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The number of knee replacements is soaring – just don't expect to run marathons after

The Age

3 hours ago

The Age

The number of knee replacements is soaring – just don't expect to run marathons after

Zara* pulls a bandage down and raps the outside of her right knee repeatedly to show me the way the pain jabs, like a sewing machine needle, insistent, continuous. She stands and hobbles across my living room, still rapping the knee, wincing. Pain, she says, has ruled her life ever since her right knee was first replaced eight years ago. 'When I walk, it's sore, it's like needles,' says Zara. 'I can't go on stairs, I can't sleep properly, during the night I wake up with pain. Some days I'm better, some days not.' Sitting again, the 66-year-old house cleaner pulls a folder out of her bag. From a pile of documents, she wrenches out several photographs. She shows me one taken the day after the operation in 2017 at a Sydney public hospital. My stomach flips. It shows a bloodied surgical wound running from the top of the inflamed purple knee towards her shin. The morning after the surgery, a young doctor visited Zara's bedside, opened the dressing and took the photograph. 'I ask him what's happened to me, why I'm in so much pain?' She knew the knee wasn't right: five years earlier, her left knee had been replaced and it had felt nothing like this. English is Zara's second language, but she persisted with her questions. 'He didn't talk to me. Maybe he doesn't have answers, I don't know.' Over the next few days her pain intensified as an infection set in. Antibiotics were administered intravenously. Zara begged for more pain medication but was told she was already on the maximum dose. Discharged after five days, her knee still hot and raging, there was no respite at home. 'I was in so much pain, crying, and my husband says, 'I take you back to the hospital.' I said, 'Last place I want to go.' ' The day after her discharge, he took her to a medical centre. 'The GP looked at my knee and said, 'What did they do to you?!' ' In early 2024, Zara returned to hospital for the ordeal of revision surgery on her right knee – another operation to remove the original prosthesis and replace it. A revision is one of the most serious outcomes of less-than-successful knee surgery and accounts for almost 7 per cent of all knee replacements. Zara's story highlights the tough choices – and serious stakes – facing hundreds of thousands of Australians with wonky knees. An estimated 1.2 million Australians live with knee osteoarthritis, the biggest reason for knee replacement surgery. The number will only continue to grow as the population ages and our waistlines expand. In 2023, Australian surgeons performed about 78,000 knee replacements, about 20 per cent more than the previous year and more than the combined number of hip and shoulder replacements. Some forecasts have predicted that the number of knee replacements in Australia will more than double by 2030, reaching about 160,000 surgeries annually. Mostly, the operations are a success: in about 82 per cent of cases, people report they are 'much better' after knee arthroplasty, the repair of a knee joint where the cartilage has degraded. My 88-year-old mother is one of them. Over six months in 2021, both of Mum's knees were replaced. Four years later, she continues to live independently, trotting up and down multiple steps in her house on Queensland's Sunshine Coast many times a day, cooking, cleaning, washing, gardening, driving, shopping and catching up with friends. She complains about supermarket prices and gout in her feet, but her knees are in tremendous shape. Yet in the case of a significant number of replacements – about six per cent – people report their knee is about the same as it was before the operation or a little worse. In 1.5 per cent of cases, people say they are much worse than before. As Zara has discovered, when there are problems, they can be big problems. Opting for arthroplasty is not a decision to take lightly. I ask my mother's surgeon, Dr Frank Connon, what can go wrong. 'Have you got three hours?' he replies. 'There's a massive litany of things that can go wrong.' In many cases, surgeons tell patients that slicing their knee open is not in their best interests and recommend they instead deploy non-surgical management options, such as weight loss, for as long as possible. Connon has taken appointments in his Noosa Hospital rooms with patients who say they want the surgery because they're having difficulty kneeling to garden or struggling in their yoga class. 'I tell them there's a solid chance we won't get them back to kneeling in the garden or doing yoga either,' he says. 'I sometimes say that, as surgeons, we're best at taking people who are completely crippled and making them less crippled. We're not good at making patients 20 years old again. We're not doing this operation to return a patient to marathon running. We're doing it so they can walk to the shops.' Knee nicknames One woman I know has names for her new knees. 'My girls are Willa and Meana,' says Liz. 'I'm 61, and they're now about 20 years old and going well – we live in lucky times!' But it was the hardest surgery of her life. 'Having two replacements at once is not for the faint-hearted.' Another woman tells me that her new knees are 'Eileen' and 'Ruby': 'They're several years old and while the surgery was the most painful thing I've ever done, it's the best thing too! I'm a gym junkie and walk my dog every day and go off like a rocket at airports!' My mother, Robin, hasn't named her new knees – possibly because they give her so little trouble that she doesn't even remember she has knees. But, for several years, they were all she could think about. She avoided walking even short distances and took to going down the 13 steps between her lounge room and bedroom determinedly backwards, clutching the bannister all the way. She acquired an odd gait, a drunken-sailor-ish sway which she found lessened the pain of each footfall. Visiting a shopping centre before her first operation, it took us half an hour to walk 50 metres, Mum's attention fixed on the next bench or cafe chair on which she could collapse. 'I'd always been reasonably active and healthy, and I was horrified I was in such a position,' she tells me now. I didn't realise how gravely her pain and immobility were affecting her mood. 'I'd reached the stage where I couldn't see much point in anything, that life wasn't worth living. Your father having gone only made it worse.' Loading But she desperately didn't want operations on her knees. 