Up close and personal: Total knee replacement in the US vs. the UK

by | Oct 19, 2017

knee replacement components

This is what goes in the knee!

One month ago, I had the opportunity to return home to England for a week to help my mom as she recovered from knee replacement. Of course, I was concerned (as surely any son would be!) about her undergoing major surgery, but my concern was also based on seeing a variety of outcomes for people after knee replacement. I wanted to go and make sure everything went well; I joked with her that I was going to make sure she was behaving herself!

From hearing the experience of friends and family, you may have mixed opinions about total knee replacements (TKR/TKA). They are typically a good surgery, but I have seen some that recover in a very straightforward manner and others that really struggle. TKA should be undertaken when quality-of-life is being significantly affected by pain, difficulty in function, and has not improved with rehabilitation. This was certainly the case for my mum. When someone decides to have a TKA they are expecting a significant improvement in quality-of-life. Many find this, but imagine what it would be like to struggle to get the knee moving after surgery, or have ongoing pain. I have seen patients like this and it feels to them like they have swapped one problem for another. There are a myriad of reasons for this from medical complications, surgical errors, to poor rehab and patient compliance. My goal was to make sure Mum did not struggle and was able to reap the rewards I know are possible with TKA.

From the media, most of you will know something about the health system in the UK; It is a socialized system called the National Health Service (NHS). Getting a TKA in this system can take a long time (12 months +), which is not much fun when you are in pain. Fortunately, following retirement, my parents had maintained private health insurance for this very reason and were able to schedule surgery when they wanted. So, her experience in scheduling the surgery was the same as someone in the US. I’ve lived in the US for 10-years, but before that I lived and worked in the UK both in the NHS and private practice, so am familiar with the typical post-surgical treatment of a TKA in each country and setting. In the US, patients would typically experience daily physical therapy while in the hospital and then would start outpatient or home health therapy 2-3 x a week for anywhere from 4-8 weeks or more. This has become the norm and is relatively encouraged by the way insurance and reimbursement works. However, there is no evidence to show that this approach to rehab works any better than others. Obviously, it has been a while since I worked in the UK, but watching Mum’s rehab reminded me how different approaches can work and explains the beliefs I have on rehab and why I have structured my practice the way I have.

Traveling to London

The long process of international travel, but well worth it 🙂

After 20 hours of traveling, I arrived in London Heathrow, picked up the rental car (think stick shift and the other side of the road) and drove the 60 minutes to the hospital. I arrived at the hospital the day after her surgery (I spoke with her the day of the surgery via wifi while transatlantic! Pretty cool!). She was doing well, sitting up in the bedside chair, and the biggest problem she was having was some nausea. She had PT daily, working on a simple set of exercises and her mobility. She left the hospital three days after the surgery having proven that she could walk with a pair of crutches and go up and down the stairs. She was discharged with a set of instructions, including exercises, and she was then at home on her own with Dad and I for a period of a week and a half until she started her first therapy appointment. During that period we encouraged her to do her exercises and brought her ice when she wanted it. I did try to see if I could help her move her knee, but she couldn’t relax enough to make it worthwhile so I left the work to her! Essentially, we were glorified cheerleaders. I dovetailed with a visit from my sister (Also a PT!) who stayed with them for a few days, and a week and a half after discharge she went for her first outpatient PT appointment. The therapist was impressed with how she was doing.  They worked a little on improving her walking gait using one crutch and gave her a progression of her exercises. She continued to work at home and had a follow-up PT appointment two weeks later. When I spoke to her today, Oct 17th 2017, four weeks after the surgery, my sister had visited with her family (Easier for them to visit from Scotland!) and Mum had walked 1.5 miles with her one crutch! I am obviously a little biased, but I think that her progress has been exceptional!

Mum doing great following knee replacement

My Mum doing great after surgery. First trip out! Also, a rare chance for us all to be together as we live so far away!

