Who Should Not Have Knee Replacement Surgery & Reasons to Avoid Knee Replacement

Total Knee Post Link Pic

In my forty years as an orthopedic physical therapist, I’ve guided countless patients through the decision-making process for total knee replacement surgery. While it’s a life-changing procedure for many, it’s essential to recognize that it isn’t suitable for everyone.

In this article, we’ll explore the specific circumstances and health considerations that may deter an individual from undergoing knee replacement surgery, underscoring the reasons why some patients should avoid this invasive procedure and consider alternative treatment strategies.

Understanding When Knee Replacement Is Not Advised

As a seasoned orthopedic physical therapist with an extensive career, I believe it’s vital to recognize when a patient’s pain and disability should not propel them towards knee joint replacement.

Though often viewed as a remedy for discomfort caused by arthritis, there are conditions in which a knee replacement may not be the most prudent course of action.

Patients with infections in the knee should not proceed with surgery, as implants can become a breeding ground for bacteria, leading to further complications.
Individuals with severe co-existing medical conditions, including uncontrolled diabetes, heart disease, or poor skin integrity around the intended surgical area also might not be suitable candidates.

Moreover, active smokers or those with a high BMI may face increased risks and thus it’s often advised they do not undergo the procedure until these issues are addressed.

The patient’s pain and disability, while significant factors for consideration, are not the sole indicators for the necessity of a knee joint replacement. It’s crucial to understand that a person’s age and activity level could also determine that they should not have this surgery, as younger patients especially may outlive the lifespan of the prosthetic, potentially facing additional surgeries later on.

In essence, while knee joint replacement can be life-changing for many, ensuring patient safety and long-term wellbeing dictates that it is not a one-size-fits-all solution.

Why Chronic Knee Pain May Not Warrant a Knee Replacement

I understand how severe knee pain can significantly impact daily life having seen multitudes of total knee replacement patients over decades. However, knee replacement surgery, while beneficial for many, is not the best course of action for everyone. If you are living with knee osteoarthritis, it’s vital to consider that this condition does not always necessitate a knee replacement.

In some cases, non-surgical interventions can manage symptoms effectively. Additionally, knee replacement might not be advised if the individual has certain comorbidities that may complicate surgery or impede recovery. Indeed, not every patient with knee issues is a candidate for this procedure.
Read my article: Knee Replacement Alternatives

Important considerations should be made regarding the severity and progression of knee osteoarthritis, and whether it has reached a stage where it disrupts function to the extent that surgery is the only solution. There’s a balance to find, not rushing into knee replacement can be as crucial as not delaying it excessively.

In some scenarios, the risks of surgery might outweigh the potential benefits, and knee replacement is not done. Factors like patient health, weight, activity level, and knee stability can influence this decision. Ultimately, knee replacement is not a one-size-fits-all solution, and for some patients, it might not be the appropriate path to pain relief and improved function.

Evaluating Knee Osteoarthritis Severity with Your Healthcare Provider

With more than 40 years of experience as an orthopedic physical therapist, I can’t stress enough the importance of thoroughly evaluating the severity of knee osteoarthritis with your healthcare provider before considering a total knee replacement. This decision is crucial, as it isn’t the right solution for everyone. Your healthcare provider will take a comprehensive look at your pain and disability associated with your knee condition.

Factors such as the patient’s age, activity level, and overall health can influence whether a knee replacement is advised.
Read my article: What Is The Best Age to Have Knee Replacement

In cases where severe knee pain isn’t significantly impacting the patient’s quality of life or the osteoarthritis hasn’t progressed excessively, non-surgical treatments may be recommended instead. The key is not to rush into surgery but to assess whether the knee joint’s condition truly warrants such an invasive procedure.

Remember, not every knee that aches necessitates a total knee replacement. Not all individuals with knee issues will benefit from surgery, and in some instances, knee replacement should not be on the agenda at all. Patients should carefully deliberate with their healthcare provider to determine if their knee pain and disability are best managed with surgery or with other, less invasive, interventions.

