What to Know About Total Hip and Total Knee Replacement Surgery

Treatment of arthritis starts without surgery. Over-the-counter pain relievers and anti-inflammatory medication may help. Using a cane or avoiding doing things that hurt may give relief as well. But you may develop pain that can only be treated by surgery. At first, you may only have pain or stiffness when walking a long way. As the arthritis gets worse, routines like taking short walks, putting on shoes, or dressing may cause pain. Arthritis of the hip and knee can affect your life in many ways – including how you feel psychologically.

The good news is that hip and knee replacements are very successful surgeries. It takes time to heal afterwards, but many people return to an active, pain-free life. Less pain usually leads to better walking ability and improvement in your overall health.

The right time for joint replacement surgery is a common concern. Many factors are important to think about: general health, time away from work, family commitments, and the time it will take you to get better afterwards. Most people decide the time is right when their knee or hip pain prevents them from living comfortably. In many cases, arthritis pain will prevent you from doing very simple things. Perhaps you cannot take care of your home or family, or you can no longer do your job. You must make the individual decision about the right time to have surgery.

People with hip and knee arthritis have disability from two things: Pain and Mechanical symptoms such as locking of the joint. Some people suffer from pain, swelling, and stiffness for years before considering surgery. Other people see a doctor when mechanical symptoms (buckling, clicking, grinding, or limping) get worse. These symptoms can jeopardize safety at home or at work. As hip and knee arthritis worsens, the stiffness of the arthritic joints also worsens. This can make the replacement surgery slightly more difficult. That may mean a longer recovery and more physical therapy. However the timing of your surgery is still dependent on your own symptoms and your own decision.

Total hip and total knee replacements have improved the quality of life for millions of people worldwide by relieving pain and restoring function and motion caused by arthritis and other joint conditions. People with successful joint replacements are able to stand, walk, rest and participate in recreational activities with little pain. While some people would be satisfied if they achieve these basic goals, others will expect to do more like participating in physically demanding sports and hobbies.

If you are considering joint replacement surgery, you should have an open, honest discussion with your surgeon about setting expectations for pain relief and function after surgery. You can learn about what to expect from the early recovery phase through the final result.

Based on your unique medical history and your physical and mental condition prior to surgery, your surgeon will also have expectations about your level of function after surgery. Setting high expectations that are unrealistic can lead to dissatisfaction with the final result. Setting expectations too low may not allow you to achieve the best possible function and result after surgery. Your expectations and your surgeon’s expectations should be aligned so that you can achieve the highest level of satisfaction with your procedure.

Surgeons aim to guide expectations for recovery through discussions with their patients so that there is agreement on the goals of surgery. In one of our studies, we observed that recovery expectations were not aligned in at least 50% of patients undergoing elective joint replacement surgery. The take home message is that it is paramount to discuss the expectations for pain relief and function with your surgeon before undergoing a total joint replacement to make sure you’re both on the same page.

There are many studies attempting to evaluate these emerging technologies and their influence of the success of surgeries. Each of these technologies has a specific goal that has fueled its development (i.e. more accuracy in implant placement, more efficient or faster surgery, etc.).

To date, there appears to be both pros and cons to each of these technologies without any clear advantages, but more research is required to determine what advantage, if any, these may offer.

Despite a substantial amount of direct-to-consumer marketing, the best approach is to discuss this topic with your surgeon. You may want to know if they use one of these technologies, why they have chosen to do so, and what their experience has been in using it.

You will likely stay in the hospital for three to five days depending on your rehabilitation protocol and how fast you progress with physical therapy. This is highly dependent upon your condition before surgery, your age, and medical problems which can influence your rehabilitation. A safe discharge plan will be arranged for either home or a rehabilitation facility.

Recovery starts right after surgery. You are helped out of bed on the day of or the day after surgery. A physiotherapist will help you to walk. Most patients will have one or two sessions of physiotherapy per day. The goal of therapy is to assist with strengthening of the muscles and walking. Therapy will also make sure that you are safe when you go home. That’s important when doing things like dressing, using the bathroom, getting up from a chair, and climbing stairs.

Walking soon after surgery helps you get better. It also helps avoid things like bedsores, pneumonia, and blood clots. While moving around helps prevent blood clots, most doctors will use a more formal programme of blood clot prevention like stockings worn on the legs, inflating foot or leg pumps, and blood thinning medications. These medications are to be continued after you go home for up to six weeks.

Fear of pain from surgery is one of the biggest reasons why people avoid having a hip or knee replacement. With better pain control utilising multimodal pain regimes and the benefits of the acute pain service within the hospital, you will have mild to moderate pain. Pain control comes from using several medications that affect both the spinal cord and the brain. Doing so means smaller doses and fewer side effects like nausea. Surgeons may also inject pain medicine into the hip or knee at the time of surgery to numb the area. At many hospitals, pain medications are given even before surgery begins.

Nausea can make recovery harder. It has many causes including stress and pain medications. Using less medication that includes narcotics (like morphine) will help to lessen nausea. There are also medications that help control nausea if it occurs.

