Many people undergo hip and knee replacement. This creates a false sense of comfort that this operation is without risk. Dr. Ramkumar wants you to fully read, process, and comprehend the risks of undergoing hip or knee replacement. This is particularly important because hip and knee replacement is an elective procedure, not a life-threatening procedure. Dr. Ramkumar understands that living with pain every day may not feel like you have a choice besides surgery, but you do.

1. You can choose modifying your activities (changing your lifestyle), taking anti-inflammatories to decrease the pain burden, physical rehabilitation and resistance training to offload the joint, injections, or shockwave therapy. You should only choose to undergo a joint replacement if the bad days outweigh the good days. Often times, patients choose to do so when they cannot sleep at night or cannot perform basic activities of daily living. There is no urgency to undergoing this surgery. You should only undergo this surgery when you are physically and emotionally ready. You absolutely should not undergo this surgery if your pain is manageable, even if your x-rays show severe changes. We treat patients, not imaging findings.

2. You need to understand that you do not have to proceed with Dr. Ramkumar. He is not for everyone. You have choices, and you should be able to get as many opinions as you want. If for some reason, you feel your insurance or financial situation has forced you to see only Dr. Ramkumar, he is more than happy to facilitate you getting another opinion from another orthopaedic surgeon who performs this procedure in your network. Do not worry about offending Dr. Ramkumar. He is more than happy to help suggest another opinion.

3. Expect your incision to be numb for life. Any time a knife cuts the skin, there are small sensory nerves in the skin that are not visible but are traumatized. There is a chance you regain some sensation over the incision, but do not expect it. If you are undergoing a robotic assisted procedure, expect two incisions. For hips, you will have one on the opposite pelvis of your operative hip. For knees, you will have one near the middle of the shin. Your incision will be as long as it needs to be to safely perform the operation. This is usually 15cm but can be more or less.

4. Pain, bruising, stiffness, and swelling can – and will – occur. Pain occurs because cutting bone and instrumenting the body is painful, especially when we have to move muscles and tendons out of their usual place with a retractors. Bruising will occur because bleeding occurs during surgery. Although we control the bleeding to perform the operation, bruising can still occur. Usually this subsides over a month, but everyone is different. Swelling should occur! We clean the joint out thoroughly to remove debris from surgery and to decrease the risk of infection. We sometimes put up to 50% of your body fluid into your joint to do so. The healing process after surgery also brings swelling, which brings nutrients to help you recover. Swelling can be present up to 6 weeks after hip replacement and up to 6 months after knee replacement. It should subside after those time points. Pain usually improves month after month. Most people are off narcotics within 5 days, but residual pain can be managed with anti-inflammatory medications. Patients with coexisting back arthritis, who have a history of narcotic use, or who cannot take NSAIDs are higher risk for postoperative pain that is out of proportion.

5. Wound complications can occur to anyone. Usually, Dr. Ramkumar uses stitches buried under the skin, but if he is worried about the quality and texture of your tissue, he will use sutures on top of the skin or staples. Even though we suture your tissue back together, it may not unite. The wound can break down if exposed to excessing bleeding, outside fluids, sweat, or if your overall health is not optimized. Sometimes this can be managed without surgery. Sometimes, this is requires another surgery. Dr. Ramkumar does not allow any ointments, creams, or remedies to be placed on the incision the first 6 weeks after surgery. He and his team will manage the wound, not a wound care specialist. Outcomes can be variable if you manipulate or touch the wound without the appropriate supplies. Anterior hip replacements are certainly at higher risk for wound complications especially if the stomach drapes over the incision and creates a sweaty environment that limits the body’s ability to heal. If Dr. Ramkumar is worried about your wound healing during knee surgery, he may place you in a knee immobilizer to prevent bending the knee, allow soft tissue rest, and decrease excessive tension on the fragile tissues. For patients who have obesity, require strong anticoagulants (Eliquis, Plavix, Xarelto), or have medical conditions like kidney or liver disease, wound complications are more likely.