Assessing Risks: Knee Arthritis Treatment Options Beyond Surgery

I have often counseled patients over four decades as an orthopedic physical therapist. who may not have a clear path toward knee replacement due to various surgery risks. It’s crucial to understand that for those battling knee arthritis, there are viable treatment options that do not involve a scalpel.

Some individuals simply should not have knee replacement surgery because their health status or knee condition does not meet the criteria for a successful outcome. Knee pain, while debilitating, may not warrant a knee replacement if the risks outweigh the potential benefits. This might include patients with certain systemic diseases, an elevated risk of infection, or problematic wound healing.

Anyone with a history of heart issues or obesity might also experience an increased risk when undergoing surgery, and therefore, knee replacement may not be advised.

In my experience, obese patients who qualify for total knee replacement surgery, go through their rehabilitation and recovery just as quickly as their non-obese counterparts.

Not everyone with knee arthritis will require a knee replacement; sometimes, a more conservative approach is the key to managing symptoms. Alternatives such as physical therapy, bracing, weight management, and injections can be critical in reducing pain and improving function.

It’s important to have an in-depth conversation with your healthcare provider to evaluate the severity of your knee osteoarthritis and to chart the best course forward that’s tailored to your individual needs. Remember, it’s not just about treatment—it’s about the quality of your life post-intervention.

  1. Patients with an active or recent infection in or around the knee joint
  2. Patients with poorly controlled diabetes that puts them at higher risk of postoperative complications
  3. Patients with severe osteoporosis that may prevent successful implantation or may lead to fractures
  4. Patients with very poor skin condition around the surgery site that may not heal properly after the operation; a high potential for infections.
  5. Patients with a history of hypersensitivity reactions to materials in the prosthesis
  6. Patients with severe peripheral vascular disease which may impair healing and circulation to the operated limb
  7. Patients with advanced heart disease who may not tolerate the stress of surgery and anesthesia
  8. Patients with uncontrollable bleeding disorders that can lead to excessive bleeding during or after the surgery
  9. Patients with major neurological conditions that may not allow proper rehabilitation post-surgery
  10. Patients with severe psychiatric illness that may interfere with surgery outcomes and recovery
  11. Patients who are acutely ill or have a systemic infection which can increase the risk of perioperative complications
  12. Patients with an active malignancy, especially if metastasis exists in the bone to be operated on
  13. Patients who are morbidly obese, as the extra weight can affect the success of the prosthetic joint and surgery recovery
  14. Patients with severely limited life expectancy due to other medical conditions
  15. Patients with unreconstructed ligament deficiencies which may lead to instability of the knee replacement
  16. Patients with a history of substance abuse that may affect the postoperative outcome and adherence to rehabilitation

Consulting an Orthopedic Surgeon About Knee Replacement Candidacy

As an orthopedic physical therapist with extensive experience, in my opinion it is critical that patients understand when they should not consider knee replacement surgery.
Although life-altering for many, certain individuals may not be suitable candidates.

During consultations, an orthopedic surgeon will assess the extent to which a patient’s pain and disability impact their quality of life. It’s essential that those with chronic knee pain fully explore non-surgical interventions before considering the knife.

A knee that is stiff or has limited function but does not cause extreme discomfort might not necessitate surgery.

An orthopedic surgeon’s evaluations also play a pivotal role in determining whether a patient’s knee osteoarthritis is severe enough to justify a knee replacement.

The orthopedic surgeons that refer their post-surgical total knee recipients all discourage knee replacement until imaging demonstrates bone-on-bone in at least one compartment.

Many instances of knee pain can be managed effectively without surgery, and knee arthritis may sometimes be addressed with conservative treatments.

Although knee replacements can provide significant benefits, they’re not without risks, and not every knee will be apt for surgery; not all patients will respond equally to knee replacement. It’s imperative to consult with an orthopedic surgeon who thoroughly understands both the potential benefits and the reasons why some should not have knee replacement surgery, ensuring that the best course of action is pursued for each individual’s situation.