Many patients are able to leave the hospital and go directly home after surgery. It is important to identify a family member or friend who will be able to help with common household tasks such as preparing meals and doing dishes. Some patients will require a stay a specialized care facility such as a nursing home or rehab hospital.

In general, patients are able to climb stairs after leaving the hospital; however, it is often initially slow and tiring. This soon improves, but most patients are happiest if initially they are able to stay on one floor after returning home from surgery.

Most patients are not safe to drive at for at least three to six weeks after surgery. This depends on a number of factors including your joints’ rehabilitation, which side underwent surgery combined with the use of a manual or automatic vehicle, the analgesics requirements at the time and the ability for the driver to safely control the vehicle. It is not recommended to drive on strong narcotic analgesics as it may impair your ability to drive and react to quick decisions. There needs to be a return of both adequate strength and reflexes in the controlling limb to drive safely. Your surgeon and their team will guide you as to when it is safe to drive. If in doubt, it’s best to not drive till review.

Most patients are out of sedentary work for about four to six weeks following surgery. Patients with very physical jobs may take as long as three months to return to work.

Many efforts are ongoing to reduce the pain patients have after surgery; however, most patients still do require some pain medications for the first six weeks after surgery. This may be longer for some patients. Especially those having undergone knee replacement surgery.

All patients benefit from specific exercises after surgery. These will be directed by your surgeon and often will involve a physiotherapist. Most patients need to do their exercises for a minimum of four to six weeks following surgery.

Most people get the bulk of their recovery from hip or knee replacement by eight to twelve weeks. The skin incision or cut takes approximately two to three weeks to heal. The time it takes to walk without a cane or drive after surgery is different for everyone. You will need physical therapy after going home. Even though the skin incision or cut will heal in two to three weeks, the process of healing can take up to a year. Scar tissue tends to soften over time, so you will continue to improve even after your physical therapy is over.

Studies show that about eight out of ten people who have hip or knee replacement are pain-free within a year. Once you are without pain, you will notice an improvement in your ability to walk. A new hip or knee may allow you to return to your favorite pastimes like walking, swimming, gardening and even some low-impact sports.

For about nine out of every ten people who have had a hip or knee joint replaced, the new joint is still working well after fifteen years. How long the replacement will last depends on a number of things. Younger individuals who are more active tend to wear out their replaced joints quicker. Older, less active individuals find their joint replacements last longer.

Replacements may fail by the parts becoming loose. The joint surfaces may wear. Bone could break down around the parts, infection could set in, or in rare cases, the parts themselves might break. Many of these problems can be seen by a doctor on x-rays before you feel that anything is wrong. This is why you should see your doctor on a regular basis after surgery even if you feel well. Treatment soon after a problem occurs is usually more simple. But if the problem is ignored, it can be much harder to fix.

Common post-operative follow-up visits include visits at 6 weeks and 10 weeks, depending on each individuals’ recovery, and out to 1 year.

In general, seeing your surgeon every three to five years is recommended. Of course, if you have any concerns or develop any problems between these appointments please let me know.

Getting a Good Night’s Sleep after Hip or Knee Replacement Surgery

One of the most common complaints after total joint replacement is difficulty sleeping. The most common cause of sleep disruption is pain. It has been reported that more than half of patients wake up with pain after joint replacement. Many factors can affect the quality of sleep after a major surgery including anesthesia-type, narcotic use and discomfort due to pain or restricted leg movements.

As sleep is crucial to the recovery process, it is important to follow appropriate pain management protocols.

Contemporary pain management protocols are designed to be multifaceted and inhibit pain in a multitude of ways. Many protocols use a variety of injections and nerve blocks for localized pain, as well as employing narcotics and anti-inflammatory medication for several weeks after surgery. As such, pain protocols should be fully followed to ensure an adequate recovery.

Usually around the second or third week after surgery, you will start to increase your activity levels while at the same time decrease your narcotic use. This often coincides with having a difficult time sleeping. When this occurs, you should take your pain medication an hour before bed to achieve better comfort and help restore your sleep cycle. A few days off from strenuous activity or physical therapy will not inhibit your recovery, but can have a tremendous effect on your ability to fall asleep and stay asleep.

Overall, sleep deprivation after total joint replacement is manageable through pain management, the occasional use of sleeping pills, and activity modification. If all else fails, it is advisable to  call your surgeon who can help you manage sleep disturbances during the postoperative period.

Belt buckles, key chains and smartphones may set off sensitive metal detectors at airport security checkpoints. Many commonly used orthopaedic implants may also set off the metal detectors. Over 90% of implanted total hip and knee arthroplasty devices will set off airport metal detectors. Many implants now include ceramic and plastic materials in addition to metal, and the metal will still likely cause an alarm.

A card from your doctor is not needed for identification of these type of implants.

If you or a family member has a metal implant, he or she should inform the security officer before screening begins.

Many patients now prefer to be screened by imaging technology (X-ray machine) to reduce the likelihood of a “pat-down” being necessary. If a “pat-down” is selected by the security officer, it may be helpful to wear clothes that allow you to easily reveal your surgical scar.

