FREQUENTLY ASKED QUESTIONS : ORTHOPEDIC SURGERY

The technology utilized in modern implants today far exceeds what was available when joint replacement surgery was first introduced. In hips, the bone eventually grows directly into the implant. This allows for the prosthesis to become a part of your skeleton as you heal in the first 4-12 weeks following surgery. Until approximately 15-20 years ago, the plastic component (polyethylene) would commonly wear out early on, causing degradation of the surrounding bone and the possibility of loosening of the implants. Now, this material has been engineered so that it can withstand decades of use. It is difficult to answer exactly how long the material can last as the most recent engineered products have not been around long enough to see them fail from simply overuse. What we know now is that it is more likely for you to require a repeat surgery for a reason other than component wear, such as a fracture, infection, or loosening of the implant.

In hips, both the acetabular component (cup) and the femoral stem are made of some form of titanium, which is specifically engineered to allow your native bone to grow into the implant. Inside the cup, a highly engineered plastic called “highly cross-linked polyethylene” is placed followed by either a ceramic or metal ball which fits on the end of the femoral stem. This combination is now considered the gold standard in hip replacement with the longest experience and most published data allowing for a variety of options to be tailored to the individual needs of each patient, including multiple head sizes and face changing, lipped, or lateralized liners.

In knees, the same engineered plastic is utilized between the femoral component and the tibial component. Both are made of a metal alloy called “Cobalt-Chromium” which are then cemented onto the bone utilizing a specific bone cement called “Polymethylmethacrylate”. This substance acts like grout as it is applied in a soft form, squeezing into the intricacies of the bone before it hardens into place.

Most likely, yes. It depends on the sensitivity of the detectors in the specific airport. Joint replacement cards are no longer provided as they are easily replicated illegally.

Poor dental hygiene is a well-known risk factor for infection following joint replacement as there are many bacteria in the mouth that can be spread into the bloodstream with simple acts such as dental cleaning and even flossing. Although the main governing organizations for both orthopaedic surgeons (AAOS) and dentists (ADA) have now released a statement that routine dental cleaning does not require antibiotic prophylaxis following joint replacement, there are a few general guidelines and exceptions to this rule:

• All patients should try to complete any expected dental work prior to their joint replacement, especially if there are any loose or infected teeth.
• If possible, try to avoid any dental work within the first 3 months following your joint replacement.
• Within the first year after surgery, patients should use antibiotic prophylaxis prescribed by your dentist for all dental work, including routine cleaning.
• Following 1 year after your joint replacement, any major dental work for the rest of your life should use antibiotic prophylaxis but for routine cleanings it is no longer mandatory unless recommended by your dentist.

Hip and knee replacement are two of the most successful surgeries performed in all of orthopaedic surgery. As in every surgery however, there are always possible risks and complications that can occur. Common to every surgery is the risk of anesthesia-related complications such as heart, kidney, and breathing problems which are higher in patients of older age and increased number of medical comorbidities. Therefore, we require a clearance letter from your primary care doctor prior to proceeding with your joint replacement.

The risk of infection and poor outcome rises with the number of medical comorbidities as well as the presence of diabetes, smoking, and obesity.  BMI (Body Mass Index) greater than 40 is a known risk factor for many different complications, so weight loss may be recommended prior to surgery in order to minimize risk of complications.  All diabetics should be aware of their hemoglobin A1C value, which should be less than 7.5 to proceed with surgery. Lastly, there is a risk of developing a blood clot in the leg or the lungs, known as a pulmonary embolism, which can be fatal. My typical protocol for protection against blood clots is aspirin twice daily. If you are at elevated risk or have a history of blood clots, you will be placed on a more potent blood thinner following surgery.

One of the risks specific to the anterior approach to the hip is irritation of the nerve supplying the outer part of the thigh near your knee. This nerve is called the “lateral femoral cutaneous nerve” and travels close to the incision site. It is rarely cut but can be disturbed by the surgery, causing a numbness or burning sensation along the distal thigh which can take up to 6 months to resolve or improve.

Most patients experience numbness on the outside of the knee following both partial and total knee replacement which can last forever but usually will slowly improve over 6 months.

Less common risks include fracture of the bone, stiffness, persistent pain, dislocation, nerve irritation, and the need for blood transfusion.

Minimally invasive surgical techniques are utilized in both my hip and knee replacements. Generally, the incision will be as small as possible, but large enough to do the procedure right. For hips, this generally depends on the size of the thigh but ranges from 3-6 inches. The important thing I like to convey to patients is that I will not compromise the outcome of the procedure just for a small incision as there are plenty of studies showing a higher risk of wound complications and component malposition with too small of an incision.

For knees, my preference is to perform one side at a time due to literature suggesting higher rates of complications including infection, bleeding, cardiac and pulmonary distress, and incidence of blood clots following simultaneous bilateral surgery. Depending on your recovery from the first surgery as well as your other medical risk factors, I would consider performing the contralateral joint replacement as soon as 6-8 weeks later.  For hips, there is newer data suggesting that in appropriate candidates, having both hips replaced during the same surgery using an anterior approach does not carry any increased complication rate.  For the right candidate, simultaneous bilateral anterior hip replacement is a surgery that I perform.