The Impact of Metal Ions on Knee Joint Health

When considering the knee’s elaborate structure and sensitivity, the introduction of metal ions post-surgery is a significant consideration. Metal ions can be released into the knee joint from the wear and tear of artificial knee components.

In 2010 I had a total hip replacement with the DePuy prosthesis.
He had significant pain that was not diagnosed until after the recall announcement.
I saw pictures of the open surgical site as it was being replaced.
It was a greenish-black coagulation of goup, for lack of a better term, with the consistency near axle grease. 

Although modern knee prostheses are designed to minimize this, it remains a concern for some patients. In particular, individuals with a known sensitivity to metals should exercise caution, as this could lead to an adverse reaction affecting the knee joint’s health and overall patient well-being. Knee replacement is not advised for those who have a demonstrated allergic response to metal, underscoring the importance of preoperative evaluations.

Chronic knee pain alone may not warrant a knee replacement if non-surgical knee arthritis treatment options can effectively manage symptoms. It’s essential to consult with an orthopedic surgeon about knee replacement candidacy and discuss potential risks, including how the knee might react to metal ions, before committing to surgery. Ultimately, not every knee will benefit from a knee replacement, and it’s pivotal to weigh the pros and cons thoroughly.

Recognizing the Signs That You May Not Need Knee Replacement

I have worked with countless patients grappling with the decision of whether to undergo a knee replacement. It’s important to understand that some individuals may not have clear indications for this procedure. If a patient’s pain and disability are not severely affecting their quality of life, they may not need a knee replacement.

Advances in non-operative treatments can often provide relief without the risks associated with surgery. When assessing a knee with osteoarthritis, the key is to evaluate the severity and the patient’s response to other modalities.

As an orthopedic physical therapist who has owned an outpatient orthopedic clinic for thirty years with 20 employees, I can tell you there are a multitude of effective modalities, not to mention manual procedures, that can make a significant difference in arthritic knee pain.

Sometimes, other areas of the body could be contributing to knee pain, and addressing these can markedly improve the patient’s pain and function.

As an orthopedic physical therapist with four decades of experience, I have seen my fair share of patients with knee pain that was being referred to the knee from the lower back.
Any good orthopedic physical therapist skilled in low back evaluations has seen the same

Not every aching knee signals a need for a replacement. In some cases, the presence of significant comorbidities might suggest that surgery is not the best option. Consulting an orthopedic surgeon is crucial in determining knee replacement candidacy, as they can guide you through understanding the potential impact of metal ions on knee joint health and other factors.

Remember, it’s about the quality of life, and if non-surgical strategies can ameliorate your symptoms, surgery might not be necessary.

Why Some Knee Conditions Don’t Require Surgical Intervention

I have seen many cases over four decades as an orthopedic physical therapist where surgical intervention does not necessarily equate to the best outcome. Situations where patients should not have a knee replacement often arise from various factors, encompassing the spectrum of knee conditions. In some instances, conservative management might suffice.

For example, pain that’s not debilitating and allows for a satisfactory quality of life doesn’t warrant the risks associated with surgery. Chronic knee pain is multifactorial and does not always improve postoperatively, especially if it’s related to soft tissue problems rather than joint degeneration.

Assessing the severity of knee osteoarthritis with your healthcare provider is crucial before jumping to conclusions. Not every knee with degenerative changes requires replacement. Some knees might benefit more from a combination of physical therapy, weight management, and pharmacological approaches.

Consulting an orthopedic surgeon or orthopedic physical therapist about your knee replacement candidacy involves discussing not only potential benefits but also the risks such as the release of metal ions from the prosthesis into the knee joint which can impact knee joint health.

Remember, the decision to not have knee replacement reflects a comprehensive evaluation of one’s individual situation, recognizing the signs that you may not need knee replacement is a positive step towards embracing the most appropriate approach for knee health and well-being.