'I heard a long time ago that anaesthetic is bad for old people's brains, and I was anxious to avoid having it.' I dispute her recollection that I pushed her to have the operations; my mother never does anything she doesn't want to. As we talk via Zoom, Frank Connon calls up Mum's records to remind himself of her knees. He has a lot of knees to remember – he replaces 400 of them a year. 'Right,' he says, reading out the diagnosis. 'Right knee, severe medial joint space narrowing, moderate patellofemoral joint space narrowing and basically the same thing on the left knee,' he says. 'In your mother's case, the X-rays were unequivocal – her problem was clearly severe osteoarthritis affecting both knees.' Mum needed two total knee replacements, where the femur and tibia joint surfaces on both inner (medial) and outer (lateral) sides are replaced. (In Australia, total replacements make up 85 per cent of knee surgeries; partial replacements, in which only one side of the knee is treated, make up about seven per cent.) For Mum, non-surgical options were not viable. Her independence was at stake. 'It was starting to look like knee replacement or residential care,' Connon says. Excess weight contributes to more than a third of knee osteoarthritis cases. To visualise what actually goes on under the skin of a human knee, I turn to YouTube. 'A well-functioning knee joint is critical to mobility,' intones the voice-over. The 3D medical animation shows the knee joint to be a fiendishly intricate structure where the thigh (femur) and the shin (tibia) meet. The ends of these bones are each covered with a layer of rubbery connective tissue called cartilage which can be up to three millimetres thick. This cartilage allows the bones to glide effortlessly over each other and form a hinge when the knee moves, enabling us to stroll through a park, climb stairs or torture ourselves with squats at the gym. Knee osteoarthritis occurs when the cartilage and other tissue gradually erode. 'As your car tyres wear down their tread over the years, some people's knees seem to be fitted with tyres that last for 40,000 kilometres and some people seem to be fitted with tyres that last for 70,000 kilometres,' says Connon, 'and they can be affected by how you use them. So if you go rally-car driving, you're going to wear out the tyre tread faster than if you drive sensibly to the shops once a week.' The doctor says many patients attribute their osteoarthritis to their days playing sport but the reality is that excess weight contributes to more than a third of knee osteoarthritis cases. 'They're either carrying a few extra kilos, they've got bad genetics, or they've just been around for a long time, because the fact is, if you live long enough, you almost certainly will get osteoarthritis.' Connon tells me that my mother's knees showed the most common pattern of osteoarthritis: the cartilage in the medial 'compartment' of each knee was the most severely worn, but her overall knee alignment was relatively normal. It was 'bread and butter', he says of the surgery. I ask if he lost sleep the night before. He laughs. 'I did not! This was one where we could use the most standard techniques.' A matter of millimetres In early 2021, I drove Mum to Noosa Hospital for her first operation – on her left knee. She was stoic, resigned. In her room in the low-slung facility nestled in scrubby bush we unpacked her bag and I set up the Wi-Fi on her iPad; in the days ahead, Words with Friends would be one of her few distractions. Outside her window, a kookaburra landed on a branch and cackled. I told Mum that it was Dad, that he had flown in to wish her good luck. She managed a weak smile. We have history with this hospital: a decade earlier, with a similar view, Dad died here after a long engagement with prostate cancer. More than four years later, Connon describes to me how the day unfolded after I kissed Mum goodbye, and she was wheeled off. Once in the operating room, an anaesthetist would have given her a spinal anaesthetic plus a small dose of general anaesthetic, as is the case for most people undergoing arthroplasty in Australia. 'Particularly in a patient of your mum's age, we're trying to keep the dose of general anaesthetic as low as we can,' Connon says. 'We're trying to ensure they're not freaked out that we're cutting their knee open and putting a new one in, but the spinal is what's keeping their legs numb and doing most of the work.' He confirms Mum's fears were valid: older patients given only general anaesthetic face increased risk of post-operative delirium and reduced cognitive capacity. Laid out on the instrument table next to my mother's inert body: surgical tools including forceps, scalpels, saws and drills; the metal alloy knee implant or prosthesis with an articulating surface to replace the role of damaged bone and cartilage – generally, says Connon, an 'off-the-shelf' product chosen from a range of sizes; and Swiss custom-made cutting 'jigs', crafted to fit Mum's knee based on a CT scan. One of the orthopaedic surgeon's critical tasks is to pinpoint within a millimetre where on the femur and tibia to make bone cuts – the slots into which the prosthetic components fit. Once, surgeons relied solely on manual techniques involving metal alignment guides and the hand-measuring and marking of bone surfaces to do this, but technology has expanded their options: most now use either robotic assistance, computer navigation, or 'patient-specific instrumentation' (PSI) – the cutting 'jigs' (also called 'image-derived instrumentation' and 'custom-made cutting guides'). Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) shows that the use of robotic assistance has steadily increased since its introduction around 2016. In NSW, Victoria and Queensland more than a third of knee replacements now use the technology. During surgery, its contribution includes real-time mapping to guide surgeons in making bone cuts and correctly positioning implants. The surgeon remains fully in control. Connon uses robotics in some operations: 'The additional information it gives me in a difficult case helps get the knee replacement just right when the bone or soft-tissue anatomy isn't standard,' he says. For Mum's surgery however, he chose instead to use PSI. 'There are incremental risks with robotics. They've dropped in the years since your mum's operation, but having a robot adds a bit of time to the operation; in an 83-year-old lady that adds a small but non-zero risk of infection or periprosthetic fracture – a broken bone at the implant site.' When it was clear that my mother wouldn't feel a thing – during the operation at least – Connon picked up his scalpel and made a vertical incision down the front of her knee. 'We then have to tackle the quadriceps tendon,' he says. 