I prepared for my knee replacement surgery. But I had a lot to learn.

Cortisone shots, physical therapy, anti-inflammatories and semiannual injections of hyaluronic acid, which helped cushion and lubricate my joints, kept me on my feet. But both knees had lost almost all their shock-absorbing cartilage. I was, in arthritic knee parlance, “bone on bone.”

A few months after my 60th birthday, I began preparing for one of the most common elective orthopedic surgeries in the United States: total knee replacement, also known as total knee arthroplasty.

Between 850,000 and 1 million patients have total knee replacements annually, a number expected to grow to at least 1.2 million by 2040, according to a 2023 study. About 60 percent of patients are women, and the surgery largely remains a purview of baby boomers: the mean patient age is 67.4, according to the American Joint Replacement Registry. But younger people are increasingly taking the plunge.

Before the surgery, I did my homework. I consulted five orthopedic surgeons before selecting one, read numerous articles and clinical studies, joined a Facebook support group for “knee replacement warriors,” watched YouTube videos of surgeons and physical therapists offering advice, and did “pre-hab” to strengthen the muscles in my legs for rigorous post-surgical rehabilitation.

But what I experienced after my surgery showed me that I was nowhere near prepared.

For a total knee replacement, a surgeon removes the damaged cartilage and arthritic parts of the thigh and shin bones and replaces them with usually metal components, which now serve as the surface of the joint, according to the American Academy of Orthopaedic Surgeons. Those components will glide across a smooth plastic disc inserted as a stand-in for the knee’s cartilage. The surgeon also often resurfaces the back of the knee cap and fits it with a plastic cover or “button” before replacing it and closing the surgical incision.

The procedure has been described by many patients as “brutal.”

Difficulties are sometimes minimized by surgeons, said James Rickert, a board-certified orthopedist and president of the Society for Patient Centered Orthopedics. “I think it’s easy for providers to market procedures as a panacea,” he said. “It’s easy to emphasize the benefits, and it’s easy to minimize the risks.”

“It’s a crazy surgery, and patients get left in the dark sometimes,” said Samantha Smith, a Dallas-based physical therapist. Smith offers online courses for knee replacement patients and created and moderates a more than 19,600-member Facebook group for knee replacement patients, of which I’m a member. “I’ve talked to surgeons about how much they proactively share with patients,” she said, “and they’ve told me that if patients knew before surgery what they’ll likely face, they wouldn’t go through with it.”

Other surgeons say that it’s the most effective way to deal with intractable arthritis.

The satisfaction rate for knee replacement surgery hovers around 80 percent, studies have shown, a near-record high for elective surgeries, said Daniel J. Riddle, a physical therapist and professor at Virginia Commonwealth University in Richmond.

“It’s hard to find a surgery that’s safer, and when it works, it works great,” said Nick DiNubile, a Philadelphia-area orthopedic surgeon specializing in sports medicine. It could be a “life-changing procedure,” he said, but some patients could be dissatisfied because of “unmet expectations.”

“We need to dig deeper into dissatisfaction,” DiNubile said. “Is it pain? Is it functional loss? If you understand the dissatisfaction, you can design a treatment plan to address the shortcomings.”

My surgery in September 2022 was a near-textbook procedure. I received the same light anesthetic or sedative most colonoscopy patients receive — and a spinal nerve block for pain. The surgeon relied on “robotic assistance,” a computer that provides real-time data. Research shows that the technique minimizes incision lengths and soft-tissue damage, and guides surgeons to do more precise bone cuts and place the implant to optimally work with a patient’s specific anatomy.

Within two hours of surgery, my husband helped get me to the car. (Most patients must take their first steps within a couple of hours of surgery, which, like mine, can take place at outpatient surgical centers.) At home, I ate a light dinner and made it up a flight of stairs to sleep in my own bed.

The first two to three weeks were painful and arduous because of the seriousness of the surgery and the extensive physical therapy exercises patients do multiple times daily. But my pain management plan worked, and my early progress went according to plan. At my two-week check-in, my surgeon asked where my prescribed walker or cane was, and laughed when I responded that I kept forgetting them.

