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Common questions

Knee replacement

This fact sheet is designed to help MBF members and their families be better prepared for their healthcare experience if they are having knee replacement surgery.

Not all of the information here will be applicable to everyone, so it is important to discuss your individual circumstances with your doctor and perhaps with other healthcare professionals in the team caring for you. Please, never hesitate to ask 'why' or to have something explained to you until you understand it. If, after you have been given an answer, you still feel as though there are unanswered questions, ask again or ask someone else. You can help the healthcare team to help you if you feel free to communicate your needs to them. Further research and reading will also help you make more informed decisions.

 

What is knee replacement surgery and why is it performed?

During knee replacement surgery, known medically as total knee arthroplasty, the ends of the femur (thigh bone) and tibia (shin bone) and sometimes the patella (knee cap) are removed and replaced with an artificial joint, which is also known as a prosthesis.

The most common reason for knee replacement surgery is severe arthritis of the knee that causes pain and stiffness of the knee joint to the point where it seriously restricts your movement and quality of life. Your doctor is likely to recommend a knee replacement only when other treatments for your arthritis (such as medication, physiotherapy and exercise) are no longer effective.

Less commonly, a knee replacement may also be necessary due to knee damage or decline caused by rheumatoid arthritis, haemophilia, gout, or bone death or bone growth disorders.

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How effective is this surgery?

Although the results of this surgery are felt, in general, to be highly successful, knee replacement carries all the risks of major surgery along with more specific complications. You should make sure that, when you talk to your surgeon, you are given enough information about these risks to be able to consider them fully as you are making a decision about your surgery. A number of people will experience ongoing knee pain and instability after knee replacement, although this may still be much less than their original symptoms.

In most cases, after an appropriate recovery period and physiotherapy, you are likely to experience significant reduction of pain with an increase in knee movement, often to the extent of a normal, healthy knee. Where surgery is due to arthritis, you are likely to notice improvements only a few weeks after surgery. Gradual improvements are likely to continue and full benefits may depend on such things as your current health status.

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How long will a prosthesis last?

Currently, an issue with knee replacements is that any one or more parts of an artificial joint may wear out or move over a period of time. If this situation is severe, it must be replaced by another prosthesis. This is known as a revision. Several factors will influence whether you could need a revision in the future:

  • the quality of the prosthesis you receive;
  • whether your prosthesis is subjected to high impact activity, such as running;
  • personal factors such as obesity and your age; and
  • complications of surgery such as infection or weakening of surrounding bone.

Read 'Questions to ask you doctors' to prepare for discussions so that you feel you have made an informed decision regarding your prosthesis.

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Questions to ask your doctors

Knee replacement is best and almost always performed by an orthopaedic surgeon who is highly experienced in the procedure. A doctor who has performed many knee replacements with a very low complication rate and good outcomes in terms of pain relief and movement is going to be the best person for the job.

Your GP will generally suggest one or more orthopaedic surgeons and give you a referral for the procedure.

Some questions to ask your GP or referring doctor:

  • Why do you think now is the time to have knee replacement surgery?
    • Are there other options I should consider in place of surgery, such as medication, physiotherapy or exercise?
    • What are the pros and cons of delaying the surgery?
  • Why have you recommended this particular surgeon to perform the surgery?
  • Do you know how many knee replacements this doctor may have done? How many does he or she do each year?
  • Do you know if they charge a gap that Medicare or my health fund won't cover for my inpatient procedures? Or is there someone just as suitable that is more likely not to charge a 'gap' over the medical fee? Even so, choose your doctor first on the outcomes you can expect and their experience and expertise.