'We either move it aside or, more commonly, as in your mum's case, cut right through the middle of it. Before him then lay Mum's exposed knee joint. The next step for the surgeon: to cut away the damaged, arthritic surfaces of the lower end of Mum's femur and the upper end of her tibia. 'Most people have this idea that we're chopping out huge chunks of knee but in most cases, we're only taking somewhere from six to 10 millimetres of bone and cartilage from either side of the joint.' As he talks me through the operation, I examine the souvenired PSI components on my desk – moulded white plastic replicas of the bottom of Mum's femur and top of her tibia and the corresponding jigs that resemble futuristic puzzle pieces. Their role in the operation is about to become clear: 'These fit like a glove on a knee during surgery and tell me where to make the cuts so I put the implant in the correct position,' Connon says. 'They ensure we use the correct-sized implant but, more critically, that we put it in the correct spot with minimum fuss.' From this point it is a swift process – typically, knee replacements take about an hour. Once positioned, the implant is secured using bone cement, polymethyl methacrylate. 'It's actually the same stuff used to secure fake nails,' Connon says. 'And then we sewed her up.' The morning after Mum's operation, I arrived early at the hospital. Pain-killing medication was topping up her stoicism and she was sufficiently robust to launch into a tirade about the hospital breakfast. A few minutes later, Connon bounced into her room with a coffee for her from the hospital cafe. 'They don't make many like her any more,' he tells me. 'She's a determined lady!' Never-ending pain Zara drops by my apartment for our first interview after a day spent cleaning other people's homes. I offer her tea or coffee but all she wants is a glass of water. She sits at my dining room table, sips on the water and seems close to tears. Her left knee replacement from 2012 is a testament to how successful the surgery can be. But her right knee, replaced in 2017, tells a different story. Zara doesn't want to be identified by her real name so I can't contact the specialist who gave her a new right knee to ask questions. But no matter what happened, the eight years since have been hell. Gingerly, she lifts her right knee to show me how limited the movement in it is. It's larger and angrier than her left. 'There's still infection there,' she says. 'Everything is never-ending.' For years, Zara's diary has been filled with medical appointments to see doctors, for steroid injections, physiotherapy, X-rays, CT scans and, through it all, still pain. In late 2023, a new specialist sent her for more scans. 'He called me and said, 'This is not good, the prosthesis has to be taken out, it's coming out of place, it's dislocated, and the bone is damaged.' I started crying; I didn't expect that. I couldn't talk.' Zara's story highlights the fact that a knee replacement is not insignificant surgery. In many cases where patients are unhappy after their operation, the issue lies in the mismatch between their hopes for the surgery and the level of function they ultimately regain – what Frank Connon calls 'the expectation gap'. But rare and more serious complications can also arise, including 'foot drop', where nerve damage impedes a person's ability to lift the front of their foot, and arterial injury, involving damage to a nearby artery that can lead to bleeding, thrombosis or even amputation. Infection is rare, but it's the complication surgeons fear most. 'Once you get a deep infection, it can be difficult to clear; for some patients it can't be,' says Connon. 'You have to justify to yourself and the patient anything that lengthens the operation unnecessarily because that's going to increase your infection risk.' The AOANJRR identifies two critical predictors of whether a knee will require revision surgery. Age is the first. Knee replacements don't last forever and patients who undergo arthroplasty at 55 or younger have a 15 per cent chance of needing a revision at 20 years. The second is infection, a risk that's greater in patients with elevated BMI scores (body mass index) and/or other health conditions. Zara was not overweight. She says her health was good. 'I was young,' she says. Now she has high blood pressure, reflux she attributes to all the tablets she takes, and fatty liver disease. 'Maybe it's because I have depression and when I'm in pain I eat things that are bad for me.' According to the AOANJRR, a large number of variables determine a knee replacement's success, including the patient's health when they have the operation – conditions such as diabetes or high blood pressure can increase the risk of complications – the specific nature of the knee problem, the way the operation is performed, and the type of artificial joint replacement used. Additionally, the success of knee operations varies depending on the surgeon performing the operation and where a person lives. Rural hospitals (which tend to treat more people from disadvantaged backgrounds, who are statistically more likely to be heavier and have co-morbidities) generally use less advanced technology. Loading That said, technology is not a silver bullet for knee replacement. 'There is little evidence in scientific literature – as opposed to promotional marketing material – to suggest that robotics makes a difference for the average patient's outcome,' says Connon, acknowledging it's a controversial subject among surgeons. He says that incremental improvements in a number of other areas including surgery duration, swelling reduction techniques and newer styles of implant have each contributed to improved knee replacement outcomes as much as robotics or any other contemporary instrumentation used to precisely position implants. Nor does having a knee-replacement operation in the private system, as my mother was fortunate enough to be able to have, necessarily guarantee a better outcome (in 2023, more than three-quarters of knee replacement procedures were in private hospitals). 'The starting point for the average public patient that hits the operating table is usually demonstrably worse than a private patient,' says Connon, who works one day a week in a public hospital teaching young doctors how to replace knee joints. 'They have other health problems that will contribute to the outcome, including diabetes, obesity, heart problems and they're more likely to smoke.' Other factors come into play too, including the fact that, in the public system, surgical teams typically work across a wide range of operations. 