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KNEE REPLACEMENT  ·  SECTION 3

A Surgeon's Complete Knee
Replacement Guide

Everything you need to know — from diagnosis through recovery and life after surgery. Including the subvastus muscle-sparing approach and Mako robotic precision

A NOTE FROM DR. CALENDINE — KNEE REPLACEMENT

If you're reading this section, you are probably already dealing with knee pain that is affecting your life.

This section explains how knee arthritis progresses, when replacement makes sense, how the surgery works, how recovery differs from hip replacement, and what results you should realistically expect. My goal is not just to explain the operation, but to help you understand how to navigate the entire process the right way — from decision to recovery.

Cory Calendine, MD, Orthopaedic Surgeon, Bone & Joint Institute of Tennessee

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CHAPTER 1

Understanding Knee Arthritis

Knee replacement doesn’t get the same headline hip replacement does — but for the millions of patients who’ve gone from barely walking to hiking, traveling, and moving through their days without a second thought, the result is no less extraordinary. Chapter 1 starts where every honest conversation about knee replacement has to start: with what’s actually happening inside the joint. Dr. Calendine explains why the knee isn’t the simple hinge most patients picture, why soft tissue carries so much of the load, and why cartilage, once gone, is gone for good.

You’ll learn how the knee’s three compartments — medial, lateral, and patellofemoral — shape every surgical decision that follows, and why arthritis doesn’t always announce itself gradually. Some patients feel fine until a single walk or minor fall tips a quietly worn joint into sudden pain. That’s not the injury causing the arthritis; it’s the straw that breaks the camel’s back. Understanding this is the foundation for everything ahead — including why the muscles around your knee matter as much as the surgery itself.

Anatomical knee joint model showing femur, tibia, patella, and ligaments used to explain knee arthritis to patients.

CHAPTER 2

Is It Arthritis? Getting the Diagnosis Right

Before any conversation about surgical options, recovery timelines, or what happens in the operating room, we have to be certain we’re treating the right problem. The knee is easier to localize than the hip — patients can usually point right to where it hurts — but locating the pain isn’t the same as identifying what’s causing it. Chapter 2 walks through how Dr. Calendine sorts knee arthritis from the conditions that mimic it, and why operating on the wrong problem never solves the right one.

 

You’ll learn why one in three adults over forty shows a meniscus tear on MRI — often with no pain at all — and why finding a tear doesn’t mean the tear is the problem. Dr. Calendine explains the critical difference between traumatic tears in younger patients and degenerative tears that coexist with arthritis, the landmark study showing arthroscopy offers no real benefit in arthritic knees, and how history, exam, and weight-bearing imaging must line up before any surgical recommendation is made.

Anteroposterior weight-bearing knee X-ray showing femur, tibia, patella, and joint space used to diagnose knee arthritis.

CHAPTER 3

Your Surgical Options for Knee Replacement

Not all knee replacements are the same. The components used, the surgical approach taken, and the technology employed in the operating room all vary — and those differences matter. Chapter 3 walks through the core surgical options directly: total versus partial knee replacement, and how the surgeon actually accesses the joint. Dr. Calendine explains why “knee resurfacing” is often a more accurate description than “replacement,” and why partial knee replacement is an excellent option for the five to ten percent of patients who truly qualify — and the wrong answer for everyone else.

 

You’ll also learn why the surgical approach matters as much as the implant itself. The standard approach splits the quadriceps tendon — the engine of knee recovery — while the subvastus, or quad-sparing, approach goes beneath the muscle entirely and leaves it fully intact. Dr. Calendine explains why this approach, combined with Mako robotic precision, has become his preferred technique for most primary total knee patients — and the key questions every patient should feel empowered to ask their surgeon before deciding.

CHAPTER 4

Understanding Risks | Before You Decide

Knee replacement is one of the most successful elective procedures in medicine, with decades of outcome data and overwhelmingly positive patient experiences. But you deserve a complete picture before you decide. Chapter 4 is Dr. Calendine’s honest account of every meaningful risk — infection, stiffness, blood clots, persistent pain, nerve considerations, and long-term implant wear — along with exactly what his practice does to minimize each one. The purpose isn’t to scare you away from surgery. It’s to make sure nothing surprises you.