Obviously, this is only one case, so it does not prove that one approach is superior to another. However, having worked in both countries, I do not feel like I have seen more superior results in the US. The difference in care in the UK, in this case, is not due to the socialized healthcare as some might claim; for example, all of Mum’s care was at a private hospital. (I do acknowledge there is room for improvement in both systems and you are always welcome to ask my opinion!) Instead, the philosophy is different. In the US, most people’s experience of going for PT following TKA involves 2-3 time a week of the therapist making them do the repetitious exercises, the therapist bending their knee, and some electric stimulation and some form of ice therapy. There is a lot of hand-holding and, to be honest, I see overtreatment which can have negative consequences. I see patients who have been pushed too hard by PTs who are worried about a stiff knee, but the aggressive therapy creates pain that itself leads to stiffness! In the UK, the more spaced out appointments ask the patients to be more responsible for their progress. Certainly, there is some risk with this approach when a patient does not report concerns/problems. Even though I am aware of this risk, I still favor an approach that is more similar to the UK approach with all of my patients, as I believe that my patients are smart, able, and don’t need their hand held all the way through rehab. Many of my patients are busy professionals and do not have the time for multiple visits per week! I make sure that there are adequate ways to communicate with me to reduce the risk of unintended consequences occurring between appointments. I believe that where the patient is more involved, they will see more lasting/resilient results. I will qualify this by saying that everyone is different and some people will want the hand-holding, and I am fine with that initially if it is truly needed. However, I feel it is incumbent upon me, and a professional/ethical responsibility, to promote self-efficacy and self-reliance.

When you have been practicing/working any job for a period of time (in my case 15 years now) you can’t always understand why you do everything the way you do. I have tried as a professional to stay up to date on the latest research and that is the biggest guide to my practice. But, my experiences have also guided me, and mine are quite different from most PTs having worked in two countries, various practice settings, and under two healthcare systems. If you think my approach might be a good fit to help you with any pain, injury, or rehab needs, please do send me a message. You can contact me via email or phone. I am always happy to chat!

Image Credits:

  • Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh RA, Arnold MP, Friederich NF. Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?. BMC Musculoskelet Disord. 2010;11:167.
  • Google Maps
The female athlete triad a diagnosis that we need to look for in our female athletes

The Female Athlete Triad

Table of Contents Female Specific Research - The Gap Is Narrowing Right to work, right to vote, and in many ...
Read More
No all stress fractures need an expensive boot

Boots For Stress Fractures and What Exercises Help The Most?

Table of Contents Have you noticed how many people are given a boot to treat stress fractures? If you’ve had ...
Read More

Blood Flow Restriction Training

Table of Contents Why should we lift? Living an active life requires certain levels of strength. For example, when we ...
Read More
Tendon Compression an important thing to consider for some tendons

Tendon Compression – Important to Consider For Some Tendons!

Not all tendons and tendon pain should be treated the same. For example, we tend to consider Achilles tendon pain ...
Read More

What Is The Right Running Shoe For Me?!

Modern advances (and claims) have not done much for injury risk! Runners assign a huge level of importance to footwear ...
Read More
Carpal tunnel and neck pain care in huntsville and madison alabama

When is Carpal Tunnel Not Carpal Tunnel

There is often the assumption that numbness in the hand is due to carpal tunnel syndrome. However, oftentimes these symptoms ...
Read More
Loading...

0 Comments

Submit a Comment

Your email address will not be published. Required fields are marked *

google logoPhysioWorks, Sports and Wellness, Inc.PhysioWorks, Sports and Wellness, Inc.
5 Stars - Based on 48 User Reviews

facebook logoPhysioWorks, Sports and Wellness, Inc.PhysioWorks, Sports and Wellness, Inc.
5 Stars - Based on 22 User Reviews

Never miss a blog!

I have been working with Andrew for a few months and have had a lot of relief from lower back pain due to a powerlifting injury. He is very professional and patient to explain everything I had questions about. I highly recommend PhysioWorks to anyone seeking a solution to their needs. With Andrew's help I have managed to avoid back surgery and gained confidence to get back in the weight room and lift properly and safely!

Melissa Astin Avatar Melissa Astin
4/29/2019

Andrew is on top of the latest research and therapy practices! As a fitness instructor, being in good physical health is a job requirement. After an injury, Andrew worked to get me back up to speed quick! He takes time to address the physical as well as the mental aspects of recovery. Instead of needing to go for visits 3x per week, I saw him 3x over the course of a couple months and actually saved money. I appreciate the athlete log-in for videos so you can do them at home. Lastly, Andrew is an honest and dedicated professional. Would... read more

Tonya Meier Hardy Avatar Tonya Meier Hardy
2/07/2019

After limping my way through a 100km trail race and finally giving in to my bilateral Achilles tendinopathy, I went to Andrew for help. His well researched approach to therapy helped me progress from barely walking to increasing my running mileage so that I could make it to the start line of my goal 100mi race a little over 3 months later. Andrew's passion for sports therapy is obvious. His methods are based on the latest research in Orthopedics. You won't find a better PT in the area.

Luke Hough Avatar Luke Hough
1/30/2019

- Want to be treated without surgery or medication? -

Claim your FREE consultation with the PT who has the most

⭐️⭐️⭐️⭐️⭐️ Google reviews in Huntsville Alabama!