When Knee Replacement Surgery Raises Concerns

Each patient considering whether to have surgery warrants a personalized assessment. There are several reasons why someone should not opt for knee replacement surgery. Understanding these surgery risks is crucial in making an informed decision.

For instance, certain systemic infections or severe skin diseases affecting the knee area can be a red flag for surgery, increasing the potential for complications.

Active infections elsewhere in the body can also pose a significant risk if they spread to the joint post-surgery.

Moreover, patients with poorly controlled chronic medical conditions, such as diabetes or heart disease, may find the stress of knee replacement surgery too great, impacting recovery outcomes.

Those with a history of allergic reactions to metal implants should be cautious, due to the impact of metal ions on knee joint health, which can lead to adverse reactions.

Additionally, if conservative treatments are effectively managing knee arthritis, surgery might not be necessary. It’s essential to consult with an orthopedic surgeon about knee replacement candidacy to determine if the benefits of surgery truly outweigh the risks. Often, a collaborative approach between patients and healthcare providers can help identify the most appropriate path that may not always lead to surgery.

Reasons to Avoid Knee Replacement: Device Failure and Allergies

I have seen many advancements in knee replacement surgery over my four decades as an orthopedic physical therapist. It is crucial to recognize that total knee replacement not suitable for everyone.

There are compelling reasons to avoid knee replacement surgery, with device failure and allergies being significant concerns. Knee replacements have improved over the years, but the possibility of device failure persists. This can be due to a range of factors including wear and tear over time or mechanical issues.

Patients with higher activity levels or those who are overweight might be at increased risk for prothesis failure. Moreover, allergies to materials used in knee implants, such as metal ions, can lead to adverse reactions. These allergies are often overlooked but can cause chronic pain and inflammation, leading to the potential failure of the prosthetic knee.

Select individuals may experience sensitivity to metal ions released into the knee joint, which can manifest with symptoms that compromise joint health and necessitate further intervention. Therefore, if you’ve known allergies or sensitivities, particularly to metals, knee replacement surgery might not be the best choice. Considering these factors, it’s essential to have a comprehensive discussion with your healthcare provider before deciding on knee replacement surgery.

Potential Complications: Non-Surgical Knee Pain Management

When considering whether to proceed with a knee replacement, understanding potential complications is crucial for patients.
It’s not uncommon for individuals to explore non-surgical options as a holistic approach to knee pain management, particularly if the patient’s pain and disability can be managed through less invasive methods.

In my experience as an orthopedic physical therapist, seeing patients in their homes for the first three weeks after surgery for more than a decade, all my patients had failed extensive physical therapy before the surgeon would consider surgery.

Such decisions to not have surgery are often influenced by the individual’s overall health, activity level, and the severity of knee pain. Knee osteoarthritis, a common reason for knee pain, does not always necessitate surgery.

Non-surgical knee pain management strategies, such as physical therapy, weight management, and medication, can substantially improve a patient’s quality of life without the inherent risks that come with surgery. For those who are hesitant about replacing a knee and the complications that may ensue, delving into non-surgical alternatives is not only worthwhile but often encouraged.

However, it’s essential to recognize that non-surgical options may not provide the same level of relief as a knee replacement in severe cases. Thus, thorough evaluation with your healthcare provider is indispensable to assess the balance between the potential complications of surgery and the benefits of non-invasive knee pain management.

Is Knee Replacement Surgery the Right Choice for You?

Determining if knee replacement surgery is the right choice requires a multifaceted assessment. This procedure is a significant intervention, and while it can offer substantial relief and restore functionality in patients with severe knee osteoarthritis, it’s not suitable for everyone.

When chronic knee pain emerges, it does not automatically warrant a knee replacement surgery, as other less invasive treatments may alleviate discomfort effectively. Thoroughly evaluating knee osteoarthritis severity with your healthcare provider becomes crucial, as not all joint damage necessitates surgical solutions.