'The theatre teams in private hospitals are set up to run like a production line, so nursing staff are more experienced at a more limited number of operations and churning through them.' Nevertheless, he says, the net improvement in function and quality of life after surgery for public patients is similar to that experienced by those in the private system. Just before I send this article to my editor, I check in with Zara to see how she's doing. She is, she says, a little better than the day we met. But she's worse than before she had the revision on her right knee in 2024. 'I avoid walking. My knee is sore, I still get needles.' During the post-operative appointment with the specialist who performed the revision, she complained about her pain. He told her that her patella (kneecap) was moving. 'I asked him, 'Why is it moving, you just finished the operation?' And he says, 'The operation doesn't fix everything.' ' Zara was firm. 'No more operations,' she told him. Dictating case notes into a recorder, the specialist said: 'No more appointments.' Someone Zara knows told her she should sue the hospital and doctors for the problems she's had. 'No,' she told them, 'I don't want money.' Now, talking to me on the phone, she says, 'I just want to be better, that's all.' And maybe, she thinks, her story can help other people. Too soon for surgery In late 2019, my friend Narelle started to feel twinges in her left knee. 'I battled with it for a while,' she says. 'I was taking Panadol and rubbing Voltaren gel on it constantly – god, I went through so many tubes of that stuff.' Narelle, a semi-retired lawyer who was then 62, tried over-the-counter anti-inflammatories too, but they upset her stomach. She spent a fortune with a physio but it was 'useless', she says: 'At that time – mid-COVID, in a lot of pain and not knowing how to deal with pain, only doing Zoom sessions – it just didn't help.' Her pain worsened, the knee swelled and even walking the few steps to her letterbox was agony. Her GP referred her to an orthopaedic surgeon. In mid-2020, Narelle saw the specialist at his inner-Sydney rooms. After reviewing her X-rays and MRI scans he told her she had a medial meniscus tear and osteoarthritis. But, he said, it was too soon for surgery. Instead, he recommended she strengthen the muscles supporting her knees and lose some weight. 'I remember feeling abandoned,' she says. 'I thought, 'This is the beginning of the end, how am I going to live the rest of my life, how can I be a person who lives in the world?' And it was all happening in the middle of COVID isolation. I was quite frightened.' Australian surgeons are robustly interventionist in their approach to knees, with replacement rates 73 per cent higher than the OECD average. Research published in 2019 in the journal BMC Musculoskeletal Disorders projects that, by 2030, the cost to the healthcare system of total knee replacements could climb to $3.4 billion, posing significant budgetary and workforce challenges. The latest Osteoarthritis of the Knee Clinical Care Standard, released last August with aims including improving patient care, reducing unnecessary surgeries and promoting non-surgical management, will go some way to address the unsustainable burden of our bad knees. Knee surgery should never be seen as a quick fix for osteoarthritis, said orthopaedic surgeon Adjunct Professor Christopher Vertullo when the standard was released. 'In my own practice, about a third of referred patients don't need to see me, and about 60 per cent … have had an inappropriate investigation or scan, without any initial management for osteoarthritis,' noted Vertullo, the deputy clinical director of the Australian Orthopaedic Association National Joint Replacement Registry and one of the experts involved in reviewing the standard. 'Surgery is fantastic for end-stage osteoarthritis of the knee … but for an occasional ache, you are likely to be dissatisfied with the outcome.' Narelle might argue with the description of her pain as an 'occasional ache'; it was, she says, 'like a knife in the joint, really sharp, really overwhelming'. But, in any case, the surgeon she saw left her with no choice but to explore other ways of tackling the problem. Her health fund program gave her a set of scales, a FitBit smart watch, consultations with a dietitian and a physiotherapist, and delivered her protein shakes to replace two of her meals each day. She lost 17 kilograms. 'But it was starvation, it was ridiculous, and when I stopped I put all the weight back on.' 'He said, 'OK, I'm going to teach you a way to stand up that won't hurt.' … It didn't hurt!' Narelle Narelle sat down at her computer and started to search. She stumbled on Form Physiotherapy, an Adelaide practice specialising in 'pain-science-informed physiotherapy'. She recalls her first online appointment with team member Jack Murphy. 'I'm saying, 'It hurts, it hurts, it hurts, please give me some exercises that will make it better.' And he's saying, 'Well, I might give you exercises, but mainly I want to talk about how you experience pain and the way your brain gives you messages about pain.' ' Over the next year, Narelle had regular online sessions with Murphy. 'Jack didn't spend much time talking to me about losing weight. He said, 'Yeah, there's all that stuff about load but really it's about what your brain is doing in relation to pain.' Apparently, when you have chronic pain your brain becomes slightly hysterical about it and goes into over-protective mode.' As Narelle came to understand more about her brain's role in her pain, Murphy started to work with her to adapt some of her basic movements. He asked her if it was painful to stand up from sitting. 'I told him, 'Yeah, it really hurts.' He said, 'OK, I'm going to teach you a way to stand up that won't hurt.' He told me to try leaning forward, not using my hands and using momentum to push off my feet. It didn't hurt! He said, 'Right, pretty soon you'll be able to walk without it hurting.' ' Loading When Murphy asked what her goal was, she told him she wanted to be able to walk around Uluru. 'And I could now, I'd have to pace it a bit but I could.' Recently, Narelle started lifting weights under a physiotherapy-led program called Onero, which is designed to improve bone density and reduce fracture risk in individuals with osteoporosis. 'It has made a world of difference to how I feel – much stronger, much less pain – and I've gone down a dress size.' At my desk, thinking about the success of Narelle's alternative solution to her knee pain, I fiddle with the white moulded jigs for Mum's knees, trying to fit the pieces together like a puzzle. I think about the extraordinary science that has made knee replacement surgery so commonplace and, generally, so successful. Then I look at my watch – it's time to go to the gym. I don't ever want my knees to be cut open.

