10 Things You Should Know About Joint Replacement

(This article previously appeared on Grandparents.com.)

Doctors share inside information on what it's really like to get joint replacement surgery.

Thirty percent of Americans aged 45 to 64 have arthritis that’s been diagnosed by a doctor. For people aged 65 or older, that number rises to nearly 50 percent. Osteoarthritis (brought on by wear and tear) and rheumatoid arthritis (which is an autoimmune disease that attacks the joints) are the most common scenarios that lead to joint replacement surgery, says Dr. Claudette M. Lajam, a hip and knee reconstruction surgeon at NYU Langone Medical Center in New York City. “Surface cartilage [between joints] can wear out, which creates abnormal stresses across the joint — it doesn’t roll and glide smoothly anymore. This can be painful and cause the joint to become stiff.”

More than 1 million adults in the U.S. have surgery to replace their hip or knee each year, according to the National Institutes of Health (NIH). Why the rush for bionic bones? For one, Lajam says, advancements in implant technology in the last 15 years translate to better functionality and less pain for patients. Second, America’s 76 million boomers expect to remain active late in life, despite the inevitable joint degeneration that accompanies aging — so demand is growing.

“Since total joint replacement offers pain relief and restored mobility, these active older folks don’t need to let pain and loss of function from arthritis slow them down. People come in and say, ‘Doc, my hip is killing me — I can’t reach to put my shoes on anymore,’” Lajam says. “There is nothing like a hip replacement — you can’t walk and then, two to three days later, you can walk. You can see the pain in people’s faces before surgery. Then two to three months afterwards, they look like a different person. It’s remarkable.”

In most cases, increasing levels of everyday pain that analgesics and NSAIDs can’t fix are a sign you should visit a doctor. “You might be in a lot of pain, life starts shrinking, and you can’t do things you used to,” Lajam says. “If patients can’t control their symptoms with medication, physical therapy, injections or losing weight, they’re a good candidate for surgery.”

An objective red flag that you probably need surgery is if X-rays or imaging reveal significant damage to the cartilage or a deformity. “When joint deformity gets very bad, it becomes more difficult to fix it — you lose ground,” she says. “The soft tissues around the joint might not respond as well after surgery when the joint is very deformed, and postoperative results are not as good. There’s only so much we can do to restore function once the joint has passed a certain point.”

Experts agree that pain management has come a long way in the last 15 years. "We’ve started to inject pain medication directly around the joint during surgery,” Lajam says. "They last for five to six days — we get remarkable results from that kind of pain protocol. We can get away with not prescribing as many pain narcotics."

Plus, doctors will administer local injections immediately after the 1- to 1 1/2-hour surgery to minimize swelling and decrease the pain response, says Dr. Michael Alexiades, an orthopedic surgeon at the Hospital for Special Surgery in New York City. "The day of surgery to the day after, pain level is at a three out of 10," Alexiades says. "Once the pain blockers wear off, pain usually increases the second or third day after surgery — it may get to a six or seven."

Hip replacement, which is slightly less common than knee replacement, is a less painful process, in part because the hip joint doesn't sustain as much pressure as the knee, plus the range of motion isn't as wide.

Been meaning to take care of a pesky cavity or swollen gums? Get thee to a dentist, pronto. Any infection in your body can destabilize healing and potentially spread to your brand new joint, so experts recommend topping up your oral health way before you head in for surgery. “Infection elsewhere in the body can spread — and metal can’t fight infection,” Lajam says. “There’s no way to fix it except for taking all the pieces out. If you need dental work, get it taken care of six months before surgery.”

As long as your joint pain isn’t related to anything that could qualify as a pre-existing condition (such as an old sports injury), insurance companies, including Medicare, will foot the bill. Your doctor just needs to document your case properly and show that a) you have pain and legitimate limitation of mobility, b) X-rays or other imaging studies reveal objective deformity or damage to your joint and c) you’ve tried alternative therapies to no avail.

Having your joint replacement surgery claim rejected could be very costly. The total hospital bill can range from $50,000 to $125,000, according to a New York Times article, which explained why the surgery may actually be cheaper if done outside the U.S. (travel expenses included).

Rehabilitation, which consists of exercises and stretching done at home or in a rehab facility, is an essential step to getting your range of motion back after joint replacement surgery. And the good news is it only takes an hour or less, three to five days a week for about 12 weeks, provided you stick to the regimen and don't overtax yourself.

The timeline for knee rehab looks something like this, Alexiades says: Just a few hours after surgery, hospital staff help you take a few steps on your own. "The first day, we don’t expect them to take long walks, but we want to show them they can get up and put weight on the knee," he says.

On day two, physical therapists in the hospital start working with your range of motion, and most patients are cleared to go home and start rehab work there within two to four days.

If you have stairs in your home, hospital therapists will make sure you can walk them on your own before they release you. If you choose home rehab, a physical therapist will make daily visits to help you bend and straighten the knee and do mild strengthening exercises, which get easier as the pain and swelling subside. The goal: to be strong enough to get to an outpatient rehab facility on your own to continue the work. Within three months of surgery, most patients can engage in daily activities with little to no pain.

Most joint replacement surgeries are successful, and post-surgery problems like infection, blood clots and dislocation are generally treatable, according to NIH. But your risk of complications may rise if you have immune-weakening conditions like heart or kidney disease — or if you have an unhealthy lifestyle. “Complication rates are three to five times higher for people who smoke,” Lajam says. “With very obese people, complication rates are six to seven times higher. I try to get folks to stop smoking and get their weight down before surgery,” to improve their chances of a positive outcome.

Any infection you get post-surgery — even if it's 10 years post-surgery — puts your new joint as risk, which means you diligently need to fight infections at the first sign. "We're finding that many patients are getting late infections," says Dr. Brett Levine, a hip and knee reconstruction and replacement specialist and an active member of the American Academy of Orthopaedic Surgeons. "They're diabetic and overweight, and they're not thinking about the joint. A joint replacement doesn’t have blood supply — antibiotics don’t get to it. You'll often need an operation to fix the infection."

Unfortunately, joint replacements aren't a forever solution, but if you maintain a healthy lifestyle and get annual check-ups to monitor the new joint, it should last you at least 15 years, if not 20. "You have to follow up every year to make sure it’s not wearing out," Levine says. "If you wait 10 to 12 years before seeing a specialist, instead of changing out one part, you might have to replace the whole thing. You lose that window."

Realistic expectations are another important aspect of joint replacement success. "It’s a lifestyle change," Levine says. "Once you get a replacement, running, jumping and high-impact activities are limited, if not cut out, to optimize the length of time a replacement will last. If you push to do your old activities too quickly, you will stress the wound. This is a huge surgery — slow down, take your time and recover well."