When to Choose Total Knee Arthroplasty

Many patients with knee osteoarthritis are told that they should live with the pain until it becomes unbearable, and then have total knee arthroplasty (TKA). At Shelbourne Knee Center, these are not the only choices.

“If somebody has a painful, arthritic knee, there are a lot of treatments we can try to make them better without surgery,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. During the initial visit, Dr. Benner and the patient discuss what the patient has already tried and what has and has not been effective. “Then I lay out the possibilities and choose the best treatment(s) based on a shared decision-making model with the patient,” says Dr. Benner.

Non-Surgical Treatments First

Non-surgical treatments—the first-line treatment—focus on decreasing pain and swelling and improving range of motion (ROM) and strength. Patients participate in the Knee Rehabilitation Program for OA, which starts with exercises to restore knee extension and then knee flexion equal to the normal knee. Strengthening to achieve good leg control and improve everyday function follow the ROM therapy.

Cortisone injections and medications, primarily NSAIDs, control symptoms and decrease swelling and pain. They also enable patients to complete physical therapy. “If the patient has done all of that and is still in pain, then it’s time to consider knee replacement,” says Dr. Benner.

Physical Therapy Works  

Shelbourne Knee Center data show that physical therapy significantly relieves pain and improves function in patients with knee OA. Results for 396 patients who participated in the OA Rehab Study show that1:

  • Most patients improved with non-operative treatment
  • Only 24% went on to have a TKA
  • ROM and patient-reported pain, symptoms, activities of daily living, ability to participate in sport and quality of life improved.

Optimized TKA Outcomes

If the patient decides that surgery is the right treatment, improvements in ROM made through the Knee Rehabilitation Program for OA facilitate a better surgical outcome and a faster, easier recovery. Dr. Benner’s use of an evidence-based implant system and strategies to minimize pain also optimize outcomes.

“The implant system I use has a wide variety of sizing options to most closely approximate the patient’s knee anatomy, is designed to minimize complications and allows our patients to rehab their knees aggressively after surgery,” says Dr. Benner.

Minimizing pain helps patients tolerate physical therapy. Limited or no use of narcotics is a key part of the TKA pain-management protocol. In the hospital, TKA patients receive a low-dose continuous infusion of Toradol (ketorolac) to control inflammatory pain. A study by Dr. Benner and colleagues of 191 patients who received ketorolac (n = 116) or opioids (n = 75) found that post-op ketorolac improved pain control while reducing the use of opioids and adverse effects.2

Patients also take Tylenol, and after completing Toradol they take the NSAID Mobic (meloxicam). As needed, they also can take Tramadol or Norco (a combination of acetaminophen and hydrocodone, an opioid).

The TKA pain management protocol also includes: 

  • Prevention of post-op swelling
  • Rest during the first seven days post-op 
  • Use of a continuous passive motion machine and a Cryo/Cuff to reduce swelling and pain. 

Post-op rehab focuses on restoring ROM, followed by strengthening.

“Ultimately, the decision about the right time for surgery is made by the patient, not me,” says Dr. Benner. “I empower them to make their own decision.”

For more information about TKA and other treatments for knee OA at Shelbourne Knee Center, call 888-FIX-KNEE or email skckneecare@ecommunity.com.


  1. Shelbourne DK. Nonoperative Treatment of Knee Osteoarthritis, presentation at the Herodicus Society Meeting, June 2018.
  2. Schwinghammer AJ, Isaacs AN, Benner RW, et al.  Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother. 2017 Jun;51(6):451-456. doi: 10.1177/1060028017694655. Epub 2017 Feb 1.