Short-term warnings, but little midterm advice

About three weeks into my recovery, I realized I wasn’t prepared for what would unfold over the next several months.

Pre-surgery, I received the standard warnings about rare, but potentially serious surgical risks such as blood clots and infection, and specific precautions to avoid them. But I received little guidance about issues many patients face as they continue to recover.

“The research done is typically on patients’ short-term experience, the length of the hospital stay, the complication rate, or the really long-term: How long will this” implant “last?” Rickert said. “There’s very little research on the actual patient experience in the midterm.”

I suffered from disrupted sleep for about two months. Many patients have sleep issue for weeks, and sometimes months because of pain and their inability to get into a comfortable position.

Another common problem tends to be depression fueled by pain, lack of sleep and the lengthy recovery which restricts mobility and autonomy. One in five knee replacement patients struggle with depression, while 15 to 20 percent battle anxiety triggered by the procedure, Riddle said. While I was not clinically depressed, I had severe anxiety as the surgical date loomed, and it remained elevated as my rehab stalled.

I was often exhausted because of near-total physical deconditioning because, like many patients, I was partially incapacitated for the first two to three months. Surgeons and physical therapists counsel that full recovery can take 12 to 18 months. My mantra became: “I’m so tired of being so tired.”

The physical therapy I underwent was challenging, largely because of a little-understood neurological response called “protective muscle guarding” that plagued my rehab. It occurs when the brain, trying to protect the traumatized knee, “locks” the leg muscles, impeding physical therapy exercises. To overcome protective muscle guarding and get my muscles to cooperate with my physical therapy, I pursued several tested therapies that helped, including lymphatic massage, extracorporeal shock wave therapy, aqua therapy and cupping.

Seventeen months after my surgery, the sometimes dehab dull ache of arthritis in my knee is gone. I’m back on the pickleball court and generally sleep well. My knee extension — the ability to completely straighten my knee, which is important in a healthy walking gait — is better, but my balance and flexion — how much I can bend my knee — are slightly worse.

Many people are surprised when I offer a less than an enthusiastically over-the-top assessment of my knee replacement surgery. My rehabilitation and recovery were far longer and more arduous than I had been prepared for.

Without my understanding and accommodating employer, a desk job and comprehensive private insurance, I don’t know how I would’ve done this. I spent about $7,000 out of pocket related to the surgery, coinsurance, deductibles, co-pays, medical devices and other types of care to overcome muscle guarding.

I am now taking steps to avoid or delay replacing my other knee. I’ve lost about 35 pounds. Weight loss, specific exercises and other physical activity have helped patients forgo surgery, according to patient educational programs in the United Kingdom, Canada and Australia, Riddle said. Research presented at the 2023 meeting of the Radiological Society of North America showed that strengthening “the quadriceps in relation to the hamstrings may be beneficial.”

But if I have to replace my other knee, I will focus as carefully on selecting my physical therapist as my surgeon. “The surgeon does the surgery, makes sure the implant is in there correctly, and then turns the patient loose on the PT,” Smith said. “The physical therapist is with the patient for months, two to three times a week.” Many for-profit practices require physical therapists to work with two to three patients simultaneously. My progress accelerated when I switched to Johns Hopkins, which uses a model of one physical therapist-one patient per appointment.

Having lived through it once, I also will be better prepared for the challenges the surgery can cause and better advocate for myself by asking surgeons and physical therapists probing questions about changes in treatment and surgical advancements since my first knee was replaced.

I will also better advocate for myself by asking tough questions of surgeons and physical therapists about pain management, poor outcomes, sleep issues and other negatives of the recovery process.

My replaced knee will never be as good as my knee was before arthritis, but arthritis is a progressively debilitating and irreversible disease. If I have to undergo another knee replacement, I hope with the hindsight of what I learned the first go-round, one-to-one physical therapy and tempered expectations, my recovery will be less physically and mentally exhausting.