectations, telling them what it’s going to be like, telling them they may not like it for a while, and that rehab is vital. PMA (positive mental attitude) is very important.”
WHAT HAPPENS AT THE HOSPITAL?
Patients are usually in hospital for three to six days when having a knee replacement operation.
“Patients are up walking the day after the operation and walking up and down stairs before they leave hospital,” he says, “but following exercise instructions at home – the rehab – after the operation is really important.”
Rehabilitation after the operation usually involves:
• Using two crutches for two to four weeks. • Followed by using a single crutch for two to four weeks. • Driving is not allowed for six weeks.• Farmers are allowed to “tip around” on the farm eight weeks after the operation. • Tractor driving may be possible after eight to 10 weeks.• Full farming duties may be resumed after 12 weeks. “Most farmers want surgery done in May to early June,” says Mr Edwards. “It’s a lull time, it seems, for many, and they want to fit the operation in then when it’s a quieter time on the farm.”
BEST DEVELOPMENT – BETTER BEARINGS
From Stuart Edwards’s point of view, the best development in relation to knee replacement surgery in recent years is the improvement in the material that the knee bearings are made from.
“Newer plastic is now available for the bearings that fit between the tibia (leg bone) and femur (thigh bone).
“This material has better wear properties and we believe it will improve the longevity of the knee replacements.”
GLUCOSAMINE – THE JURY IS OUT
*Glucosamine was in the news is 2013 after scientific papers suggested that it wasn’t as effective as previously thought. What does Stuart Edwards say about that?
“As with everything in medicine, my feeling is that if it helps the patient then it doesn’t matter what the statistics or the papers suggest. For glucosamine there are two seminal papers – one that says it gives some benefit and one that says it doesn’t.
“In a young patient with mild degeneration, I always ask them as part of their regime to take glucosamine for four to six months. If they notice some symptom improvement I tell them to keep on taking it, but if they don’t then there is little point in doing that. The jury’s out it, but it may help some people.”
CASE STUDY
PADDY AND ANN BIRD
Paddy and Ann Bird live in Stamullen, Co Meath, and are 64 and 62 respectively.
The young-at-heart couple have each had both knees replaced. Both are very active and play badminton and jive regularly.
When we spoke they had just reached the semi-final stage in the Dublin and district badminton league.
“It started off with me having trouble with my left knee,” Paddy says. “I had a lot of pain and I was dragging my leg a bit and I had terrible trouble getting out of the bed, the bath and the car, but I thought I only had cartilage trouble. It was a bit of a shock when I saw the consultant in the Cappagh Hospital and he told me both my knees were a mess and that I needed replacements in both. That was seven years ago in 2008.
“Even though I’d been in a motorbike crash years ago which would have affected the condition of my knees, it was still a surprise to be told I needed replacements sooner rather than later.
“My wife Ann also needed replacements and she had her’s replaced each time eight weeks before I had mine done.”
Paddy took up badminton when he was 33 years old after the crash forced him to give up football. He enjoys the game immensely and coaches Stamullen schoolchildren in the sport, from first class up, in his spare time.
“I was only in hospital four days each time with the knee operations,” he says, “and I was lucky with the recovery I had.
“I think the fact that the muscles in my thigh and calf were strong before the operation helped me but it was still a matter of persevering and doing the exercises that they give you.
“It can be a bit sore doing them but you have to work through that and do them. It’s like everything – if you don’t put an effort into it you won’t get better.”
Ann is 62 and has been a pitch and putt champion and is glad to have had the “knees done”.
“Paddy drove me mad when he got his first one done,” she says, “because I was in pure agony but he was fine.
“Maybe it was the smoking that went against me but I was on a stick for about six months the first time. The second operation wasn’t as bad thankfully and I’m flying now, apart from probably needing a hip replacement down the line.
“I never thought I’d go back playing badminton but I have, although it took me about three years to build up the confidence. Paddy was back playing after six weeks. I played soccer and gaelic football when I was younger and had and had cartilage taken out of both knees in the ’80s.
“There could be a hereditary factor in my case as well with the arthritis, which meant my recovery was a bit slower than Paddy’s. I found it hard doing the exercises some of the time because it was a bit sore, but I persevered. It’s all about persevering.”