Sydney Morning Herald

3 hours ago

Sydney Morning Herald

The number of knee replacements is soaring – just don't expect to run marathons after

Zara* pulls a bandage down and raps the outside of her right knee repeatedly to show me the way the pain jabs, like a sewing machine needle, insistent, continuous. She stands and hobbles across my living room, still rapping the knee, wincing. Pain, she says, has ruled her life ever since her right knee was first replaced eight years ago. 'When I walk, it's sore, it's like needles,' says Zara. 'I can't go on stairs, I can't sleep properly, during the night I wake up with pain. Some days I'm better, some days not.' Sitting again, the 66-year-old house cleaner pulls a folder out of her bag. From a pile of documents, she wrenches out several photographs. She shows me one taken the day after the operation in 2017 at a Sydney public hospital. My stomach flips. It shows a bloodied surgical wound running from the top of the inflamed purple knee towards her shin. The morning after the surgery, a young doctor visited Zara's bedside, opened the dressing and took the photograph. 'I ask him what's happened to me, why I'm in so much pain?' She knew the knee wasn't right: five years earlier, her left knee had been replaced and it had felt nothing like this. English is Zara's second language, but she persisted with her questions. 'He didn't talk to me. Maybe he doesn't have answers, I don't know.' Over the next few days her pain intensified as an infection set in. Antibiotics were administered intravenously. Zara begged for more pain medication but was told she was already on the maximum dose. Discharged after five days, her knee still hot and raging, there was no respite at home. 'I was in so much pain, crying, and my husband says, 'I take you back to the hospital.' I said, 'Last place I want to go.' ' The day after her discharge, he took her to a medical centre. 'The GP looked at my knee and said, 'What did they do to you?!' ' In early 2024, Zara returned to hospital for the ordeal of revision surgery on her right knee – another operation to remove the original prosthesis and replace it. A revision is one of the most serious outcomes of less-than-successful knee surgery and accounts for almost 7 per cent of all knee replacements. Zara's story highlights the tough choices – and serious stakes – facing hundreds of thousands of Australians with wonky knees. An estimated 1.2 million Australians live with knee osteoarthritis, the biggest reason for knee replacement surgery. The number will only continue to grow as the population ages and our waistlines expand. In 2023, Australian surgeons performed about 78,000 knee replacements, about 20 per cent more than the previous year and more than the combined number of hip and shoulder replacements. Some forecasts have predicted that the number of knee replacements in Australia will more than double by 2030, reaching about 160,000 surgeries annually. Mostly, the operations are a success: in about 82 per cent of cases, people report they are 'much better' after knee arthroplasty, the repair of a knee joint where the cartilage has degraded. My 88-year-old mother is one of them. Over six months in 2021, both of Mum's knees were replaced. Four years later, she continues to live independently, trotting up and down multiple steps in her house on Queensland's Sunshine Coast many times a day, cooking, cleaning, washing, gardening, driving, shopping and catching up with friends. She complains about supermarket prices and gout in her feet, but her knees are in tremendous shape. Yet in the case of a significant number of replacements – about six per cent – people report their knee is about the same as it was before the operation or a little worse. In 1.5 per cent of cases, people say they are much worse than before. As Zara has discovered, when there are problems, they can be big problems. Opting for arthroplasty is not a decision to take lightly. I ask my mother's surgeon, Dr Frank Connon, what can go wrong. 'Have you got three hours?' he replies. 'There's a massive litany of things that can go wrong.' In many cases, surgeons tell patients that slicing their knee open is not in their best interests and recommend they instead deploy non-surgical management options, such as weight loss, for as long as possible. Connon has taken appointments in his Noosa Hospital rooms with patients who say they want the surgery because they're having difficulty kneeling to garden or struggling in their yoga class. 'I tell them there's a solid chance we won't get them back to kneeling in the garden or doing yoga either,' he says. 'I sometimes say that, as surgeons, we're best at taking people who are completely crippled and making them less crippled. We're not good at making patients 20 years old again. We're not doing this operation to return a patient to marathon running. We're doing it so they can walk to the shops.' Knee nicknames One woman I know has names for her new knees. 'My girls are Willa and Meana,' says Liz. 'I'm 61, and they're now about 20 years old and going well – we live in lucky times!' But it was the hardest surgery of her life. 'Having two replacements at once is not for the faint-hearted.' Another woman tells me that her new knees are 'Eileen' and 'Ruby': 'They're several years old and while the surgery was the most painful thing I've ever done, it's the best thing too! I'm a gym junkie and walk my dog every day and go off like a rocket at airports!' My mother, Robin, hasn't named her new knees – possibly because they give her so little trouble that she doesn't even remember she has knees. But, for several years, they were all she could think about. She avoided walking even short distances and took to going down the 13 steps between her lounge room and bedroom determinedly backwards, clutching the bannister all the way. She acquired an odd gait, a drunken-sailor-ish sway which she found lessened the pain of each footfall. Visiting a shopping centre before her first operation, it took us half an hour to walk 50 metres, Mum's attention fixed on the next bench or cafe chair on which she could collapse. 'I'd always been reasonably active and healthy, and I was horrified I was in such a position,' she tells me now. I didn't realise how gravely her pain and immobility were affecting her mood. 'I'd reached the stage where I couldn't see much point in anything, that life wasn't worth living. Your father having gone only made it worse.' Loading But she desperately didn't want operations on her knees. 'I heard a long time ago that anaesthetic is bad for old people's brains, and I was anxious to avoid having it.' I dispute her recollection that I pushed her to have the operations; my mother never does anything she doesn't want to. As we talk via Zoom, Frank Connon calls up Mum's records to remind himself of her knees. He has a lot of knees to remember – he replaces 400 of them a year. 'Right,' he says, reading out the diagnosis. 'Right knee, severe medial joint space narrowing, moderate patellofemoral joint space narrowing and basically the same thing on the left knee,' he says. 'In your mother's case, the X-rays were unequivocal – her problem was clearly severe osteoarthritis affecting both knees.' Mum needed two total knee replacements, where the femur and tibia joint surfaces on both inner (medial) and outer (lateral) sides are replaced. (In Australia, total replacements make up 85 per cent of knee surgeries; partial replacements, in which only one side of the knee is treated, make up about seven per cent.) For Mum, non-surgical options were not viable. Her independence was at stake. 'It was starting to look like knee replacement or residential care,' Connon says. Excess weight contributes to more than a third of knee osteoarthritis cases. To visualise what actually goes on under the skin of a human knee, I turn to YouTube. 'A well-functioning knee joint is critical to mobility,' intones the voice-over. The 3D medical animation shows the knee joint to be a fiendishly intricate structure where the thigh (femur) and the shin (tibia) meet. The ends of these bones are each covered with a layer of rubbery connective tissue called cartilage which can be up to three millimetres thick. This cartilage allows the bones to glide effortlessly over each other and form a hinge when the knee moves, enabling us to stroll through a park, climb stairs or torture ourselves with squats at the gym. Knee osteoarthritis occurs when the cartilage and other tissue gradually erode. 'As your car tyres wear down their tread over the years, some people's knees seem to be fitted with tyres that last for 40,000 kilometres and some people seem to be fitted with tyres that last for 70,000 kilometres,' says Connon, 'and they can be affected by how you use them. So if you go rally-car driving, you're going to wear out the tyre tread faster than if you drive sensibly to the shops once a week.' The doctor says many patients attribute their osteoarthritis to their days playing sport but the reality is that excess weight contributes to more than a third of knee osteoarthritis cases. 