You’ll learn why infection gets more attention than its one-to-two-percent rate suggests, how nasal staph screening and strict perioperative protocols keep Dr. Calendine’s rates well below national averages, and why stiffness is the risk that most distinguishes knee recovery from hip recovery. Dr. Calendine also explains manipulation under anesthesia — what it is, why it isn’t a failure — along with the realities of persistent pain, DVT prevention, and how careful patient selection and robotic precision narrow the margin for complications before surgery even begins.

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Real answers about your knee. A clear path forward.

Whether you’re exploring whether knee replacement is right for you or ready to discuss your specific situation, Dr. Calendine’s office is here to help. Download the complete knee replacement guide for the full picture — or schedule a consultation to talk through your options directly. No referral required.

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CHAPTER 5

OR Technology: Robotic Knee Replacement

Precision matters in knee replacement in ways that are difficult to overstate. The knee moves in six distinct directions at once, stabilized almost entirely by soft tissue — and when components are even slightly off, the consequences compound across every step a patient takes afterward. Chapter 5 explains why Dr. Calendine uses the Mako robotic system on every primary knee replacement he performs, not selectively, and how a CT-based three-dimensional plan built around your individual anatomy becomes the foundation for the entire procedure before you ever arrive at the hospital.

 

You’ll learn what makes Mako in the knee different from Mako in the hip: in addition to mapping the bony anatomy, the system provides real-time intraoperative feedback on your own ligament tension and soft tissue balance as the knee moves with trial components in place. That feedback lets Dr. Calendine refine the plan on the spot — tailoring component position to your exact reality. The robotic arm doesn’t operate independently. It makes precise execution of the surgeon’s judgment possible, consistently, on every single case.

CHAPTER 6

The Implants | What Goes In and Why

Every knee replacement involves the same fundamental task: removing the damaged joint surfaces and replacing them with implant components that recreate the mechanics of a healthy knee. The materials used, the fixation method, and the design of the bearing surfaces all influence how the hip performs and how long it lasts. Chapter 6 explains the four components that work together as a system —  and why the better question is not “which implant is best” but “which implant does your surgeon know well.”

You’ll learn how modern cementless fixation actually works — why a precisely press-fit implant allows your own bone to grow directly into the porous surface, creating a bond that is designed to last. Dr. Calendine explains when cemented fixation is the right choice, and how the bearing surface decision drives implant longevity: why highly cross-linked polyethylene spacers are a top choice, what earlier bearing combinations taught us, and why the materials used today produce minimal wear over decades of normal use.

Side-by-side X-ray comparing severe knee arthritis to a completed total knee replacement with femoral and tibial components.

CHAPTER 7

Preparing for Knee Replacement Surgery

The outcome of your knee replacement is not determined entirely in the operating room — it begins weeks before surgery, in the decisions you make and the conditions you optimize. The knee depends more heavily on the patient’s own effort, before and after surgery, than almost any other joint replacement. Chapter 7 walks through exactly what medical optimization looks like — cardiovascular health, blood sugar control, body weight, smoking cessation, medication review, dental health, and bone health — and explains why each category moves the needle on your outcome in ways most patients underestimate.

 

You’ll also learn why Dr. Calendine considers prehabilitation one of the most powerful things you can do before surgery — not because the joint needs protecting, but because the quadriceps is everything in knee replacement recovery. Pain is information. Low-impact movement in the weeks before surgery builds the reserve you’ll draw from afterward. This chapter also covers home preparation, arranging support, what to expect from physical therapy, and the critical reminder that preparation is an investment in your outcome.

CHAPTER 8

Surgery Day: What Actually Happens

For most patients, surgery day is the most anxiety-producing part of the entire knee replacement experience — and the anticipation is almost always worse than the reality. Chapter 8 walks you through the day from the moment you arrive to the moment you go home. You’ll learn what happens in the pre-operative area, how the adductor canal and IPACK nerve blocks provide meaningful pain relief without turning off the quadriceps, and why spinal anesthesia combined with IV sedation means most patients are calm, comfortable, and largely unaware of the experience itself.

