Full knee joint replacement(s) at age 90

[Dreikanter]

Has anyone had experience of an elderly parent having full joint replacements on one or both knees? My DM has decided that she wants both knees done at the same time and has now found a private surgeon that says he can do this (first surgeon she contacted wouldn't operate).

I'm concerned that she has underestimated the recovery and rehab necessary; she's on her own and plans to go to a convalescent home for a fortnight after discharge, and then go back to her own home. Both my DSis and I live a number of hours away and wouldn't be able to spend long periods of time staying with her. She has little muscle mass and hasn't been able to walk very far for a number of years, and I also suspect just won't want to do the physio.

She wants to rush into getting it done next month. My DSis and I have tried discussing the practicalities but she won't listen. She has had both hips replaced but was in her early 70s then and had my dad around to help (a lot).

Any advice / experience would be really useful.

That's really interesting @Fivehares and @FixTheBone

I am in my 70s and had both knees done six months apart. There were no issues with the TKRs but my lack of proprioception balance is still very difficult.

I've had just one knee done. The pain is excruciating and full recovery takes at least 18 months.

I feel for you.

what does "full recovery" mean? would something like jogging be okay?

I’ve heard from a friend (fit, mid sixties) that it’s excruciating for the first few days. Hope you recover quickly.

She'll never walk again if she does this

Thank you. My op was a few years ago now. It's excruciating for much longer than a few days. Removing the staples was painful. The numbness from the nerves is also painful and continues for a long time. Sleeping is very difficult because of the pain and getting comfortable in bed. I had every painkiller offered.

It's a lot more than a few days. I had to live with my nan for a week as I couldn't manage my stairs

Has surgeon 2 spoken to his regular anaesthetist about her? At age 90, even with no major comorbidities, a single joint replacement is major surgery and comes with some risk. I would strongly suggest exploring whether there is an anaesthetic consultant pre-op clinic where they’ll be able to consider any other medical problems she has and give a better impression of her overall risk of morbidity and mortality if she proceeds.

@Greybeardy Thanks for that - the only thing DM had told me is that it would be done under epidural and not involve a general. One of my concerns is that she seems to know very little about the whole thing - proposed op, immediate recovery period and longer term rehab.

I have two very elderly parents one in a care home.

I hope I am allowed to say I am heartily sick of older people deciding they will do what they want and stuff the consequences . After all they think they have you to pick up the pieces if the worst happens but of course they believe it won’t (at 90 plus).

You want to say OK do what you wish but don’t coming running to me if it goes wrong but they know and you know there you will be picking up the pieces again and again..

I have to say that my two surgeries were NOT excruciating and that pain relief was on offer if I did. My problem was balance and that has been difficult. I'm still using a stick 18 months later. I think this would be a very ill-advised procedure for someone of 90.

I didn’t have a new replacement but a knee rebuilt. I was 40 - I totally underestimated the pain, was not allowed to weight bear for six weeks and recuperation took months.

id be worried, sadly, that your mum might never get out of that care home again.

Thanks for that - the only thing DM had told me is that it would be done under epidural and not involve a general.

That could be the case. I was offered that for my hip replacement and I think the anaesthetist referenced something about being appropriate for older patients with heart issues. I chose the general anaesthetic but I think you can have the epidural plus sedation if you need it.

I had spinal block and sedation for both my hip and knee. I'd choose it again for my next hip. I hate having general

That's interesting. I'm contemplating it for my next hip replacement as I felt dreadful for a week after the general. But I gather it's a pretty brutal operation - were you aware of any of it?

If she has one done, watch her like a hawk and if it hurts at all try to take her back to the original surgeon.

My DGM (89) had one done, all the physio, was walking really well for about six months. Then it started hurting — doctors said it was just the new knee settling, then bursitis, then septic arthritis. Turns out that her kneecap (they don't give you a new kneecap) had broken in two. She had to have it removed and has never managed to walk well since. It's such a shame.

