When should you consider joint replacement?

There is no textbook answer to this question. The answer lies within each person on an individual basis. The correct time is when the pain is severe and prevents you from enjoying normal life activities. Traditionally, orthopaedic surgeons have encouraged patients to wait as long as possible before having surgery. With new implant designs and improved longevity, patients can have joint replacement earlier, before losing valuable years “waiting” until they were older.

What should you expect from joint replacement?

The vast majority of patients who undergo joint replacement experience excellent outcomes, including significant pain relief, improved mobility, and a return to normal daily activities.

Long-term data from hip and knee replacements performed 15–20 years ago show survivorship rates of approximately 95% at 15 years and 70% at 20 years. With today’s advanced implant technology, expected survivorship rates for modern hip and knee replacements at 20 years are now greater than 95%.

Similarly high survival rates and patient satisfaction have been demonstrated with both anatomic and reverse shoulder arthroplasty. Overall, hip, knee, and shoulder replacement procedures are considered among the most successful surgeries in all of medicine, consistently showing high patient satisfaction and low complication rates.

What should you do to prepare for joint replacement?

Once you have decided to discuss anterior approach hip replacement, partial knee replacement, total knee replacement, or anatomic or reverse shoulder replacement, call our office to schedule a consultation. If a surgery date has already been set, be sure to make appropriate arrangements for time off work. The amount of time needed will vary based on the individual and the physical demands of their occupation.

It is also recommended that you have someone available to assist you after surgery. This support is typically only needed until you are mobile enough to be independent. If you smoke, please stop immediately, as smoking significantly increases surgical risks and the likelihood of complications.

Bactroban Nasal Ointment

We will be giving you a prescription for Bactroban (Mupirocin) ointment to apply to your nasal passages to prevent staph infections during surgery.

Directions for use: Apply generously inside each nostril with a separate Q-tip for each nostril and each application. (you should be using 2 Q-tips for each application) This is done twice a day starting 5 days before your surgery, so that you finish the last application the night before surgery.

Hibiclens Body Wash

Hibiclens is provided to help reduce skin bacteria at the incision site. Prior to surgery, wash the affected body part (the entire limb) once or twice daily for 5 days before surgery, and you may also use it on the morning of your procedure.

After surgery, we recommend using a gentle antibacterial soap to clean the incision. Most patients are allowed to shower within 72 hours after surgery and begin gently washing the incision; however, always follow your individual surgeon’s postoperative instructions. Do not take tub baths or soak the incision for 6 weeks after surgery.

The Incision

Your incision will be closed with absorbable sutures beneath the skin. The top of the incision will be covered with either Dermabond surgical glue, which creates a watertight seal, or Steri-Strips to help reinforce the closure for approximately two weeks after surgery.

The dressing applied in the operating room will typically remain in place for one to two weeks, depending on the type used. You may begin showering three to four days after surgery; however, please follow the specific instructions provided on the day of your procedure, as some dressings are waterproof while others must be removed prior to showering.

Once showering is permitted, allow water to run gently over the incision and cleanse the area with antibacterial soap. Do not scrub the incision. Avoid soaking in a bathtub, hot tub, or swimming pool for six weeks following surgery.

Swelling/Bruising

It is normal for the operative leg to swell after total knee or hip replacement surgery. This swelling may extend below the knee and is an expected part of the healing process that will gradually resolve over time.

Following shoulder replacement surgery, you may also experience swelling and bruising around the incision, including in the upper arm, forearm, and hand. This is common during the first two weeks after surgery and is considered a normal part of recovery.

Physical Therapy

You will begin walking within hours after surgery. Following hip or knee replacement, you will typically start walking with the help of a walker and gradually transition to crutches or a cane as your balance and strength improve, unless otherwise directed by your care team after discharge.

For shoulder replacement surgery, you will receive physical therapy orders on the day of your procedure. Unless therapy has already been scheduled, please arrange your first appointment within the first week after surgery. This usually begins with in-home therapy for the first month, followed by a gradual transition to outpatient rehabilitation.

Be sure to use your sling as instructed, and avoid pushing off or lifting with the operative arm during the early stages of recovery.

Restrictions

After shoulder replacement surgery, patients should wear their sling as directed while sleeping, napping, and when moving around for the first month following surgery. Avoid pushing off or lifting with the operative arm during the early stages of recovery. Activity levels will gradually increase over the next several months as healing progresses and strength improves.

Follow Up

Your first follow-up appointment in the office will typically take place four weeks after shoulder replacement surgery or six weeks after hip or knee replacement surgery. Most follow-up visits are conducted with one of our physician assistants unless there are specific concerns you would like to discuss directly with your surgeon.

