Who Should Not Get a Knee Replacement Yet? An Honest Look at Timing and Disappointing Results

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Patients ask me who should not get a knee replacement far less often than they ask the opposite question, and I think that is backwards. The most common thing I hear after surgery is “why didn’t I do this sooner.” But there is another conversation I have just as often: the one where I talk somebody out of a knee replacement, or at least out of doing it right now.

I’m Dr. Cory Calendine, a board-certified orthopedic surgeon in Franklin, Tennessee. I do hip and knee replacement exclusively: more than 700 joint replacements a year, for over twenty years.

Who should not get a knee replacement yet?

Four groups of patients should not get a knee replacement yet: people with only mild arthritis on weight-bearing X-rays, people whose pain may be coming from somewhere other than the knee joint, people carrying expectations the operation cannot meet, and people who have not yet tried nonsurgical care.

None of those means never. Every one of them means not yet.

Here are the four red flags I watch for in a clinic visit.

1. A mild knee X-ray attached to a very big pain story. That mismatch usually means something else is driving the pain.
2. Expectations that do not match the operation. Back to work in two days. Running at two weeks.
3. Pain the exam cannot localize to the joint. That is when I start looking at the hip, the tendons, and the spine.
4. A knee that has not tried anything yet. No therapy, no activity changes, no injections.

Surgery should not be the first thing a knee tries.

Who should not get a knee replacement at all?

Absolute reasons are uncommon: active infection, an extensor mechanism that cannot work, skin over the knee that will not heal, or health too fragile for the recovery. Most other barriers are timing problems. Smoking, uncontrolled diabetes, and a very high BMI raise complication risk, but each can usually be improved before surgery rather than ruling it out forever.

Does arthritis on an X-ray mean you need a knee replacement?

No. Arthritis on an X-ray is a finding, not a prescription. Replacement is the only cure for knee arthritis, but “the only cure” and “the next step” are two different things.

Arthritis sits on a scale, like tread wearing on a tire. Ten thousand miles into a fifty-thousand-mile tire, you do not replace the tire. There is still good life in a mildly arthritic knee.

Surgery should be the last resort. That is a surgeon telling you that. I walk through the full nonsurgical menu in my guide to treating hip and knee arthritis without surgery.

Why do patients with mild arthritis do worse after knee replacement?

Because arthritis causes knee pain, but so do a lot of other things: tendonitis, bursitis, a meniscus tear, even a bad hip. Replace the joint and whatever else was hurting is still there.

The numbers back this up. In one study of painful knee replacements with no other identifiable cause, 49 percent of those patients had only early-grade arthritis before surgery, compared with 5 to 10 percent in the comparison groups. In a separate series of 996 patients, preoperative arthritis severity was the only factor that predicted satisfaction: compared with severe grade IV disease, dissatisfaction was roughly 2.6 times more likely with grade III changes and roughly 3 times more likely with grade II.

The X-ray is never the whole story; your function and quality of life matter. But severity on the film does track with satisfaction afterward, and that is worth sitting with if your arthritis is still mild.

What else can cause knee pain that looks like arthritis?

The two mimics I catch most often are a meniscus tear in a knee with mild arthritis, and severe hip arthritis sending its pain down to the knee. Both are common. Both get missed.

The meniscus tear that did not need a replacement

A 52-year-old man came to see me years ago. His MRI report mentioned arthritis, and that is what he fixed on.

Standing, weight-bearing X-rays told a different story: he had lost maybe ten percent of his cartilage. Very mild. What the MRI also showed was a significant meniscus tear, and that tear was what hurt.

We scoped it instead: a twenty-minute procedure and two days on crutches. I ran into him socially five or six years out, and the knee is still going great.

A scope is not a cure for arthritis. But a confirmed meniscus tear alongside mild arthritis can be the right thing to treat.

The hip that was doing the talking

A 72-year-old woman came in for severe knee pain. Her knee film showed mild arthritis, but her exam did not match: no swelling, normal motion. When I moved her hip, her knee lit up.