Those considering knee replacement surgery should assess risks carefully. There are a variety of knee arthritis treatment options beyond surgery that may be worthwhile to explore, including medications, injections, and physical therapy.

Consulting an orthopedic surgeon about knee replacement candidacy is a critical step for those who may not have responded well to non-surgical methods. It’s important to recognize that certain conditions leading to knee pain do not require such invasive intervention, and the value of risk assessment cannot be overstated.

Reasons to avoid knee replacement can range from individual concerns, such as allergies to the metals used in the devices, to the potential for device failure. Furthermore, the impact of metal ions on knee joint health is an aspect sometimes overlooked but necessary to consider for patients sensitive to these materials.

Potential complications should always be weighed against the anticipated benefits when making the decision for knee replacement surgery.

Exploring Alternatives to Knee Replacement for Long-Term Knee Health

When considering your long-term knee health, it’s essential to understand that knee replacement surgery isn’t always the definitive answer. For individuals faced with chronic knee pain or diagnosed with conditions such as knee osteoarthritis, alternatives to knee replacement should be thoroughly evaluated.
Read my article: Knee Replacement Surgery Alternatives

These alternatives can range from lifestyle modifications, including weight management and low-impact exercises, to medical interventions like physical therapy, anti-inflammatory medications, and hyaluronic acid injections. In cases where knee replacement surgery may raise concerns, due to potential device failure or an individual’s sensitivity to metal ions, seeking these non-surgical approaches can provide relief and improve function while minimizing risks.

Conservative treatments may be advisable, especially when knee conditions don’t require surgical intervention. Consulting with an orthopedic surgeon about your knee replacement candidacy is also an opportunity to discuss the impact of knee replacement and why some individuals may be advised to avoid it, such as those at heightened risk for complications or those who may experience issues related to allergies to certain materials in the prosthetic.

It is vital to explore all avenues of treatment to safeguard your knee health and consider knee replacement surgery only after all other options have been exhausted or shown to be ineffective. By being well-informed and working closely with your healthcare provider, you can make the best decision for your circumstances.

Read my other articles about Total Knee Replacement

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Q: Who should consider avoiding total knee replacement surgery?
A: Total knee replacement surgery may not be suitable for everyone. Patients with infections in the knee, severe co-existing medical conditions like uncontrolled diabetes and heart disease, poor skin integrity around the surgical area, high BMI, and active smokers should consider avoiding the procedure. Young individuals might also consider alternatives as they may outlive the prosthetic and face additional surgeries later on.

Q: Can knee osteoarthritis be managed without surgery?
A: Yes, knee osteoarthritis does not always necessitate knee replacement surgery. In some cases, symptoms can be effectively managed through non-surgical interventions such as physical therapy, bracing, weight management, and injections.

Q: What factors influence the decision to undergo knee replacement surgery?
A: Several factors influence the decision, including the severity and progression of knee osteoarthritis, the impact on the patient’s quality of life, patient’s health, weight, activity level, stability of the knee, and the patient’s overall response to non-surgical treatments.

Q: What are the risks associated with knee replacement surgery?
A: Risks can include infection, increased potential for complications in patients with certain systemic diseases, problematic wound healing, allergic reactions to metal implants, device failure, release of metal ions into the knee joint, and the need for future surgeries due to prosthetic wear.

Q: What should patients with knee pain and disability consider before opting for knee replacement?
A: Patients should have in-depth conversations with their healthcare providers to comprehensively evaluate their condition, as knee pain and disability alone may not warrant a knee replacement. They should assess the severity of their condition, explore non-surgical treatment options, consider their overall health and any potential allergies to implant materials, and weigh the potential benefits against the risks of surgery.


Dr. Donaldson is dually licensed; physical therapy in 1975 and doctor of chiropractic in 1995. He held credentials of Orthopedic Clinical Specialist in physical therapy for 20 years, QME in California, and taught at USC. He owns and operates an orthopedic physical therapy practice. See "About Me" page.

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