Our surgeons work closely with the physician assistants and the entire care team to ensure continuity of care and to address any questions or issues throughout your recovery.

Infection

Any time an incision is made and the inside of the body exposed, an infection can occur. You will receive antibiotics on the day of surgery to prevent a surgical wound infection from developing. If you have a body mass index (BMI) over 40, your risk of infection is significantly increased and weight loss is recommended before proceeding with hip or knee replacement surgery. If an infection develops around an artificial joint replacement, you will require another surgery to wash out the wound and exchange some of the components. You will be on IV antibiotics for 6 weeks after that surgery and followed by infectious disease physicians. If the infection is not cured, the implants may need to be removed for a period of 8-10 weeks with another course of IV antibiotics. Re-implantation occurs after this period, but recovery is delayed significantly.

Bleeding

Most patients undergoing shoulder, hip, and knee replacement will not lose enough blood to require blood transfusion.  If you develop a large collection of blood under the skin (hematoma), you may have to return to the operating room to have it evacuated (removed). 

Nerve Injury

Nerve injury is uncommon following joint replacement surgery.

During anterior approach hip replacement, motor nerve injury is extremely rare. The primary nerve at risk is the lateral femoral cutaneous nerve, which provides sensation to the top of the thigh but does not control muscle function. Permanent injury to this nerve is rare. Some patients may experience a small area of numbness on the front or outer thigh after surgery, which typically decreases in size over 2–3 months.

After knee replacement surgery, it is common to have a small numb area along the outside portion of the knee. The genicular nerve, which passes beneath the kneecap, is unavoidably affected during any incision on the front of the knee. This area of numbness usually improves and becomes less noticeable over time.

With shoulder replacement surgery, transient nerve symptoms such as numbness or tingling in the arm, forearm, or hand can occur. These symptoms are typically mild and temporary and may be related to the anesthetic nerve block, surgical positioning, swelling, or temporary nerve irritation during surgery. More significant nerve complications are uncommon, occurring in approximately 1–4% of cases, with reverse shoulder replacements carrying a slightly higher risk than anatomic shoulder replacements due to altered biomechanics. The axillary nerve is the most commonly affected nerve and may cause temporary deltoid weakness or numbness over the outer shoulder, with symptoms usually improving gradually over time.

Leg Length Inequality

This is one of the most common patient complaints following traditional hip replacement surgery. The anterior approach, which is utilized by our surgeons, addresses this issue by using fluoroscopic x-rays in the operating room to ensure equal leg length while adjustments can still be made. Even with x-ray assistance, small leg length differences can occur but are rare.   

Dislocation

Dislocation can occur with extremes of movement, especially during the first 2–3 months after surgery.  The risk of dislocation is significantly reduced using the anterior approach for hip replacements to the point that no dislocation precautions are used after this surgery.  If a dislocation occurs, you will have to return to the hospital to have your joint replacement put back in place.

Fracture During Surgery

It is possible to fracture the femur bone while implanting the femoral stem of the artificial hip. The component is wedged tightly into the canal of the femur taking care not to use too much force, but on occasion, a crack in the bone will occur. If this does occur, we can expect the bone to heal without problem. If this happens, restrictions may be placed on weight bearing after surgery.  Fractures can also occur during knee or shoulder replacement surgeries but these are extremely rare. 

Blood Clots

A blood clot, or deep vein thrombosis (DVT), is a known postoperative complication of joint replacement. If a DVT develops, it can travel to the lungs causing a pulmonary embolus (PE) which is life threatening. All patients after hip replacement are placed on blood thinners for this reason. You will have compression stockings and leg compression boots in the hospital to increase circulation. Symptoms of DVT/PE include new or unusual leg or calf pain, chest pain and shortness of breath. If you experience any of these symptoms at home, please consult with a medical doctor.

Increased Risk for Smokers

Smoking greatly increases your chances of infection, wound complications, and deep vein thrombosis. Smokers also are at increased risk for pulmonary complications in the hospital. If you smoke, it is in your best interest to stop before considering surgery.

Increased Risk for Obese

If your BMI is over 35, your risks of surgery are increased. Patients with BMI over 40 have extreme obesity and are at very high risk. Complications that are seen in obese patients at increased rates are wound dehiscence (pulling apart), infection, blots clots (DVT), dislocation, fractures, implant loosening, prolonged hospital stay and poorer overall satisfaction rates. Your wound may be closed with non-absorbable suture due to high dehiscence rates and a special vacuum dressing may be applied which stays on for 2 weeks after surgery. If your BMI is above 45, you will not likely be a candidate for surgery.