The surgeon said if they'd caught it earlier they'd have tried to wire it (?), put her on bed rest, and then done the other knee so there wasn't as much pressure on the "good" leg.

So to me, both at once actually sounds quite good to avoid that (although I'm obviously not a doctor). I suspect recovery would be pretty awful though.

DH is a hip and knee surgeon. Her age wouldn’t prevent him operating, that would be down to any other comorbidities and how well she is in her health; but he would go through the pros and cons very thoroughly. He would NEVER EVER do both knees at once (he wouldn’t do bilateral hips either) and most decent consultants would say the same whatever your age, it’s really not the done thing anymore ~ yes, sometimes others would and IMO that’s around time and shunting people through quicker.

It should be noted that 1 in 10 patients who have a new knee are disappointed and that 10% continue to have ongoing pain.

And booking care for a good 6weeks post op is the best idea~Most patients only stay in 2-3nights post op.

Whatever happens, she will have a thorough assessment pre-operatively, and she should see OT and physio which should help. Good luck.

Not a thing. You just choose how zonked you want to be and I chose fully. You wake up like you've been asleep. None of that awful after general wooziness. That's what I hate.

That’s really helpful - thank you.

A 6 week care stay sounds much more sensible.

Surely any comorbidities (the very best 90 year old will have at least a few) and the pre op anaesthesia assessment will outrule such a big elective surgery?

@EmmaH2022 jogging on a knee replacement is a bit of a no no, you’d have increasing inflammation and you’d wear the joint out quicker; they aren’t designed for running.

@red4321 it is quite brutal and I wouldn’t stay awake if I could chose. Your hip has to be dislocated then bits sawn off and new bits hammered in, and I wouldn’t want to hear it🙉

That's really interesting @MrsElijahMikaelson1 - that's what I'm worried about - going through all that and the end result not being any better than my current pain/immobility- can you say what it is that makes people feel disappointed? I'm really trying to manage my expectations! I know I won't be running marathons but I'd quite like to be able to walk the dog without hobbling like little old lady!

Re. the anaesthetic technique:
Epidural would be pretty unusual (but may have advantages in bilateral surgery). I’ve never done/seen an epidural used solely for anaesthesia (have done regular ortho lists for all of that time too and never done a bilateral hip or knee replacement).

Spinal is most common for both hip and knee replacements. Spinal can be combined with sedation and, because the positioning in hip replacements (lying on your side) can be quite uncomfortable after a while, sedation is quite often used. For knee replacements it’s not so necessary because you’re lying on your back. Avoiding drugs that interfere with the brain (ie. sedation) can have some advantages, particularly for the very elderly, for whom post-operative cognitive dysfunction (a response to the combined insult of surgery and sedation/anaesthesia) is a real concern. It is possible to bock out the sound with headphones and my average knee replacement set-up is a spinal with the patient staying awake & listening to music via headphones (or chatting if they’re not bothered by the noise). They know there’s the option of sedation if it’s awful, but very few ask for it.

Being 90 doesn’t absolutely preclude major surgery, but patients need to have clear insight of the limitations and things that can go wrong. To provide that insight though someone (eg the surgeon/anaesthetist/an orthogeriatrician) needs to have full access to medical history, test results etc. A patient’s functional state before embarking on major surgery is really important - the fitter you are, better nourished you are and more engaged you are with the processes of rehab then the better things are likely to go.

@Greybeardy thanks again, that’s really helpful. I’m only going on what DM has told me on the basis of two consultations with the surgeon, several months apart. Maybe it was a spinal rather than an epidural? I don’t know. It might be me that’s got it wrong or DM. She may have just said they won’t do a general and it’s me that has thought epidural rather than spinal. She gets cross when I ask her what has been discussed because I think she doesn’t know / can’t remember / hasn’t asked the question. It’s like dealing with a petulant child so much of the time.