Hip films showed severe hip arthritis. She had trouble believing me, because all of her pain lived in the knee. So we injected steroid into the hip joint, and for a week afterward she had no knee pain at all. That settled it.

She had a hip replacement about ten years ago and has no hip or knee pain today. Some patients with a bad hip feel it only in the knee, which is reason enough for a full evaluation before anything gets replaced.

What percentage of knee replacement patients are dissatisfied?

Historically, up to about 1 in 5. That is the landmark number, and I am not going to hide from it.

I think we are better than that today: better implants, better pain control, better recovery protocols. Most current estimates land closer to 1 in 10, and one prospective study of 1,217 patients found 18.6 percent were unsure or dissatisfied at one year.

But the number is not zero. A knee replacement fixes arthritis; it does not fix everything that can hurt around a knee. Swelling and tendonitis can persist, surgery carries real risks, and occasionally an implant fails mechanically and needs revision knee replacement.

Why do some knee replacements disappoint?

The biggest driver is expectations, and that one is largely in your control. Knee replacement research is consistent: unmet expectations are the strongest predictor of an unhappy knee.

If you go in believing this is a quick fix and you will be back at work in two days with no restrictions, you are likely to be disappointed.

Here is the conversation I actually have. A knee replacement is best at taking away pain. It is next best at improving function. It is third best at improving your ultimate range of motion.

Pain, then function, then motion. My goal for every patient is all three, but they tend to arrive in that order.

Can you wait too long for a knee replacement?

Yes, and patients rarely hear this part. Motion after surgery follows a rule worth knowing: the stiffer you are going in, the more likely you are to be stiff coming out.

Waiting also lets muscles weaken and the rehab hill get steeper. So there is a balance. Not too early, and not for years past the point where nonsurgical care stopped working. I cover the other side of that decision in when it is time for a knee replacement.

What bothers me most is the line “you have arthritis, replacement is inevitable, so you might as well get it done.” That is not how this works. Surgery is a big decision that has to be individualized.

What if you already had a knee replacement and you are disappointed?

Get evaluated. A disappointed knee deserves answers, not resignation.

Sometimes it is the tendons, the hip, or the back doing the talking. Sometimes it is the implant itself, and some of those problems are fully fixable.

An unhappy knee is a question to be answered, not a sentence to serve.

How do you know you are ready for a knee replacement?

You and your surgeon should be able to say three things together: the disease is ready, the expectations are realistic, and you are optimized (as strong and as healthy as you can be going into a major operation).

Mild arthritis deserves nonsurgical care first. Confusing pain deserves a diagnosis first. That is what puts people in the group that says “why didn’t I do this sooner.” My review of the knee replacement success rate covers what the operation delivers when timing is right; the American Academy of Orthopaedic Surgeons also publishes a patient overview of total knee replacement.

If you want a straight answer about whether your knee is ready, I see patients from Franklin, Nashville, Columbia, and across Middle Tennessee at the Bone and Joint Institute of Tennessee, 3000 Edward Curd Lane, Franklin, TN 37067. Call (615) 791-2630 or schedule a consultation online. No referral required.

Disclosure and medical disclaimer: This article reflects Dr. Calendine’s independent clinical perspective and is for education only. It is not a substitute for advice from your own surgeon. Individual results vary. In a medical emergency, call 911.

References

1. Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468(1):57-63. PMID 19844772.
2. Polkowski GG 2nd, Ruh EL, Barrack TN, Nunley RM, Barrack RL. Is pain and dissatisfaction after TKA related to early-grade preoperative osteoarthritis? Clin Orthop Relat Res. 2013;471(1):162-168. PMID 22923158.
3. Schnurr C, Jarrous M, Gudden I, Eysel P, Konig DP. Pre-operative arthritis severity as a predictor for total knee arthroplasty patients’ satisfaction. Int Orthop. 2013;37(7):1257-1261. PMID 23525526.
4. Scott CE, Howie CR, MacDonald D, Biant LC. Predicting dissatisfaction following total knee replacement: a prospective study of 1217 patients. J Bone Joint Surg Br. 2010;92(9):1253-1258. PMID 20798443.