My Aunt Evelyn is in her 80s. She built her own business and is there at her desk every day. Why? She loves it and couldn’t imagine being anywhere else. The only thing wrong with this picture? She needs new knees — after years of painful arthritis, she hobbles through her workdays and her leisure time, too. But because she has seen too many friends have terrible trouble getting through recovery, she is afraid to have the operation.

Well, there’s very good news for my intrepid aunt and for other folks with bad knees! Modifications in the way knee surgery is done now mean considerablyless pain and a faster, easier recovery. I checked in with Friedrich Boettner, MD, who specializes in total knee and hip replacement at the Hospital for Special Surgery in New York City, to talk about the latest improvements.

First, he gave me a little background. Every year, nearly 300,000 Americans become owners of new knees, trading in their problematic joints for replacement prostheses. Having started in the 1970s, the procedure itself is not new. Although it has seen many improvements, until the current methods for performing total knee arthroplasty(TKA) patients experienced considerable pain, with hospital stays of seven to 14 days, oftentimes followed by inpatient rehabilitation and a long recovery of several months. Today, the hospital stay is significantly shorter (usually three to five days) and patients often are walking with a cane within a few days to weeks.

Anesthesia — Less Is More

Dr. Boettner told me that many of the recent improvements have to do with the patient’s experience during the surgery and the first few days of recovery. For example, no more are knee-replacement patients intubated and sedated with heavy narcotic drugs. The new strategy is to inject regional anesthesia — doctors use a spinal epidural that allows them to do the procedure and later to control pain with an epidural pain pump. With this more nuanced approach in place, patients are put to sleep with a milder drug than before, reducing the chances of postoperative nausea and confusion. The epidural catheter can remain in place for up to 48 additional hours, allowing for excellent pain control in the early postoperative period.

Yet another advance is the changed approach to nausea, that frequent and unwelcome postsurgical visitor. Nausea can be caused by anesthesia, pain medications or even pain alone. These days, doctors no longer wait for symptoms to appear but administer antinausea medication during surgery and again early after the surgery — an approach that eliminates that awful queasy sensation completely for many patients. It also allows them to get up the day after the procedure. “Just being able to walk the day after surgery,” says Dr. Boettner, “creates much more positive momentum for recovery.”

Surgery — More Is Less

There’s been an important improvement in the way surgeons actually cut patients’ knees, too — and it’s the oppositeof what you might think. The advent of minimally invasive surgical techniques in the last decade or so allowed doctors to perform knee-replacement surgery without having to cut muscle tissue or the quadriceps tendon to access the knee. Doctors could make smaller and smaller incisions and still get the knee replaced, and this was a source of real pride, says Dr. Boettner. But then a strange thing happened — many doctors began to realize that smaller wasn’t really better after all. For surgeons performing knee replacement to position the prosthesis exactly right, they need a large enough incision to see and accurately place the implants. Dr. Boettner explained that surgeons know now that for optimal results, a four-inch to five-inch incision provides a better viewing area while still allowing muscles and tendons to be spared.

The upshot of these various advances — it’s fair to say that the idea of putting off knee-replacement surgery for as long as possible is no longer valid. Surgery and recovery are far easier than they used to be… and for 85% to 90% of patients, the prostheses now last for 20 years. There is no reason (I hope you’re listening, Aunt Evelyn!) to live with a knee that you can’t come close to straightening or one that gets unbearably stiff and painful.