Knee replacement surgery is increasing exponentially, much more than other joint operations,” says Stuart Edwards, a consultant orthopaedic surgeon based at the Mater Private hospital in Cork and at Aut Even hospital in Kilkenny.
“It’s an epidemic in a way and will put a lot of strain on healthcare systems globally, particularly in America and Europe, in the future. An American research paper has shown that knee operations will increase by 600% over the next 20 years, for example.”
The most common age for women to have this operation is in their mid-60s and it is similar for men but age can range from the 30s to the early 90s, Mr Edwards states, and carrying extra weight can be a big cause.
“Carrying extra weight gives a higher incidence of developing osteoarthritis.”
He cites how even one pound of extra weight can increase the pressure on your knees.
“I tell patients that, in the knee, one pound in body weight equates to six to eight pounds in force across the knee if you do a deep squat, for example. Losing just one pound then will mean a half a stone off your knee in force. It’s really quite remarkable the difference weightloss makes.”
However, genetic influences and trauma (injury in accident) can also be reasons why people need knee replacement operations. Knee replacement surgery is slightly more prevalent in women, he says.
“That’s because there is a slightly higher predisposition in women to what we call primary arthritis, but it affects both males and females.”
Mr Edwards has been carrying out knee replacement operations for nine years, fitting almost 1,500 replacement knees during that time.
WHEN DO YOU NEED ONE?
At what stage should a person consider a knee replacement?
“The general rule is if you are symptomatic with pain in the knee for six weeks or have significant swelling or noise in the knee for more than six weeks you should get advice from your GP,” he says.
“If basic conservative treatment doesn’t help, seek an early referral to a specialist. The overall message is that you don’t have to suffer in pain or in silence.”
He points out, however, that just because you may seek a specialist opinion doesn’t mean that you will definitely be advised to have an operation.
“It’s all about shared decision making. We formulate a plan and you don’t necessarily have to have anything done there and then. There are other options to try first.”
FARMERS LEAVE IT LATE
Many people present late for knee replacement operations, he says, and farmers are late-presenters 99% of time in his experience.
“They don’t want to get anything done until they literally can’t keep going on the farm. So, unfortunately, you can see quite significant disease with farmers who let it go too far.
“This can cause difficulty with the primary operation because the arthritis has worn away so much bone.”
TREATMENT OPTIONS
What are the treatments options?
“If the knee is pre-arthritic you can offer those patients four treatment options, from conservative treatment to surgery,” he says.
1. Conservative treatment includes:• Weight reduction.• Taking anti-inflammatory medication.• Using a stick or walking aid.• Taking a glucosamine* supplement.• Physiotherapy. • Braces.2. Injection therapy is the second option: “Injections of cortisone, steroid or hyaluronic acid are offered. Hyaluronic acid is like WD40 for the knee and it can work fairly effectively for a person who doesn’t want to pursue a new knee. Where the symptoms aren’t quite bad enough (for an operation) it may keep the person ticking over for a few years until such time as they say they’ve had enough of their own knee and want a replacement.”3. Arthroscopy keyhole surgery is the third treatment option: “This is for people who have cartilage tears in their knee but the consensus is that it is of limited value for an established arthritic knee. If there is only a bit of wear and tear it can be useful.”4. Knee replacement surgery: “You can have partial and full knee replacements. Of those who come to my clinic, 90% are too far gone for a partial replacement. So, in my experience, most have the full operation.”Are knee replacement operations less successful than hip replacement ones?
“There is a perception that this is the case but there are subtle differences between the two.
“With a hip replacement there is less pain after the surgery and less physiotherapy is needed, but there is much more restriction. After a hip replacement operation you can’t bend over to tie your shoelaces, for example, and you’ve got to have a raised toilet seat and sleep on your back for a while.
“With a knee replacement operation there is a lot more physiotherapy involved and usually more pain, but there are less restrictions. The success rate with knee replacements is approximately 85-90% and with a hip replacement it is 90-95%.”
A lot is down to the patient, he adds.
“You have to put the work in. I tell patients: ‘There is one person that makes a knee replacement work and that’s the patient.’”
The preparatory counselling before the operation is also very important, he states.