 

Once in the operating room, Dr. Calendine walks you through exactly what happens during a subvastus knee replacement guided by the Mako robotic system — from incision to implant placement to periarticular injection and closure. The procedure itself takes one to two hours. Transfusion is extremely rare. You’ll get up and walk the same day as surgery — not the next day — and most patients find the first evening at home more manageable than expected. Surgery day isn’t the end of something. It’s the beginning.

CHAPTER 9

Recovery: Week by Week

Knee replacement rehabilitation is more demanding, the milestones require more active work, and the range of what’s normal is wider than many elective procedures. Chapter 9 walks through recovery week by week — from the same-day walk after surgery, through the early days of ice, elevation, to the first physical therapy sessions focused on range of motion and retraining the quadriceps. The guiding principle of early recovery is simple: do not do too much too early. A smooth, progressive, upward trajectory requires restraint in the first days.

 

You’ll learn what to expect through weeks two and three as the quad responds and most patients transition from walker to cane, why the temporary dip some patients feel around days seven to fourteen is normal and not a setback, and when desk work, driving, the gym, and sports like golf, tennis, and pickleball realistically become available again. Three months is the milestone most patients point to as the moment recovery felt complete. But knees continue strengthening for one to two full years. Your timeline is yours — measure progress against where you started, not against someone else.

Patient taking early steps with a walker after knee replacement surgery, visible incision, clinician supporting at their side.

CHAPTER 10

Expectations & Life After Knee Replacement

This is the chapter most patients wish they had read before their consultation —  because it puts everything together in the way that actually matters: what does this surgery deliver, and what does life look like on the other side of it? Chapter 10 walks through what decades of evidence and millions of procedures have shown. Patient satisfaction rates after total knee replacement are among the highest of any elective procedure in medicine, and the results today — with robotic precision, improved implants, and refined surgical technique — are better than ever.

 

Dr. Calendine also addresses the honest numbers directly: why up to fifteen percent of patients nationally report persistent discomfort, why his own outcomes track well below that, and why the margin is somewhat wider in the knee than in simpler joints. You’ll learn what knee replacement can and cannot do, what implant longevity looks like for younger patients, and why the partnership between surgeon and patient is the most powerful variable in any outcome. The goal isn’t a perfect knee — it’s a reliable knee that lets you live your life.

Multigenerational family walking together on a sandy beach at sunset, grandparents active alongside daughter and grandchild.

HEAR IT FROM DR. CALENDINE

A Surgeon's Perspective on Knee Replacement

Section 2 | Knee Replacement Guide

Back To Section 1 | Joint Replacement Essentials

A Surgeon's Complete Guide to Knee Replacement

If hip pain is what brought you here, Section Two goes the full distance. In ten detailed chapters, Dr. Calendine covers everything from understanding hip arthritis and pinpointing where your pain is actually coming from, to choosing between the anterior and posterior surgical approaches, evaluating Mako® robotic technology and OrthoGrid AI guidance, selecting the right implant, preparing for surgery, and knowing what to expect week by week through recovery. This is the complete clinical picture — written for patients who want real answers, not reassurance. Whether you’re considering hip replacement in Nashville, Franklin, or anywhere in Middle Tennessee, this is the guide to read before your consultation.

GO TO COMPLETE HIP REPLACEMENT GUIDE

Before You Decide — The Essentials

Section Two took you deep into hip replacement — but some of the most important questions come earlier. How does arthritis actually develop? How do you know when it’s time? And what should you try before surgery becomes the conversation? Section One is the foundational pillar of this guide: three chapters on understanding hip and knee arthritis, recognizing the signs you may need replacement, and working through every major non-surgical option — activity modification, physical therapy, weight management, NSAIDs, bracing, injections, and an evidence-based look at stem cell treatments. If you’re earlier in your decision than this hip section assumes, start here. It’s the chapter every patient wishes they had read first.

GO TO THE ESSENTIAL | BEFORE YOU DECIDE

COMMON QUESTIONS ABOUT THIS GUIDE

Frequently Asked Questions

Is knee replacement really the only cure for knee arthritis?

Yes. When cartilage is gone and the joint has failed, no medication, injection, or therapy reverses that underlying damage. Non-surgical treatments manage symptoms — sometimes effectively for years — but knee replacement is the only treatment that eliminates the structural source of the pain. For the right patient at the right time, the result is profound and lasting.