'They're either carrying a few extra kilos, they've got bad genetics, or they've just been around for a long time, because the fact is, if you live long enough, you almost certainly will get osteoarthritis.' Connon tells me that my mother's knees showed the most common pattern of osteoarthritis: the cartilage in the medial 'compartment' of each knee was the most severely worn, but her overall knee alignment was relatively normal. It was 'bread and butter', he says of the surgery. I ask if he lost sleep the night before. He laughs. 'I did not! This was one where we could use the most standard techniques.' A matter of millimetres In early 2021, I drove Mum to Noosa Hospital for her first operation – on her left knee. She was stoic, resigned. In her room in the low-slung facility nestled in scrubby bush we unpacked her bag and I set up the Wi-Fi on her iPad; in the days ahead, Words with Friends would be one of her few distractions. Outside her window, a kookaburra landed on a branch and cackled. I told Mum that it was Dad, that he had flown in to wish her good luck. She managed a weak smile. We have history with this hospital: a decade earlier, with a similar view, Dad died here after a long engagement with prostate cancer. More than four years later, Connon describes to me how the day unfolded after I kissed Mum goodbye, and she was wheeled off. Once in the operating room, an anaesthetist would have given her a spinal anaesthetic plus a small dose of general anaesthetic, as is the case for most people undergoing arthroplasty in Australia. 'Particularly in a patient of your mum's age, we're trying to keep the dose of general anaesthetic as low as we can,' Connon says. 'We're trying to ensure they're not freaked out that we're cutting their knee open and putting a new one in, but the spinal is what's keeping their legs numb and doing most of the work.' He confirms Mum's fears were valid: older patients given only general anaesthetic face increased risk of post-operative delirium and reduced cognitive capacity. Laid out on the instrument table next to my mother's inert body: surgical tools including forceps, scalpels, saws and drills; the metal alloy knee implant or prosthesis with an articulating surface to replace the role of damaged bone and cartilage – generally, says Connon, an 'off-the-shelf' product chosen from a range of sizes; and Swiss custom-made cutting 'jigs', crafted to fit Mum's knee based on a CT scan. One of the orthopaedic surgeon's critical tasks is to pinpoint within a millimetre where on the femur and tibia to make bone cuts – the slots into which the prosthetic components fit. Once, surgeons relied solely on manual techniques involving metal alignment guides and the hand-measuring and marking of bone surfaces to do this, but technology has expanded their options: most now use either robotic assistance, computer navigation, or 'patient-specific instrumentation' (PSI) – the cutting 'jigs' (also called 'image-derived instrumentation' and 'custom-made cutting guides'). Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) shows that the use of robotic assistance has steadily increased since its introduction around 2016. In NSW, Victoria and Queensland more than a third of knee replacements now use the technology. During surgery, its contribution includes real-time mapping to guide surgeons in making bone cuts and correctly positioning implants. The surgeon remains fully in control. Connon uses robotics in some operations: 'The additional information it gives me in a difficult case helps get the knee replacement just right when the bone or soft-tissue anatomy isn't standard,' he says. For Mum's surgery however, he chose instead to use PSI. 'There are incremental risks with robotics. They've dropped in the years since your mum's operation, but having a robot adds a bit of time to the operation; in an 83-year-old lady that adds a small but non-zero risk of infection or periprosthetic fracture – a broken bone at the implant site.' When it was clear that my mother wouldn't feel a thing – during the operation at least – Connon picked up his scalpel and made a vertical incision down the front of her knee. 'We then have to tackle the quadriceps tendon,' he says. 'We either move it aside or, more commonly, as in your mum's case, cut right through the middle of it. Before him then lay Mum's exposed knee joint. The next step for the surgeon: to cut away the damaged, arthritic surfaces of the lower end of Mum's femur and the upper end of her tibia. 'Most people have this idea that we're chopping out huge chunks of knee but in most cases, we're only taking somewhere from six to 10 millimetres of bone and cartilage from either side of the joint.' As he talks me through the operation, I examine the souvenired PSI components on my desk – moulded white plastic replicas of the bottom of Mum's femur and top of her tibia and the corresponding jigs that resemble futuristic puzzle pieces. Their role in the operation is about to become clear: 'These fit like a glove on a knee during surgery and tell me where to make the cuts so I put the implant in the correct position,' Connon says. 'They ensure we use the correct-sized implant but, more critically, that we put it in the correct spot with minimum fuss.' From this point it is a swift process – typically, knee replacements take about an hour. Once positioned, the implant is secured using bone cement, polymethyl methacrylate. 'It's actually the same stuff used to secure fake nails,' Connon says. 'And then we sewed her up.' The morning after Mum's operation, I arrived early at the hospital. Pain-killing medication was topping up her stoicism and she was sufficiently robust to launch into a tirade about the hospital breakfast. A few minutes later, Connon bounced into her room with a coffee for her from the hospital cafe. 'They don't make many like her any more,' he tells me. 'She's a determined lady!' Never-ending pain Zara drops by my apartment for our first interview after a day spent cleaning other people's homes. I offer her tea or coffee but all she wants is a glass of water. She sits at my dining room table, sips on the water and seems close to tears. Her left knee replacement from 2012 is a testament to how successful the surgery can be. But her right knee, replaced in 2017, tells a different story. Zara doesn't want to be identified by her real name so I can't contact the specialist who gave her a new right knee to ask questions. But no matter what happened, the eight years since have been hell. Gingerly, she lifts her right knee to show me how limited the movement in it is. It's larger and angrier than her left. 'There's still infection there,' she says. 'Everything is never-ending.' For years, Zara's diary has been filled with medical appointments to see doctors, for steroid injections, physiotherapy, X-rays, CT scans and, through it all, still pain. In late 2023, a new specialist sent her for more scans. 'He called me and said, 'This is not good, the prosthesis has to be taken out, it's coming out of place, it's dislocated, and the bone is damaged.' I started crying; I didn't expect that. I couldn't talk.' Zara's story highlights the fact that a knee replacement is not insignificant surgery. In many cases where patients are unhappy after their operation, the issue lies in the mismatch between their hopes for the surgery and the level of function they ultimately regain – what Frank Connon calls 'the expectation gap'. But rare and more serious complications can also arise, including 'foot drop', where nerve damage impedes a person's ability to lift the front of their foot, and arterial injury, involving damage to a nearby artery that can lead to bleeding, thrombosis or even amputation. Infection is rare, but it's the complication surgeons fear most. 'Once you get a deep infection, it can be difficult to clear; for some patients it can't be,' says Connon. 'You have to justify to yourself and the patient anything that lengthens the operation unnecessarily because that's going to increase your infection risk.' The AOANJRR identifies two critical predictors of whether a knee will require revision surgery. Age is the first. Knee replacements don't last forever and patients who undergo arthroplasty at 55 or younger have a 15 per cent chance of needing a revision at 20 years. The second is infection, a risk that's greater in patients with elevated BMI scores (body mass index) and/or other health conditions. Zara was not overweight. She says her health was good. 'I was young,' she says. Now she has high blood pressure, reflux she attributes to all the tablets she takes, and fatty liver disease. 