Regular activity/exercise will actually help to strengthen the muscles around your new joint, provide stability, and help your mobility. If anything, inactivity is potentially harmful to your new joint replacement, and to your health in general. The extra body weight that tends to come from a sedentary lifestyle puts a greater load on your joint and may increase wear and tear.

They weigh between half to 1kg.

Common activities allowed include walking, hiking, golf, swimming, doubles tennis, stairclimber, treadmill, road cycling, stationary bicycling, elliptical trainer, low-impact aerobics, rowing, dancing, gardening, tai chi and weight machines.

If you are experienced, you can perform downhill or cross-country skiing, snowboarding, surfing, weightlifting and pilates.

In general, most patients are advised to avoid running, jumping, or impact sports after surgery. Such activities include things like jogging, soccer, touch football, high impact aerobics, singles tennis, squash and martial arts. It is hoped that these recommendations will make your joint replacement last longer.

If you need total knee or total hip replacement surgery-and your weight is significantly higher than it should be-your doctor may advise you to lose weight before your procedure. Even though you may feel fit and healthy at your current weight, studies show that a patient with a BMI greater than 40 is more likely to experience serious complications both during and after surgery than a patient of normal weight. Your doctor wants you to be aware of these risks so that you can take steps to minimize them before your procedure.

What is BMI?

BMI is a measure of body fat based on height and weight. Typically, the higher your BMI, the more body fat you have. Your doctor will use the following calculation to determine your BMI:

BMI = weight (kg) / height (m)2

For an adult, the following BMI ranges apply:

BMI Ranges Weight Status

• 18 to 24 - Normal
• 25 to 29 - Overweight
• 30 to 39 - Obese
• 40 to 49 - Morbidly obese

Health Conditions That May Impact Surgery

Patients with obesity are more likely to have certain diseases and health conditions that increase the risks of surgery. These include:

• Cardiovascular disease, including high blood pressure
• Type 2 diabetes
• Obstructive sleep apnea

Metabolic syndrome-a group of health conditions that increase your risk for developing cardiovascular disease and type 2 diabetes

It is important to be in the best health possible before your surgery. If you have one of these conditions, your doctor will work with you to ensure that it is managed and under control before your procedure.

Increased Risk of Complications

There are risks associated with every surgery. However, some risks are greater for patients with obesity.

Complications During Surgery

Anesthesia. It is more difficult to administer anesthesia to a patient with obesity. Complications may be due to the patient's body shape and anatomy, or to health conditions that can affect breathing. Challenges for the anesthesiologist include:

• Locating veins to administer general anesthesia and necessary medications
• Ensuring that oxygen and airflow are sufficient
• Properly positioning the needle when delivering spinal and epidural nerve blocks and other types of regional anesthesia

Operative times. There are technical challenges associated with performing surgery on a patient with obesity, so operative times are often longer. In general, the longer you are in surgery, the greater your risk of experiencing complications.

Complications After Surgery

Compared with a patient of normal weight, a patient with obesity is more likely to experience the following complications after surgery:

• Infection
• Poor wound healing
• Difficulty breathing
• Blood clots
• Pulmonary embolism-a blood clot in the lungs

Lesser Outcomes after Joint Replacement

Joint replacement will help relieve your pain and enable you to live a fuller, more active life. However, if you have obesity, you may never achieve the increased mobility and range of motion experienced by a patient of normal weight.

You may also experience more implant and prosthesis complications after surgery, including:

• Component loosening and failure
• Dislocation of the replacement joint, especially in the hip

In some cases, a second "revision" surgery may be necessary to remove failed implants and replace them with new ones.

Reducing Your Risks

In most cases, total hip and total knee replacement are elective procedures. For this reason, your doctor may recommend that you try nonsurgical treatments-such as medications and physical therapy-in order to delay your joint replacement surgery. This will give you time to lose weight and reduce your BMI before your procedure.

Losing Weight

The key elements to losing weight are diet and exercise. In general, you should try to make the following lifestyle changes:

• Reduce your fat and calorie intake. Try to eat meals that are full of fruits, vegetables and whole grains, lean meats, and low-fat dairy. Drink plenty of water and avoid sugary drinks that are high in calories.

Get more physical activity and exercise. If you have constant hip or knee pain, you may not be as active as you were before. Low-impact activities-such as swimming, biking, or using an elliptical machine-will put less strain on your joints than strenuous exercise and will still be effective in helping you lose weight.

Making a Change Now

Patients who need joint replacement surgery often intend to lose weight after their procedure-when their relief from pain will enable them to be more physically active.

In reality, however, studies show that just a small percentage of patients with obesity actually lose weight after joint replacement-the majority of patients maintain the same BMI after surgery.

Rather than waiting, there is great value in establishing a healthier lifestyle now-before your joint replacement surgery. Losing weight and reducing your BMI will decrease your risk for complications and increase the likelihood of a successful surgical outcome. In some cases, it may also decrease your pain to the point where joint replacement may no longer be needed-or can be put off for a number of years.