“I call it counselling but it is part of the consent process of understanding what’s involved. It’s about getting to know the patient’s expectations, telling them what it’s going to be like, telling them they may not like it for a while, and that rehab is vital. PMA (positive mental attitude) is very important.”
WHAT HAPPENS AT THE HOSPITAL?
Patients are usually in hospital for three to six days when having a knee replacement operation.
“Patients are up walking the day after the operation and walking up and down stairs before they leave hospital,” he says, “but following exercise instructions at home – the rehab – after the operation is really important.”
Rehabilitation after the operation usually involves:
• Using two crutches for two to four weeks. • Followed by using a single crutch for two to four weeks. • Driving is not allowed for six weeks.• Farmers are allowed to “tip around” on the farm eight weeks after the operation. • Tractor driving may be possible after eight to 10 weeks.• Full farming duties may be resumed after 12 weeks. “Most farmers want surgery done in May to early June,” says Mr Edwards. “It’s a lull time, it seems, for many, and they want to fit the operation in then when it’s a quieter time on the farm.”
BEST DEVELOPMENT – BETTER BEARINGS
From Stuart Edwards’s point of view, the best development in relation to knee replacement surgery in recent years is the improvement in the material that the knee bearings are made from.
“Newer plastic is now available for the bearings that fit between the tibia (leg bone) and femur (thigh bone).
“This material has better wear properties and we believe it will improve the longevity of the knee replacements.”
GLUCOSAMINE – THE JURY IS OUT
*Glucosamine was in the news is 2013 after scientific papers suggested that it wasn’t as effective as previously thought. What does Stuart Edwards say about that?
“As with everything in medicine, my feeling is that if it helps the patient then it doesn’t matter what the statistics or the papers suggest. For glucosamine there are two seminal papers – one that says it gives some benefit and one that says it doesn’t.
“In a young patient with mild degeneration, I always ask them as part of their regime to take glucosamine for four to six months. If they notice some symptom improvement I tell them to keep on taking it, but if they don’t then there is little point in doing that. The jury’s out it, but it may help some people.”
CASE STUDY
PADDY AND ANN BIRD
Paddy and Ann Bird live in Stamullen, Co Meath, and are 64 and 62 respectively.
The young-at-heart couple have each had both knees replaced. Both are very active and play badminton and jive regularly.
When we spoke they had just reached the semi-final stage in the Dublin and district badminton league.
“It started off with me having trouble with my left knee,” Paddy says. “I had a lot of pain and I was dragging my leg a bit and I had terrible trouble getting out of the bed, the bath and the car, but I thought I only had cartilage trouble. It was a bit of a shock when I saw the consultant in the Cappagh Hospital and he told me both my knees were a mess and that I needed replacements in both. That was seven years ago in 2008.
“Even though I’d been in a motorbike crash years ago which would have affected the condition of my knees, it was still a surprise to be told I needed replacements sooner rather than later.
“My wife Ann also needed replacements and she had her’s replaced each time eight weeks before I had mine done.”
Paddy took up badminton when he was 33 years old after the crash forced him to give up football. He enjoys the game immensely and coaches Stamullen schoolchildren in the sport, from first class up, in his spare time.
“I was only in hospital four days each time with the knee operations,” he says, “and I was lucky with the recovery I had.
“I think the fact that the muscles in my thigh and calf were strong before the operation helped me but it was still a matter of persevering and doing the exercises that they give you.
“It can be a bit sore doing them but you have to work through that and do them. It’s like everything – if you don’t put an effort into it you won’t get better.”
Ann is 62 and has been a pitch and putt champion and is glad to have had the “knees done”.
“Paddy drove me mad when he got his first one done,” she says, “because I was in pure agony but he was fine.
“Maybe it was the smoking that went against me but I was on a stick for about six months the first time. The second operation wasn’t as bad thankfully and I’m flying now, apart from probably needing a hip replacement down the line.
“I never thought I’d go back playing badminton but I have, although it took me about three years to build up the confidence. Paddy was back playing after six weeks. I played soccer and gaelic football when I was younger and had and had cartilage taken out of both knees in the ’80s.
“There could be a hereditary factor in my case as well with the arthritis, which meant my recovery was a bit slower than Paddy’s. I found it hard doing the exercises some of the time because it was a bit sore, but I persevered. It’s all about persevering.”
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