Deciding whether to have knee surgery

Dr Lai Kah Weng, Orthopaedic Surgeon

Being told you could have an operation is not the same as being told you should. Most knee problems have more than one reasonable course, and which one suits you depends on things a scan cannot see — what you need to get back to, how much the knee is actually stopping you doing, and what you are willing to spend on recovery.

This page is about how to have that conversation. It makes no recommendation about any condition or any operation; what applies to your knee depends on findings only an examination can establish.

Start with the diagnosis, not the operation

Before discussing what an operation involves, establish what is being operated on and how confident anyone is about it.

Ask what exactly is damaged, and how that was determined — from the examination, from imaging, or from both agreeing. A finding on a scan that does not match what the examination found is worth talking about rather than glossing over, because scans of knees frequently show things that are not causing the problem the patient came in with.

Ask, too, whether the finding explains your symptoms. Those are two different questions, and the gap between them is where a lot of unnecessary surgery lives.

Ask what happens if you do nothing

This is the most useful question in the conversation, and the one patients ask least often.

“Nothing” here means nothing for now — not never. A good answer describes what is likely to happen to the knee if you wait, what would tell you that waiting had stopped working, and when you would be seen again to check. If waiting is a reasonable option, it should come with a review date attached. If it is not a reasonable option, you should be told plainly why.

An answer to this question is also the only way to judge what an operation is actually offering you. A procedure that improves on doing nothing is worth considering; one that mainly improves on a version of doing nothing that nobody proposed is not.

Ask what recovery means for you specifically

Recovery is where the real cost of an operation sits, and it is the part most often described in general terms.

Push for specifics about your own circumstances. How long before you could drive — and does that depend on which knee it is, and whether you drive manual? How long before you could manage stairs at home, or a full day at your kind of work? What will you not be able to do alone in the first weeks, and who is going to help? Is physiotherapy part of the plan, how much of it, and is it included in what you are being quoted?

Somebody who lives alone on a third floor without a lift is being offered a different operation, in practice, from somebody who does not.

Consent is a conversation, not a form you sign on the day. By the end of it you should be able to say, in your own words:

  • what is being done, and why that rather than the alternatives;
  • what the realistic range of outcomes is, including the less good ones;
  • what can go wrong, how likely that is, and what would be done about it;
  • what recovery requires of you;
  • what happens if it does not work.

If you cannot explain those to someone else afterwards, the conversation is not finished. Ask for it to continue rather than signing.

You are entitled to take the information away and decide later. A decision that does not have to be made in the room usually should not be.

Getting a second opinion

Asking for one is routine, and it is not an insult to anyone.

A second opinion is most useful when the first one surprised you, when a significant or irreversible procedure is proposed, when two clinicians have already said different things, or simply when you are being asked to decide something large and want to be sure. It is least useful as a search for the answer you wanted — if you ask enough people, someone will eventually agree with you, and that is not the same as being right.

To make one worth having, bring the same material you brought the first time: the images themselves, the reports, and any letter you were given. A second opinion formed from a summary of the first opinion is not really an independent one.

Deciding not to decide yet

Choosing to wait is a decision, and it should be recorded as one — with what you are waiting for, what would change your mind, and when you will be seen again.

That is a different thing from drifting. The difference is the review date.

If you have not yet had the consultation, what happens at a knee consultation describes how the appointment itself is structured and what to bring.

Nothing on this page is advice about your own knee. For anything urgent, call 995 or go to the nearest emergency department.