Preoperative Questions

No. This is a specific discussion in clinic. Notably, with elevated BMIs, patients are at increased risk of perioperative complications, but this is something that we can discuss in clinic, and discern if it is a risk that both parties (patient and Dr. Mosher) are willing to undertake.

We prefer to have A1C below 8. If it is above 8, we will order a fructosamine level on the patient for further evaluation. However, in some patients with very challenging control of their diabetes, their PCP may reach out and state that getting the patient below these goals is not possible. Then, we may proceed with the understanding that elevated risks are expected.

Yes. In patients with active infection and lacking medical optimization (primary care provider does not feel you are ready), we will not proceed with surgery at that time.

We understand that joint pain can be debilitating and severely limit daily activities. However, research has shown that the use of opioids prior to joint replacement leads to increased complications and more difficulty managing pain after surgery. We recommend weaning these, if possible, but do no view this as an absolute reason to defer on surgery.

AAHKS article regarding opiod use prior to knee replacement (Link) and hip replacement (Link)

We recommend working to maximize your physical fitness, leg strength, core strength, optimizing nutrition, and setting up your home for a safe healing environment–limiting fall risks and setting up social assistance for a week or so after surgery. For shoulder replacement, work on gentle shoulder range of motion and strengthening.

AAOS knee conditioning program (Link)

AAOS hip conditioning program (Link)

AAOS shoulder conditioning program (Link)

AAHKS hip conditioning program (Link)

AAHKS hip and knee conditioning program (Link)

PCM stands for principal care management. This is a specific code we bill your insurance company to cover your preoperative optimization including orchestrating follow-up with your primary care provider and reviewing their notes, reviewing labs, sending in all your preoperative medications, preoperative nutritional optimization, discussing social supports needed at home after surgery, etc. While this is billed to your insurance, infrequently, a small fee may come to the patient $<50, and be listed under “PCM Management."

Most patients go home the same day, but some stay overnight. This is usually older patients who live alone, patients with medical conditions requiring overnight monitoring, etc. If this is needed, that is not a big deal, we just have to do your surgery at the hospital, and you cannot be done at the surgery center.

Less than 2-3% of patients undergoing elective joint replacement (even lower for shoulder replacement) will need a rehab stay. This is usually only in the most debilitated patients, and those without any social support. Insurance will almost UNIFORMLY DENY paying for acute rehab. Thus, you will have to go to a skilled nursing facility, which is frequently a rehab wing on a nursing home, which has worse care than home. In short, we STRONGLY encourage all patient’s to go home, as numerous studies have found that complications (clots, infection, medical complications, etc.) are much higher in patients going to rehab facilities after surgery. If you desire to go to a rehab facility, this will be a detailed discussion in clinic when booking your surgery.

AAHKS article regarding discharge home vs alternatives (Link)

We strongly recommend cessation of all nicotine products as this can inhibit wound healing, increase complications, and increase the risk of infection. However, we understand cessation from all nicotine is a challenging and often life-long endeavor. Any smoking/tobacco/nicotine cessation you can perform will only benefit your overall health and is strongly recommended; however, this is not a necessity for operative management.

AAHKS article regarding smoking cessation (Link)

The guidelines and literature have some differing in this answer. The literature shows that the HbA1C should be less than 8, while the guidelines are less than 7. We recommend strict glucose control in the perioperative period. If your A1C is elevated, but you have had a more recent change in your glucose control, we will obtain a fructosamine for evaluation. If that is below a certain level we can proceed. However, in patients with poorly controlled diabetes, there is an increased risk of infection, overall medical complications, and wound complications.

AAHKS article regarding decreasing infection risk (Link)

We recommend some version of protein supplementation prior to and immediately following surgery in all patients who do not have kidney disease. This will help wound healing. This can be as simple as going to the local grocery store and obtaining protein powder for supplementation, and using this once or twice daily for 2-3 weeks before and after surgery.

We have no age restrictions for either total hip replacement. This is a discussion regarding the benefits of surgery vs the risks. While the risks increase with age extremes, total hip replacement remains a safe surgery, and offers substantial benefits to patients of any age (old or young). 

We do not utilize BMI restrictions. These are poor markers of overall health, and prefer to evaluate the entire patient to evaluate appropriateness for surgery. With this, we do not recommend “crash diets” to obtain a specific weight, as this can lead to malnutrition and wound healing complications. We recommend a balanced diet.

We will give you 1 baby aspirin twice daily to take for blood clot prevention for 4 weeks. Then we will give you scheduled Tylenol three times daily for 2 weeks (then as needed), Celebrex or Meloxicam once daily (for 3 weeks, then as needed), and oxycodone every 6 hours as needed for pain. Some patients may also get Lyrica and/or Tramadol for 1-2 weeks. Lastly, we recommend an aggressive bowel regimen of Colace, Senna, and Miralax after surgery for at least 3-5 days or until normal bowel function resumes, and can prescribe that if desired.

We will treat this with medications and lifestyle. We encourage walking and working on foot pumps at least once every 1-2 hours when awake. You will also take medication for a period of time as well. You will take 1 baby aspirin twice daily to prevent blood clots for 4 weeks. If you are already taking Xarelto or Eliquis, you will take a half dose for 1 week then resume your normal dose. If you are taking Coumadin, you immediately resume your normal dose the day after surgery. If you take aspirin and Plavix, you take 1 baby aspirin daily, and resume your normal Plavix therapy the day after surgery.