For the majority of my anterior hip replacements, I use a company called Depuy. The cup is called Pinnacle and the stem is called Actis. For partial and total knees, I use an implant called Triathlon by Stryker.  On occasion, I will use different implants if it is better for the patient’s unique anatomy or to best address the complexity of their problem.

Individual recovery is highly variable and depends on your preoperative level of activity and mobility as well as your overall health. The first two weeks following joint replacement are the most difficult. Patients will slowly transition from a walker to a cane as the joint heals and recovers from surgery. We will see you back in the clinic at 2-3 weeks after surgery to check the wound and address any concerns or questions you may have. The following month will bring drastic improvements in mobility, strength, confidence, and pain control, with patients often returning to their baseline activities. Your joint replacement will continue to improve through 3-4 months after surgery, with a noticeable improvement each day. In fact, more recent data tells us that your joint replacement continues to improve even after 1-2 years following your surgery.  In general, hip replacement patients tend to recover a bit quicker and with a bit less pain than knee replacements.

Depending on overall health, preoperative level of function, and social support at home, most hip and knee replacement patients can be discharged home from the hospital the day after surgery. Some patients may even be candidates for discharge home the same day, and this can be discussed further in the office.  Some reasons that may make it unsafe to go home the day after surgery include significant cardiac disease or multiple medical comorbidities which we will discuss at your office visit.  I am a major proponent of patients going home as opposed to going to inpatient rehab facilities or nursing homes.  Nearly all patients who are healthy enough to undergo an elective joint replacement are healthy enough to go home following surgery with appropriate support at home from family and friends.  Published data suggests that rehab facilities are associated with higher infection rates and higher readmission rates so I prefer discharge home whenever possible to ensure the best possible outcome for you.

In greater than 90% of patients, no, a nursing home is not required. With modern surgical techniques, early mobilization and multimodal pain control, nursing homes have a very limited role in the recovery after joint replacement. Instead, research has demonstrated improved outcomes with recovery at home, with less incidence of infection and confusion, and earlier return to everyday activities. Typically, this is accomplished with the help of friends and family who are able to live with the patient for the first 5-10 days following surgery.  For older patients with more complicated medical issues who truly have no social support, a rehab facility may be an appropriate option.

All patients are discharged from the hospital with a walker. Most patients then feel comfortable dropping the walker for a cane anywhere from 5-14 days after surgery. It is important to take advantage of these ambulatory aides as the risk of falling is greatest within the first two weeks of surgery due to general weakness and the effects of the surgery and anesthesia.

You will receive physical therapy while in the hospital and then at home with home health for the first 2 weeks after surgery. A prescription to begin outpatient therapy will be given to you at your first post-operative office visit.  Some anterior hip replacement patients may not require any formal outpatient physical therapy but this is decided on a case by case basis  Partial and total knee replacement patients benefit from early therapy to ensure maximum range of motion can be obtained.

All of my surgeries are performed at NorthShore Skokie Hospital in Skokie, Illinois.  This hospital recently underwent a $350 million dollar renovation and offers state-of-the-art operating rooms and all private patient rooms.

My usual protocol includes spinal anesthesia to numb the patient from the waist down. This allows for a much safer procedure from a cardiac and pulmonary standpoint with many of the risks and complications of anesthesia minimized. Instead of general anesthesia, you are placed in a twilight sleep which is easily reversible allowing you to wake from your surgery more quickly and without the fogginess of general anesthesia. In addition to a spinal, both total and partial knee replacement patients will also receive a nerve block along the femoral nerve in the thigh, called an “adductor canal block”, which allows for additional pain relief following the surgery but without resulting in muscle weakness or paralysis. This combination allows for the patient to participate with physical therapy within only a couple hours of the surgery with less discomfort.

For primary hip and knee replacements, the surgery itself takes a around an hour to do. However, the whole process of getting you to the operating room, transferring you to the table, setting up anesthesia, and waking up makes this process longer than that. More complicated joint replacements and revisions may take longer depending on what is being done.

Almost all incisions for primary hip and knee replacement are closed using absorbable sutures under the skin followed by skin glue, creating a cosmetic and thin scar.  On certain occasions, such as revisions or in patients with very thin skin, staples or nylon sutures will be used.  These do require removal, typically 2-3 weeks after surgery.

Yes – every patient having an elective joint replacement will receive some form of blood clot prevention medication. Your individual risk factors for the development of blood clots, including any history of previous blood clots will be discussed in the office. Most patients are at standard risk and will take an 81mg tablet of aspirin twice daily for 3 weeks following surgery. If you are at elevated risk, Coumadin may be considered.

After surgery, a combination of anti-inflammatory medication, Tylenol, and low dose pain medicine such as tramadol or norco is typically all that is required.

Multimodal pain management is a term that refers to attacking the pain from surgery at every level, and is done with trying to minimize opioid or narcotic pain medication. Our pain management strategy begins before the surgery even starts with a cocktail of preoperative medications aimed to trick the body not to initiate a cascade of inflammatory mediators that usually cause pain. During the surgery, the utilization of minimally invasive techniques combined with a local pain cocktail injection at the surgical site and spinal anesthesia ensure you wake from your procedure in the least amount of discomfort possible.

