Is TKR the right decision for you?

The most honest answer to this question is a clinical one: total knee replacement is appropriate when the joint has reached end-stage disease and every reasonable non-surgical option has been tried. For most patients, the underlying diagnosis is osteoarthritis — progressive cartilage loss that eventually leaves bone grinding on bone. Rheumatoid arthritis and post-traumatic arthritis following a previous knee injury are less common but equally valid indications.

What makes someone a candidate in practice is a combination of three things: a confirmed diagnosis on imaging (X-ray as the standard starting point; MRI where cartilage detail matters), persistent pain and functional limitation that has not responded to physiotherapy, weight management, anti-inflammatory medication, injections, or bracing, and a physical examination that confirms the pattern and severity of joint damage.

The distinction between total and partial replacement is one the surgeon draws, not the patient. Partial (unicompartmental) replacement works well when only one compartment of the knee is affected and strict anatomical criteria are met — it preserves more native tissue and typically carries a faster initial recovery. Where disease has spread across multiple compartments, total replacement is the appropriate choice. Both decisions are based on the extent and pattern of damage found on assessment.

For patients who are not yet at bone-on-bone stage, cartilage-preservation procedures may remain an option; if a consultant has recommended TKR, those alternatives will have been considered and ruled out. The practical threshold that moves most patients to this conversation is function-limiting pain that no longer responds to conservative care — that combination, supported by imaging, is what justifies surgical candidacy.

Prehabilitation: what the evidence actually says

Structured pre-operative physiotherapy — prehabilitation — is worth doing, and the trial evidence is substantial enough to act on. A systematic review and meta-analysis of 48 randomised controlled trials found moderate-certainty evidence that a structured prehab programme improves physical function, knee flexor strength, and 6-minute walk test performance in patients awaiting total knee replacement. That is a meaningful result: it means patients can arrive at surgery in measurably better physical condition than those who do nothing.

The important caveat is where that benefit sits. The same body of evidence found only weak certainty for significant gains in postoperative outcomes — prehabilitation is best understood as optimising the patient at the point of surgery, not as a guarantee of a faster or easier recovery afterwards. Both overclaiming and dismissiveness miss the point: arriving stronger and better conditioned is a reasonable goal in its own right, even if it does not reliably shorten the weeks that follow.

There is also a sound mechanical rationale for staying active that exists independently of the trial data. Cartilage has no blood supply of its own; it draws oxygen and glucose from synovial fluid, which is driven into the joint by the compression and release of movement. Prolonged immobility reverses this process and accelerates structural decline. Regular, appropriately paced movement in the weeks before surgery is therefore not simply about muscle strength — it is about maintaining the joint environment for as long as possible before replacement.

In practice, a prehab programme focuses on low-load strengthening of the quadriceps, hamstrings, and hip muscles, adapted to whatever range of motion and pain level the patient can manage at the time. The specific exercises matter less than the principle: consistent effort, started early. Beginning weeks or months before a listed surgery date is more effective than a brief last-minute push. Patients who are placed on a waiting list should ask for a physiotherapy referral at that point — not after the surgery date has been confirmed.

Why knee range of motion matters before the operation

Range of motion is assessed formally at the pre-operative consultation for a practical surgical reason: if the knee cannot flex and extend within a workable range, achieving correct implant alignment during the operation becomes significantly more difficult. Patients who arrive at surgery with notable flexion loss or a fixed flexion deformity — where the knee cannot straighten fully — face a harder rehabilitation and a greater risk of persistent stiffness afterwards.

One complication worth understanding plainly is arthrofibrosis: the development of excessive scar tissue within the joint that restricts movement and causes pain even after physiotherapy has been attempted. Limited preoperative ROM raises the likelihood of this, which is why the weeks before surgery are a genuine opportunity rather than just a waiting period.

Concrete steps help here. Physio-guided stretching, heel-prop exercises (lying with the heel raised so gravity slowly extends the knee), and low-load cycling where pain allows are all ways of working on ROM before a date is set. No specific degree targets are universal — individual goals will be determined at assessment based on each patient's starting point and underlying condition.

If ROM is significantly restricted when the surgeon first reviews the knee, addressing it may become the priority before a surgical date is confirmed. A physiotherapy referral at that stage is appropriate to ask about, and early progress can directly influence the timeline.

Nutrition and medical preparation in the weeks before surgery

Before the pre-operative appointment, it is worth knowing which topics have enough published evidence to raise directly with your surgical team — rather than leaving nutrition and medication management as afterthoughts.