  • Download Complete Hip & Knee Replacement Guide (PDF)

Total knee replacement resurfaces all three compartments of the joint — the femur, tibia, and usually the patella. Partial knee replacement addresses only one damaged compartment and leaves the rest of the native knee intact. Partial replacement is an excellent option for the five to ten percent of patients whose arthritis is genuinely isolated to one compartment, with intact ligaments and acceptable alignment. For everyone else, total knee replacement is the more reliable choice.

The subvastus approach accesses the knee from beneath the vastus medialis muscle without cutting through the quadriceps tendon. The standard approach splits the quad tendon — which must then heal before the muscle can fire at full strength. The subvastus approach leaves the quadriceps fully intact, allowing earlier and stronger activation during recovery. Combined with Mako robotic precision, it delivers a less invasive approach with the most accurate component positioning available in modern knee replacement.

Precision matters enormously in knee replacement. Small differences in component alignment and soft tissue balance make meaningful differences in how the knee feels, tracks, and lasts. Mako begins with a CT-based three-dimensional plan built from each patient’s individual anatomy, then provides real-time intraoperative feedback on ligament tension and soft tissue balance. Dr. Calendine uses Mako on every primary knee replacement — not selectively — because every patient deserves the same standard of precision.

The procedure itself typically takes one to two hours from incision to closure. Knee replacement today is overwhelmingly an outpatient procedure — most patients go home the same day as surgery, and some stay one night. Your discharge plan is determined before your surgery date, not on the day itself, so you’ll know exactly what to expect in advance.

Modern pain management has transformed the knee replacement experience. Adductor canal and IPACK nerve blocks, spinal anesthesia, periarticular injection, and a carefully sequenced oral medication protocol keep most patients meaningfully comfortable through the first day and beyond. The key is staying ahead of pain — taking prescribed medications on schedule rather than waiting for significant discomfort. Recovery is demanding, but the pain is manageable and progressively improves.

The same day. Not the next day — the same day. A physical therapist or nurse will assist you to standing and walk you through your first steps with a walker before you go home. The goal on surgery day isn’t distance or performance — it’s demonstrating safe weight-bearing and basic mobility. Early movement is one of the most important elements of a successful recovery.

  •  Total Knee Replacement Recovery
  • Partial Knee Replacement Recovery

Most patients are ready to drive when they’re walking steadily and completely off narcotic pain medications — typically one to three weeks after surgery. Desk jobs generally resume within two to three weeks. Physical or active jobs take longer. Most patients return to golf, tennis, pickleball, and the gym in the weeks four through six window, gradually building back to full intensity. At three months, the large majority of patients are back to virtually all activities.

Modern knee implants wear slowly and last well. The survivorship data at fifteen and twenty years for well-designed, well-positioned cemented knee replacements is strong — the large majority of implants are still performing well at that timeframe. For younger patients hoping for thirty-year survivorship, cementless fixation is increasingly available and may offer additional long-term durability. Dr. Calendine individualizes implant and fixation choices based on each patient’s age, bone quality, and anatomy.

The most important risks to understand are infection (approximately one to two percent nationally, lower in practices with dedicated prevention protocols), stiffness requiring manipulation under anesthesia, blood clots (prevented with aspirin and early mobilization for most patients), persistent pain (reported in up to ten to fifteen percent of patients nationally, significantly lower in Dr. Calendine’s practice), and long-term implant wear. Every risk deserves to be understood — and every one needs to be understood in context. Knee replacement has one of the highest patient satisfaction rates of any elective procedure in medicine.

For most patients, yes — eventually. Recovery is not a straight line, and knees continue to strengthen and improve for one to two years after surgery. At some point — months or perhaps a year from now — the joint stops feeling like hardware and starts feeling like yours. Not a substitute for what you lost. Your knee. The way it was always supposed to feel.

Readiness is rarely about a single test or imaging finding. It’s about whether arthritis is meaningfully affecting your quality of life — whether you’ve stopped doing activities that matter to you, calculated distances before you walk, or started relying on daily medication just to get through a normal day. If conservative treatments are no longer providing adequate relief, a consultation with a fellowship-trained hip and knee replacement surgeon is the right next step. Dr. Calendine and the team at the Bone and Joint Institute of Tennessee welcome that conversation.