If I had been having the type of troubles and pain for as long as you, and this is an old post, so hope something good has happened since then, I would have sat down with my Doc and said "What new knees are out there that you can install"? You have to be in charge of your treatment. Doctors understand and will try to abide by your wishes. No one wants to have their knees or hips replaces unless they have had enough pain and agony to want a better way. This AVN condition can be beaten, but it requires drastic measures. Good Luck!

One would think that your surgeon would give you more concrete and specific reasons WHY those concerns (pain and 'quality of life') are not enough reason for him to be willing to replace your knees. Obviously, doctors' opinions and viewpoints will vary widely and each doctor/surgeon forms their own opinions based on their own experiences, research, and study.  I'm not saying his position isn't valid or medically sound, but did he clearly explain to you WHY his position is what it is?  I am rather curious as to why he has such a hard-line drawn in the sand that he will not cross, i.e., you absolutely MUST show signs of structural collapse before he will consider replacing your knees.  Is this a commonly held belief by most ortho surgeons?  (I'm genuinely asking; I don't know if it is or not.) Given that you have suffered for as long as you have in unbearable amounts of pain and have experienced an extreme decrease in your quality of life, and have by your own testimony tried every available nonsurgical alternative (pain medications, physical therapy, decrease in certain activities, etc.) and even a lesser (though still traumatic) surgery that did provide some temporary pain relief (core decompression), it would seem to me that you've "done your time" so to speak and your surgeon needs to make a better case for why he will not allow your pain and quality of life issues to influence his decision.  Or perhaps it is time to seek another surgeon's opinion (or two or three).

Granted, this isn't a very thorough or exhaustive search but a cursory Googling on total knee replacement candidacy qualifications turned up the following statements, which you may find interesting given your circumstances (underlines are mine):

"Most patients who undergo total knee replacement are age 60 to 80, but orthopaedic surgeons evaluate patients individually. Recommendations for surgery are based on a patient's pain and disability, not age."

(Taken from the American Academy of Orthopaedic Surgeons' website; see http://orthoinfo.aaos.org/topic.cfm?topic=A00389)

"The decision to undergo the total knee replacement is a "quality of life" choice. Patients typically have the procedure when they find themselves avoiding activities that they used to enjoy because of knee pain. When basic activities of daily life--like walking, shopping, or reasonable recreational pastimes--are inhibited or prevented by the knee pain, it may be reasonable to consider the surgery." 

(Taken from the UW Medicine Sports & Orthopaedics and Sports Medicine website; see http://www.orthop.washington.edu/uw/totalkneereplacement/tabID__3376/Ite...)

"The aims of TKR [total knee replacement] are relief of pain and improvement in function.  Candidates for elective TKR should have radiographic evidence of joint damage, moderate to severe persistent pain that is not adequately relieved by an extended course of nonsurgical management, and clinically significant functional limitation resulting in diminished quality of life."

(Taken from the National Institue of Health's website, from the NIH Consensus Development Conference Statement on Total Knee Replacement; see http://consensus.nih.gov/2003/2003TotalKneeReplacement117html.htm)

So I would guess that it's probably not EVERY surgeon's/doctor's opinion that your specific case wouldn't make you a candidate for replacement just because your knees haven't started to collapse yet. 

Again -- to be clear, I'm not trying to make the case that you absolutely 100% should have the replacement surgery.  I'm sure that total knee replacement is not without its significant risks, complications, and drawbacks, all of which I'm sure you know and have considered and which I hope your surgeon has gone over with you in depth.  And I certainly do appreciate that your surgeon is being conservative and cautious and is seemingly motivated by not wanting to put you through undue hardship and pain as a result of surgery he doesn't feel (for whatever reason) is the right choice for you at this time. But he isn't giving you any alternative to suffering with the undue hardship and pain as a result of the disease you have right NOW. 

So to address your specific point about pain and quality of life not being sufficient enough considerations to your surgeon -- it is a bit baffling, and there does seem to be evidence pointing towards the opposite opinion out there in the medical community.  So I would suggest it's time to begin researching other doctors/hospitals and get yourself another opinion or two.

I'm definitely interested in hearing other patients' experiences with this as well as their thoughts on the matter.

--kb

I am quite shocked that this doctor would not consider quallity of life for his patient.  How dare he suggest that you just go on suffering everyday with extrodanary pain, jeperdising your job and ultimately putting your life on hold.  To me, one of the most important parts of being a doctor is helping people make their quality of life better.  If there is a small chance that your knees will get better then he should give YOU the option of having them replaced, not take the option off the table. 

I would suggest that you look for another doctor.  I am sure any good doctor would give you the choice. Maybe someone here can suggest one.

Take care Joel and thanks for helping the AVN community!