Nutritional support

A 2022 systematic review examined protein and creatine supplementation specifically in patients undergoing elective knee replacement. The finding is specific: ensuring adequate protein intake in the weeks around surgery is a reasonable strategy to support muscle maintenance and tissue healing; creatine was also reviewed in this context. Whether supplementation is appropriate for an individual depends on existing diet and the surgical team's approach. Raise it at the pre-op consultation — the evidence justifies the question.

Blood management

Oral tranexamic acid — a medication that reduces blood loss during and immediately after TKR — is part of the peri-operative protocol at many surgical units. Patients will not be asked to source it themselves, but knowing it exists allows them to ask whether it is planned and, if not, why.

Medications to pause

Aspirin, NSAIDs, and certain supplements (including high-dose fish oils and vitamin E) can increase bleeding risk and will usually need to be paused before surgery. The surgical team will specify timing once they have a full medication list — which is why bringing a complete list to the pre-op assessment matters.

Weight

Where body weight affects anaesthetic risk or surgical planning, the pre-operative appointment is the appropriate moment for a frank conversation. Surgeons raise it not as a barrier but as a preparation factor.

Practical preparation before your surgery date

The period between confirming a date and arriving at hospital is easy to underestimate. The practical tasks below are ones that regularly catch patients short when left until the last minute.

Book physiotherapy before the operation, not after

Post-operative physiotherapy has strong trial evidence behind it (a systematic review and meta-analysis of RCTs confirmed its effectiveness after knee arthroplasty). The gap most patients encounter is availability: NHS physiotherapy often involves a wait, and private practitioners in high-demand areas fill quickly. Identify and, where possible, pre-book your physiotherapist before your surgery date — ideally the same one who has been supporting prehabilitation.

Adapt your home in advance

Discharge planning should begin well before the operation. A raised toilet seat, grab rails next to the toilet and shower, and a firm chair with armrests for standing are the essentials. If your bedroom is upstairs and stair-climbing will be difficult in the early weeks, arranging ground-floor sleeping beforehand avoids a scramble on discharge day. Walk through your home and clear trip hazards — rugs, cables, thresholds — before you leave for hospital.

Practical questions to raise with your surgical team

• Theatre and hospital stay: theatre time is typically 90–120 minutes, but total stay depends on individual progress and anaesthetic approach. Ask specifically what to plan for.
• DVT prophylaxis: blood-clot prevention after TKR is standard care and usually involves compression stockings, medication, and early mobilisation. Confirm what will be prescribed, for how long, and what to watch for on return home.
• Anaesthesia options: general and spinal anaesthesia are both used for TKR. This is worth discussing at the pre-operative assessment if you have a preference or a relevant medical history.

Understanding the cost if going privately

In the UK, private total knee replacement typically ranges from approximately £12,000 to over £18,500 depending on the centre, implant choice, and what the package covers. Before committing, confirm in writing whether the quoted price includes the pre-operative assessment, anaesthetist fee, implant, inpatient stay, and post-operative follow-up — or whether those are charged separately.

Questions worth asking your surgeon before you consent

Arriving at a pre-operative consultation with a few clear questions changes the conversation from passive consent to active participation. A well-prepared patient does not put a surgical team on the defensive — most consultants welcome it as a sign that someone has thought carefully about what they are agreeing to.

Which compartments will be replaced, and why? Understanding whether the plan is a unicompartmental (partial) or total replacement — and the clinical reason — helps patients genuinely grasp what they are consenting to, not just sign a form.

What alignment technique will be used? Conventional jigs, computer-assisted systems, and approach-specific methods each have different rationales for achieving implant positioning. Asking the surgeon to explain their choice confirms the team has considered alignment individually, not generically.

What range of motion is realistic at six weeks, three months, and one year? Surgeons can give patient-specific ranges based on the pre-operative assessment — ask for those, not population averages.

What physiotherapy protocol follows surgery, and can the team refer directly? Knowing this before the operation allows patients to arrange continuity of care rather than scrambling post-discharge.

Which activities should I not expect back, and by when? Return to walking distances, gardening, or low-impact sport depends on individual profile and surgical judgement. A straight answer now is more useful than discovering the limits six months into recovery.

Lincolnshire Knee is part of the MSK Doctors group and accepts patients without referral. A pre-operative assessment is the right place to put every one of these questions — and to come away with answers grounded in your specific knee, not in the average patient's.

1. [1] Knee Replacement — NHS. https://www.nhs.uk/conditions/knee-replacement/ https://www.nhs.uk/conditions/knee-replacement/