'Maybe it's because I have depression and when I'm in pain I eat things that are bad for me.' According to the AOANJRR, a large number of variables determine a knee replacement's success, including the patient's health when they have the operation – conditions such as diabetes or high blood pressure can increase the risk of complications – the specific nature of the knee problem, the way the operation is performed, and the type of artificial joint replacement used. Additionally, the success of knee operations varies depending on the surgeon performing the operation and where a person lives. Rural hospitals (which tend to treat more people from disadvantaged backgrounds, who are statistically more likely to be heavier and have co-morbidities) generally use less advanced technology. Loading That said, technology is not a silver bullet for knee replacement. 'There is little evidence in scientific literature – as opposed to promotional marketing material – to suggest that robotics makes a difference for the average patient's outcome,' says Connon, acknowledging it's a controversial subject among surgeons. He says that incremental improvements in a number of other areas including surgery duration, swelling reduction techniques and newer styles of implant have each contributed to improved knee replacement outcomes as much as robotics or any other contemporary instrumentation used to precisely position implants. Nor does having a knee-replacement operation in the private system, as my mother was fortunate enough to be able to have, necessarily guarantee a better outcome (in 2023, more than three-quarters of knee replacement procedures were in private hospitals). 'The starting point for the average public patient that hits the operating table is usually demonstrably worse than a private patient,' says Connon, who works one day a week in a public hospital teaching young doctors how to replace knee joints. 'They have other health problems that will contribute to the outcome, including diabetes, obesity, heart problems and they're more likely to smoke.' Other factors come into play too, including the fact that, in the public system, surgical teams typically work across a wide range of operations. 'The theatre teams in private hospitals are set up to run like a production line, so nursing staff are more experienced at a more limited number of operations and churning through them.' Nevertheless, he says, the net improvement in function and quality of life after surgery for public patients is similar to that experienced by those in the private system. Just before I send this article to my editor, I check in with Zara to see how she's doing. She is, she says, a little better than the day we met. But she's worse than before she had the revision on her right knee in 2024. 'I avoid walking. My knee is sore, I still get needles.' During the post-operative appointment with the specialist who performed the revision, she complained about her pain. He told her that her patella (kneecap) was moving. 'I asked him, 'Why is it moving, you just finished the operation?' And he says, 'The operation doesn't fix everything.' ' Zara was firm. 'No more operations,' she told him. Dictating case notes into a recorder, the specialist said: 'No more appointments.' Someone Zara knows told her she should sue the hospital and doctors for the problems she's had. 'No,' she told them, 'I don't want money.' Now, talking to me on the phone, she says, 'I just want to be better, that's all.' And maybe, she thinks, her story can help other people. Too soon for surgery In late 2019, my friend Narelle started to feel twinges in her left knee. 'I battled with it for a while,' she says. 'I was taking Panadol and rubbing Voltaren gel on it constantly – god, I went through so many tubes of that stuff.' Narelle, a semi-retired lawyer who was then 62, tried over-the-counter anti-inflammatories too, but they upset her stomach. She spent a fortune with a physio but it was 'useless', she says: 'At that time – mid-COVID, in a lot of pain and not knowing how to deal with pain, only doing Zoom sessions – it just didn't help.' Her pain worsened, the knee swelled and even walking the few steps to her letterbox was agony. Her GP referred her to an orthopaedic surgeon. In mid-2020, Narelle saw the specialist at his inner-Sydney rooms. After reviewing her X-rays and MRI scans he told her she had a medial meniscus tear and osteoarthritis. But, he said, it was too soon for surgery. Instead, he recommended she strengthen the muscles supporting her knees and lose some weight. 'I remember feeling abandoned,' she says. 'I thought, 'This is the beginning of the end, how am I going to live the rest of my life, how can I be a person who lives in the world?' And it was all happening in the middle of COVID isolation. I was quite frightened.' Australian surgeons are robustly interventionist in their approach to knees, with replacement rates 73 per cent higher than the OECD average. Research published in 2019 in the journal BMC Musculoskeletal Disorders projects that, by 2030, the cost to the healthcare system of total knee replacements could climb to $3.4 billion, posing significant budgetary and workforce challenges. The latest Osteoarthritis of the Knee Clinical Care Standard, released last August with aims including improving patient care, reducing unnecessary surgeries and promoting non-surgical management, will go some way to address the unsustainable burden of our bad knees. Knee surgery should never be seen as a quick fix for osteoarthritis, said orthopaedic surgeon Adjunct Professor Christopher Vertullo when the standard was released. 'In my own practice, about a third of referred patients don't need to see me, and about 60 per cent … have had an inappropriate investigation or scan, without any initial management for osteoarthritis,' noted Vertullo, the deputy clinical director of the Australian Orthopaedic Association National Joint Replacement Registry and one of the experts involved in reviewing the standard. 'Surgery is fantastic for end-stage osteoarthritis of the knee … but for an occasional ache, you are likely to be dissatisfied with the outcome.' Narelle might argue with the description of her pain as an 'occasional ache'; it was, she says, 'like a knife in the joint, really sharp, really overwhelming'. But, in any case, the surgeon she saw left her with no choice but to explore other ways of tackling the problem. Her health fund program gave her a set of scales, a FitBit smart watch, consultations with a dietitian and a physiotherapist, and delivered her protein shakes to replace two of her meals each day. She lost 17 kilograms. 'But it was starvation, it was ridiculous, and when I stopped I put all the weight back on.' 'He said, 'OK, I'm going to teach you a way to stand up that won't hurt.' … It didn't hurt!' Narelle Narelle sat down at her computer and started to search. She stumbled on Form Physiotherapy, an Adelaide practice specialising in 'pain-science-informed physiotherapy'. She recalls her first online appointment with team member Jack Murphy. 'I'm saying, 'It hurts, it hurts, it hurts, please give me some exercises that will make it better.' And he's saying, 'Well, I might give you exercises, but mainly I want to talk about how you experience pain and the way your brain gives you messages about pain.' ' Over the next year, Narelle had regular online sessions with Murphy. 'Jack didn't spend much time talking to me about losing weight. He said, 'Yeah, there's all that stuff about load but really it's about what your brain is doing in relation to pain.' Apparently, when you have chronic pain your brain becomes slightly hysterical about it and goes into over-protective mode.' As Narelle came to understand more about her brain's role in her pain, Murphy started to work with her to adapt some of her basic movements. He asked her if it was painful to stand up from sitting. 'I told him, 'Yeah, it really hurts.' He said, 'OK, I'm going to teach you a way to stand up that won't hurt.' He told me to try leaning forward, not using my hands and using momentum to push off my feet. It didn't hurt! He said, 'Right, pretty soon you'll be able to walk without it hurting.' ' Loading When Murphy asked what her goal was, she told him she wanted to be able to walk around Uluru. 'And I could now, I'd have to pace it a bit but I could.' Recently, Narelle started lifting weights under a physiotherapy-led program called Onero, which is designed to improve bone density and reduce fracture risk in individuals with osteoporosis. 'It has made a world of difference to how I feel – much stronger, much less pain – and I've gone down a dress size.' At my desk, thinking about the success of Narelle's alternative solution to her knee pain, I fiddle with the white moulded jigs for Mum's knees, trying to fit the pieces together like a puzzle. I think about the extraordinary science that has made knee replacement surgery so commonplace and, generally, so successful. Then I look at my watch – it's time to go to the gym. I don't ever want my knees to be cut open.