This is variable between hips, knees, and shoulders. The simple answer is that it will be as long as needed to safely perform the surgery, place the components, and mitigate complications. In general, hip and shoulder incisions will be between 10-15cm (4-6in), and knee incisions will be between 12-25cm (4-8in). However, larger patients will tend to have larger incisions to ensure that the components are placed safely and accurately while minimizing wound complications. We can also discuss the differences between the traditional longitudinal (length-wise) incision vs. the bikini incision for hip replacement in clinic.

Our goal is for you to perform every activity you desire after surgery. In reality, you will probably not be a great skier if you have never skied before, but our goal is for you to be able to do that if you desire. Everyday activities such as walking, bending, stooping, going up/down stairs, jogging, distance running, skiing, working out, cycling, etc. should not be an issue after a hip replacement. All of those activities are also possible after a knee replacement, but we should have a longer talk in clinic before resuming distance running. Lastly, for shoulder replacement, we do not recommend heavy weightlifting, but beyond that we will have no restrictions.

If you work in a sedentary job, you can probably begin returning part time at about 2 weeks after hip or knee replacement to see how things go, then improve from there. However, if you have a job involving walking, standing, manual labor, etc, it will be at least 6 weeks before you can return. For shoulder replacement, you can likely return to work 2 weeks after surgery while still using a sling. However, after shoulder replacement, if you have a manual occupation where you are required to lift objects, then it will likely be 3 months after surgery.

You can drive when you are no longer requiring a walker and weaned from narcotic pain medications after a total hip and total knee. Everyone is different regarding this. Some patients will be at this stage within a week, while others may take a month. After a shoulder replacement, you can drive when you are no longer wearing a sling and are weaned from narcotic pain medications. However, ultimately this is up to you regarding you confidence in operating a vehicle.

We recommend everyone initially use a walker to prevent falling after hip and knee replacement. Then you can slowly wean from this. However, do not wean too early. Only wean from the walker when it is more of an accessory than a functional tool. 

We have no specific restrictions after hip or knee replacement. Our recommendation is to listen to your body. If you do not tolerate a specific activity, stop, back down for a few days, then gradually try again. After shoulder replacement, we will give you a detailed outline prior to surgery—but you will likely be using a sling for 4 weeks after surgery and have lifting restrictions for at least 6 weeks.

Historically there was concern that the plastic in the implants would wear out. That is very uncommon at this time. We have this generation of plastic with 20 year results showing no wear and biomechanical studies suggesting no wear at up to 40 years after implantation. Ultimately, we can confidently say that the plastic will not wear out within 20 years, but there are other areas of possible failure within the implant that we will continue to monitor over the years.

We do everything we can to prevent infection, but it is never 0%. We use multiple skin-preparation solutions, adhere to sterile technique, use special irrigants, give prophylactic antibiotics, and use special dressings. However, if you do get an infection, we will be here through it all.

Additional information from the AAOS website regarding infection prevention after total joint replacement. (Link)

AAHKS information regarding infection prevention after hip replacement (Link) and knee replacement. (Link)

All patients will arrive at the surgery center or the hospital. Both Dr. Mosher and the anesthesia team will meet you in the preoperative area and answer any questions you may have. Anesthesia will then place a spinal for anesthesia and a block for hip and knee replacement patients. You will then be brought into the OR, and moved to the OR table. At this point, the anesthesia team will give you a small dose of sleeping medication so you sleep through the procedure while minimizing your dosage to limit side effects. If you are undergoing shoulder replacement, they will give you a general anesthesia in the operating room. After the surgery you will then be brought to the postop area, and if you are going home, physical therapy will come see you there and plan for discharge home. If you are staying overnight, you will likely see physical therapy on the floor.

Neither is necessarily better than the other. Spinal anesthesia allows for fewer general anesthetic medications to be given, which minimizes nausea, “brain fog,” has been found to be associated with fewer complications and tends to lead to improved pain control. However, in some patients with complex spinal pathologies, spinal anesthesia is not always possible, and general anesthesia can be performed safely in all patients. In our setting, we prefer spinal anesthesia for hip and knee replacement, if possible. However, this is not available for shoulder replacement, thus general anesthesia is required.

AAHKS article regarding different anesthesia options (Link)

We can call in medications prior to surgery or you can self-medicate. Constipation is quite common with usage of opiate pain medication, thus we recommend aggressive management. Our standard regimen is docusate, senna, and Miralax. If this does not work, then we will increase with dulcolax suppositories, an enema, or magnesium citrate–all of which are over the counter.

We recommend holding off on airline travel or prolonged care rides for at least 6 weeks after hip or knee replacement to prevent blood clots. However, if you must travel, we recommend frequent stops/walking a short distance every 1-2 hours. Following shoulder replacement, this can be expedited up to 3-4 weeks after surgery with frequent stops and walking as well.

Patients continue to heal for 1 year after surgery. Some patients continue to even heal after 1 year from surgery. However, most healing and recovery is done by 1 year after surgery.

This is a viable option for all patients after total joint replacement, and has been studied in multiple facilities with successful outcomes. If you desire this, please let us know in your preoperative discussion.

Many patients require PT to maximize their outcome, but this is not mandatory. Following total hip replacement, we will hold you out of PT for at least 2-4 weeks after surgery to allow for swelling and pain control. After total knee replacement, we will allow you to begin after ~5 days. Following shoulder replacement, you may begin at about the 2-week mark. We will give you some gentle home exercises to work on in the interim. All these durations are tentative, and can be discussed further in clinic.