Some questions to ask the orthopaedic surgeon:

  • Will you explain, in simple terms, how the surgery is performed?
  • What are the possible complications and/or side effects associated with my surgery?
    • What part can I play to reduce the risks?
    • Discuss healthy weight, appropriate exercise, how to quit smoking and/or your current medications with your doctor. If you are diabetic, well-managed diabetes prior to your surgery will also help your recovery.
  • How many knee replacements have you done? How many do you do each year?
  • What percent of your patients experience complications from this procedure?
  • In my case, how effective do you expect the surgery to be in terms of increased movement, reduced pain and improvement with my everyday activities?
  • Which prosthesis do you recommend and why?
    • Are you able to give me an estimate of how long my new knee will last?
    • Does this prosthesis have one of the lower revision rates?
    • Are there others I should consider?
    • Is the prosthesis you recommend a 'no gap' prosthesis?
      • If not, what is the 'gap' and is there a comparable no gap prosthesis you would recommend? If not, can you explain why?
  • How long do you expect I will need to be in hospital?
  • If I need pain or other medication, will this be supplied at the hospital or will I need to have a prescription filled after I am discharged?
  • What sort of follow-up treatment, such as physiotherapy, should I prepare for, when will it start and how frequently should I plan to do it?
  • When should I be able to bear weight on the new knee?
    • Will I need crutches, a wheelchair, or walking frame when I leave hospital?
    • Where can I lease or buy this equipment?
    • Will I need a knee brace?
    • How long do you think I will need this?
  • What are the first signs of complications that I should look out for? If I experience any of these, what should I do and who should I call?
  • How long after the operation can I expect to notice improvements?
  • How will I be able to contact you?
  • What restrictions to my everyday activities can I expect after the procedure (ie. driving, lifting heavy objects, avoiding certain types of movements)? How long will I need assistance?
  • What can I do to assist my recovery and help maximise the longevity of my artificial knee?
  • Do you charge a gap that Medicare or my health fund won't cover for inpatient services? Again, choose your doctor first based on their experience and expertise.
  • Does the anaesthetist or any other doctor who may assist with the procedure charge a gap? If so, how much should I expect that to be?

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How to prepare and what to expect

Your doctor should give you any specific instructions relating to your particular case. In general, you may expect a hospital stay of four to seven days. You should be made aware of how long after surgery you will be encouraged to walk around and begin gentle physiotherapy.

Make sure you ask for written instructions when you are discharged. These should tell you when you should see your doctor again, what medications to take or avoid, and what type of exercises to do, activities or movements to avoid (such as squatting or kneeling) and when to see your physiotherapist.

It should also include signs of complications. You should contact the hospital, doctor or whoever your doctor has advised immediately if these occur.

Your stitches will generally be removed about ten days after surgery.

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What MBF pays toward knee replacement including revision

Understanding how the healthcare system works can be confusing. This brief summary outlines what you can expect in terms of your health cover. Always check with MBF before you go to hospital.

 

Your hospital costs

MBF Advantage Hospital and MBF Premium Hospital cover will help pay for knee replacement including revision provided that:

  • you have the procedure while you have been formally admitted in a hospital;
  • it is a treatment for which Medicare pays a benefit;
  • it is not an Excluded Service on your level of cover; and
  • you've met all the standard conditions of your membership (like serving the relevant waiting periods).

Selected MBF hospital cover will pay for the following treatments and services so long as you are formally admitted to the hospital:

  • shared accommodation (or private room if available);
  • surgery-related expenses including operating theatre and intensive care if needed;
  • certain therapies such as physiotherapy and occupational therapy when provided by the hospital and associated with your hospital treatment;
  • certain drugs supplied as part of your inpatient hospital treatment; and
  • the full cost of a government-approved surgically-implanted prosthesis selected from the 'no gap' list developed by the Department of Health and Ageing. Visit here for more about prostheses and your health cover.

Please note all joint replacement procedures, including revisions, are Excluded services under MBF Budget and MBF Standard hospital cover. This means no benefit will be paid by MBF under these levels of cover for hospital and doctors' charges associated with that admission.

Remember, if you are not in an MBF Network Hospital and/or public hospital, you may incur substantial out-of-pocket expenses for your hospital charges.

Please note that the surgeon's and other doctors' charges will be part of your medical costs.