Medicinal cannabis crackdown looms as high-strength products hit market

The Age

5 hours ago

The Age

Medicinal cannabis crackdown looms as high-strength products hit market

Australia's medicines regulator has flagged a crackdown on the medicinal cannabis industry, pointing to a ballooning number of high-strength products issued through telehealth appointments. The Therapeutic Goods Administration this week put the industry on notice, floating in a confidential consultation paper obtained by this masthead that it would gauge support for 'significantly restricting or preventing access' to more than 1000 unapproved cannabis products prescribed to hundreds of thousands of Australians. The wide-ranging review will canvass substantial changes to the system permitting access to the once-illegal drug, although the consultation paper specifically notes the federal government 'is not intending to remove access to medicinal cannabis'. The TGA review warns that the strength of cannabis extracts is not limited in Australia and has grown rapidly, with some containing up to 88 per cent tetrahydrocannabinol (THC), the component in cannabis that makes users feel 'high'. One pro-cannabis MP said this was more than eight times as strong as the 'pot' many people had smoked in previous decades. Access to cannabis for medical purposes was legalised in Australia in 2016, and has sharply increased as many recreational users realise they no longer need to access the drug illicitly. Cannabis use in Australia has not changed dramatically. The federal government's Australian Institute of Health and Welfare found 13 per cent of Australians used cannabis in 2001 compared with 11.5 per cent in 2023. But the institute found that among people who used cannabis, the use of prescribed cannabis for medicinal purposes was on the rise. In the past 12 months, this masthead has detailed the supercharged growth of corporate-backed telehealth cannabis clinics and the explosion in prescribing since 2016. Major companies have emerged supplying the drug. The biggest, Montu, turned over $263 million last year.

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The number of knee replacements is soaring – just don't expect to run marathons after

The number of knee replacements is soaring – just don't expect to run marathons after

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Millions struggle to afford personal hygiene products

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The number of knee replacements is soaring – just don't expect to run marathons after

The number of knee replacements is soaring – just don't expect to run marathons after

Medicinal cannabis crackdown looms as high-strength products hit market

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