The bandage is sealed and remains in place until removed by the home health nurse at 7-10 days following your surgery.  If there is any sort of continued drainage present, our office should be notified.

I prefer all patients wear thigh-high compression stockings on both legs for the first two weeks to decrease your risk of developing a blood clot and to assist with swelling. They may be removed at nighttime.

I prefer the anterior approach for my primary hips and some of my basic revision hip replacements. This approach is tissue and muscle sparing with the advantage of an earlier functional recovery and less risk for hip dislocation. With the anterior approach, there are no true hip precautions or motion restrictions. It also allows for easier use of x-ray during the procedure to better predict leg lengths and component position. Although I will do perform traditional posterior approach for more complex or revision surgery, this would be discussed at length during the patient visit.

One of the benefits of the anterior approach is the lack of restrictions following hip replacement. No pillow is required between the legs. Although it is best to not sleep directly on the incision until it is healed, you may sleep in whatever position is most comfortable. If you have a posterior approach for your hip replacement, I do recommend using the pillow between your legs at night for 6 weeks.

One of the major advantages of the anterior hip is the lack of restrictions regarding the sitting position, so getting in a car or normal chair should be pretty easy after a few days. To get in a car, sit on the seat first and then swing in your legs, as you pivot on your bottom. Even though there are less flexion (bending) restrictions, please avoid low couches or soft chairs, as you may have trouble getting out.

In hip replacement, the term “metal on metal” refers to a metal ball which moves directly within a metal liner rather than utilizing the plastic in between. This technique was popular in the early 2000’s with hundreds of thousands of patients receiving this construct. Unfortunately, we have learned that this type of hip replacement sheds small metal shavings into the surrounding tissues which can enter the blood stream, destroy the muscle and tissues around the hip, and can lead to further complications including dislocation, weakness, and pain. Complications following metal on metal hip replacement have led to many patients requiring a revision surgery. Metal on metal total hip replacement is therefore no longer performed.

Robotic surgery refers to a robotic “arm” that is used to assist with total or partial knee replacement. The technology allows the surgeon to create a 3-dimensional model of the patient’s knee on the computer screen and virtually perform the surgery on the computer, analyzing the component positioning and balance, all before making a single cut of bone. This technology is truly revolutionary and gives the surgeon an incredible advantage to give the patient the best possible outcome. All the cuts are still performed by the surgeon but with the assistance and feedback from robotic arm. I encourage you to view the information listed here for more details.

Most patients choose not to kneel directly on their new knee as they find putting pressure directly on the healed incision is no longer comfortable. If kneeling is important for outside gardening or religious worship, it is recommended to purchase knee pads with slow improvement in comfort over time.

Walking is the best! Most patients feel most comfortable using the walker during the first week. With the anterior approach, muscles are better able to withstand the force of ground pressure, allowing patients to bear full weight and progress to using a cane by around the second week after surgery. As long as there is no pain with weight bearing, this is fine. If there is no pain you may progress to using a cane. Until you are able to walk without a limp, you should stay on the support of a cane; it does no good to walk with a significant limp, which can hurt your back or other joints. You can expect to be walking within hours of your surgery with the help of a walker and the physical therapists and nurses in the hospital or surgery center. My usual protocol does not require any restrictions with weight bearing.

Your incision will be covered by a sealed bandage. This bandage allows you to shower immediately, letting the water run over the dressing. The dressing will be removed by the home health nurse at 7-10 days following your surgery. Due to risk of wound complications and infection, please do not submerge your dressing or incision under water in the pool, hot tub, or bath until 6 weeks after your surgery.

Most patients can return to driving within 3-4 weeks of surgery, with left-sided surgery often returning more quickly than right-sided surgery. Some patients even return quicker than this.  The main barrier to driving is use of narcotic pain medication, as this is considered driving under the influence.  Once narcotics are no longer required, I typically recommend that patients go to an empty parking lot to practice before returning to the roads.

Depending on your type of work, most patients are able to return to a desk job only a few weeks following their surgery. If your job requires a lot of travel, walking, or intense lifting, you can expect a later return to work anywhere from 1-3 months after surgery.

Although you may return to the driving range to gently practice your swing, it is typically advised to wait at least 4 weeks before returning to a full round of golf.

There are no absolute restrictions on when you can fly but most patients prefer to wait at least 2 weeks as it may be quite uncomfortable on the airplane during the acute recovery following joint replacement. Remember, your risk of developing a blood clot is higher after surgery with the risk further elevated with long travel. If you choose to fly soon after your joint replacement, remember to take your aspirin, wear your compression stockings on both legs, and get out of your seat frequently. I typically recommend patients delay significant travel plans until after their 6 week visit.

Although there are no true restrictions, most patients wait until their incision has started to heal, typically around 3-4 weeks.

Again, due to the anterior approach I do not impose any true restrictions on motion. You are free to pick up small items off the floor immediately if it is comfortable to do so.