 

Your prosthesis costs

There should be at least one or more knee prosthesis available to you that will be no gap. If your surgeon recommends a no gap prosthesis, the cost of the prosthesis will be fully covered by your MBF hospital cover subject to the standard conditions. These conditions include waiting periods, any known Excess or Co-payment and any applicable Exclusions on your level of cover.

In a small number of cases, there may be other more expensive prostheses that your surgeon or doctor may recommend that could attract a gap. Ask your surgeon to explain the reasons why this particular prosthesis is being recommended for you over one without a gap. Where your surgeon recommends a gap-prosthesis for your surgery and you agree to that prosthesis, you will have to pay a gap amount.

If applicable, when and where to pay your prosthesis gap

When you are admitted to hospital for elective surgery, the surgeon should have made the hospital aware that a gap-prosthesis will be used for your procedure. The hospital will often ask you to the pay the prosthesis gap payment when you are admitted to hospital.

 

Your medical (doctors') costs

Ask your surgeon to explain the costs of your surgery including any prostheses gap amount, their own fees, any fees that other doctors involved in the surgery might charge, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as 'informed financial consent'. Obtaining this information is extremely important before any planned hospital admission.

Remember, there may be more than one doctor involved in the procedure. These may include the orthopaedic surgeon, an anaesthetist and an assistant surgeon. You may not meet them all in person.

Each doctor will charge for his or her services. See Going to hospital and Gap and informed financial consent for a guide to these costs.

Key things for you to know about medical costs and your health cover are:

  • MBF will pay benefits toward your doctors' charges for the service you receive:
    • when formally admitted as an in-patient in hospital or day surgery, and
    • when the service relates to treatment included under your level of cover, and
    • when you are entitled to a Medicare benefit for the treatment.
  • The Medicare Benefits Schedule Fee ('MBS') is the amount determined by the Commonwealth Government for the purpose of paying Medicare Benefits. For eligible in-patient services, Medicare pays for 75% of the MBS; MBF pays the remaining 25%.
  • Many doctors charge above the MBS, creating a 'gap' - an amount the patient has to pay.
  • MBF does not pay any amount charged by your doctor above the MBS unless there is an agreement in place between your doctor and MBF. This agreement is known as the MBF Medical Gap Cover Scheme.
  • MBF has created the MBF Medical Gap Cover Scheme to help reduce gaps paid by members. Doctors who participate in this scheme have agreed to accept the MBF benefit as full payment for your treatment. If a doctor has agreed to treat you under the MBF Medical Gap Cover Scheme there will be no 'gap' to pay for that doctor's charge.
  • It may be that not all doctors involved in your hospital treatment are 'no gap' doctors. So you may have to pay a gap for some doctors' services, but not others.

Remember, doctors are independent of MBF and can decide whether or not to treat you under the MBF Medical Gap Cover Scheme.

Click here for a list of 'no gap' doctors or call MBF.

 

Other costs relating to your treatment and recovery

Depending on your level of MBF extras cover, MBF can also help with the cost of:

  • physiotherapy to help you regain movement and strength in the leg;
  • occupational therapy to help you effectively modify your home and everyday activities to accommodate your restricted mobility;
  • complementary therapies such as therapeutic massage; and
  • gym membership through MBF Living Well Programs cover (restrictions apply).

MBF extras benefits are only payable for services provided in Australia by an MBF Recognised Provider. MBF Recognised Providers are health service providers that meet MBF guidelines. Call 131 137 to confirm whether or not your provider is a MBF Recognised Provider.

You can enjoy higher benefits on all preventive and general dental services and selected physiotherapy, optical, pharmacy and gym membership services (restrictions on claiming apply) by using the growing MBF MemberCare network of service providers. With our MBF MemberCare network of providers, you are guaranteed of receiving at least 70%-90% of the charge back on selected services depending on your level of cover, up to the annual limit of your cover. Find an MBF MemberCare service provider.

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Useful resources about knee replacement

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More about going to hospital, MBF Network hospitals, no gap doctors and MBF MemberCare providers

As well as calling MBF, you can find plenty of useful information about your health cover and what to expect when you go to hospital right here on this website.

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Last updated: 06-06-07

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