Getting a second opinion before a joint replacement

When to get one

Often the first advice is right, and when it is I say so. A second opinion still makes sense if any of these apply to you:

• You have been told you need a replacement, but on most days the pain is something you can live with.
• The decision was made from an X-ray, without anyone examining the joint or asking what it stops you doing.
• You are young for a replacement and were offered a total knee. When the wear is on one side only, a partial knee replacement or realigning the shin bone can be the better first operation, and both leave a total replacement available for later.
• The simpler treatments have not been tried properly: physiotherapy, losing weight if that applies, regular painkillers, perhaps an injection.
• You have been advised to have both knees done in one sitting.
• You left the first consultation without understanding why this operation, and why now.

First, is the pain coming from that joint?

This is the first thing I check, because getting it wrong is the costliest mistake. Arthritis of the hip very often shows itself as pain in the knee, down the front and inner side of the thigh. Almost anyone over sixty will have some wear on a knee X-ray, so it is easy to find a cause in the wrong place. Pain from the lower back can travel down the leg the same way, and a good deal of shoulder pain turns out to come from the neck.

A replacement cures pain that comes from a worn joint surface. It does nothing for pain that starts somewhere else, and a new knee that still hurts is very hard to put right. If your pain does not quite fit the pattern, read about hip pain as well as knee pain; the two are easily confused.

What I look at

Mostly the same things the first surgeon looked at, with fresh eyes. When a second opinion changes the plan, it is nearly always because of one of these:

• Standing X-rays. A knee X-rayed lying down can look better than it is, because the joint opens up when no weight is on it. Films taken standing show how much cartilage is really left, and which part of the knee has worn.
• Where the wear is. Arthritis limited to the inner side of the knee, with sound ligaments, is where a partial replacement belongs in the discussion. The UK's national guidance says those patients should be offered the choice. Wear right across the joint is a different matter.
• The shape of the leg. A leg that has bowed a long way changes how the operation is planned, and it is the question my own research has been about, which I have written up in robotic knee replacement: what it can and cannot do.
• How the pain behaves. Pain at night and at rest, pain that decides how far you can walk, and a knee that no longer responds to treatment all point towards surgery. An ache after a long day that has settled by morning usually does not.
• What you want back. Walking to the market, managing the stairs at home, travelling to see family. If sitting cross-legged on the floor is the thing you miss most, we need to talk about that before any operation, because a replaced knee often will not allow it.

An MRI is rarely needed to decide on a replacement for arthritis. If you have one, I will look at it, but standing X-rays and the examination usually settle the question.

The answers it can give

A second opinion almost always ends in one of four places.

• Yes, and now. The first advice was right. A good number end here, and you go ahead with more confidence than you came in with.
• Yes, but a different operation. A partial replacement instead of a total, or an osteotomy in a younger patient.
• Not yet. The joint is worn, but the pain is manageable and the treatment without surgery has not had a fair trial. Waiting a while does not usually make the operation harder, provided the leg is not bending further out of shape and you are still walking.
• Something else is causing it. The hip, the back or the neck, as above.

Whichever it is, you should leave knowing the reason, and you are free to take it back to your first surgeon. I would sooner you had your operation done well by someone you trust than done by me because you felt you had to.

Questions to ask any surgeon, me included

• Why this operation, and not a smaller one?
• What happens if I wait a year?
• What will the new joint not let me do?
• How will my pain be controlled in the first few days?
• How long is the physiotherapy, and who will do it?

Ask about pain in particular, because the answer has changed so much. Local anaesthetic injected around the joint during the operation, and nerve blocks, mean most people now stand and walk within a day of a knee replacement. Improving that early pain control was the subject of a study I was part of during my fellowship in Mumbai, published in The Journal of Arthroplasty in 2024.

What to bring

The films or the CD, not only the reports. The written advice you were given, exactly as it was written. A list of the treatments you have already tried, and the medicines you take now. What happens at your first consultation goes through the rest of the visit.

If the journey is long, a video consultation works well for a first look at your imaging and history. Examining the joint still needs a visit, and I will tell you if your answer depends on one.

Further reading

• NICE guideline NG157, Joint replacement (primary): hip, knee and shoulder. The UK's national guidance, including the choice between partial and total knee replacement.
• NHS: Knee replacement. A plain account of the operation and the recovery.
• Maniar AR, et al., including Khanna I. Addition of surgeon-administered adductor canal infiltration to periarticular infiltration in total knee arthroplasty. The Journal of Arthroplasty, 2024.

Common questions