6. Bleeding can occur in various forms. Sometimes it manifests as bruising with an associated hematoma. Sometimes it can stain the dressing and stop a few days after surgery. Sometimes it can continuously leak through the incision, which would require a repeat surgery to address the underlying issue that is causing the drainage. Usually patients who are on Plavix, Eliquis, or Xarelto are at higher risks for wet or bloody wounds. This is a concern because it can lead to infection. Balancing the risk of bleeding on these blood thinners versus the risk of a blood clot makes this a challenge.

7. Blood clots can occur in the leg. This is alarming because it is life-threatening if it moves to the lungs and becomes a pulmonary embolus. We try to mitigate this risk by (a) having you move early and often (preferably every hour) and (b) by having you take a medication that thins your blood. Usually, we prescribe a baby aspirin (81mg) twice a day. If you have a history of blood clots, stroke, or heart attack, we will recommend something stronger (usually Eliquis). Even despite these best efforts, you can still get a blood clot.

8. Fractures can occur during surgery or early after surgery. We are cutting bone during this surgery, and sometimes these planned cuts turn into an unplanned fracture line that requires additional stabilization with cables, plates, or screws. Sometimes this has to do with having osteopenia or osteoporosis. Sometimes this just happens.

9. Infection is the most common complication after hip or knee replacement. Infection can occur 2 weeks, 6 weeks, 1 year, 5 year, or 20 years after joint replacement. It is the lingering specter that our profession does not fully understand why this occurs. However, the thought is that replacing your natural parts with foreign material serves as a magnet for bacteria. Bacteria can be introduced both during surgery, from our blood stream, from our urinary tract, from our mouth, from our skin, or from our gastrointestinal tract. Any lining that is compromised or infected can seed a joint replacement. That is why it is exceedingly important you come into this operation as clean and whole as possible. Dr. Ramkumar recommends you get a dental cleaning latest one week leading up to the procedure. Similarly, any skin cuts, loose/painful teeth, urinary tract infection symptoms, or gastrointestinal symptoms should be immediately reported so we can help you manage this. Usually, we will delay the surgery until you arrive maximally optimized and fully healthy to mitigate this infection risk. We don’t really have any great advice to prevent infection 10 years down the line besides generally maintaining good health. This can mean avoiding heavily processed food, exercising regularly, and not allowing medical conditions to fester. Our blood stream has bacteria on average every 6 days, and if our immune system is depressed then it can result in failure to combat infection around your metal prosthesis. Infection is a life-altering and devastating complication that almost always results in reoperation. The success of eradication infection is bleak, which is why Dr. Ramkumar focuses on optimizing patients’ health beforehand. If you get an infection around a joint replacement, the chance of death can be as high as 26% within 5 years. Almost always, eradicating infection requires at least two reoperations and 6 weeks of antibiotics. Sometimes, plastic surgery is required to help with wound coverage and healing. Infection is the number one cause of complications after joint replacement.

10. Injury to major arteries or nerves is rare but can happen.

  • a. For knees, the major artery is the popliteal artery that can sometimes occlude with simply bending the knee to perform the procedure. This complication almost never occurs from a direct injury with a retractor or instrument. There are also anatomic variations of the popliteal artery that bring it dangerously closer to the surgical field than expected. If injury to the popliteal artery occurs, it is treated with a vascular surgeon who will perform a procedure to restore blood flow to the leg. If blood flow cannot be restored, amputation may be necessary in extremely rare scenarios. The major nerve is the common peroneal nerve. This disproportionately affects patients who are knock kneed, which results in stretch injury to this nerve when the leg is straightened during knee surgery. This can result in drop foot, which means you can step on the gas pedal but not lift the foot. Dr. Ramkumar tries to prevent this by not excessively correcting the deformity. This means your knee will not be perfectly straight, but closer to the way it naturally was when you were an adolescent. Any nerve injury can be temporary or permanent.
  • b. For hips, the major artery is the superficial femoral artery. If this is injured, it is treated again with a vascular surgeon who will perform a procedure to restore blood flow to the leg. The major nerve is the sciatic nerve, which can cause a drop foot. This means you will not be able to lift your foot, but you will be able to press on the gas pedal. Your foot could drag when you walk. This is treated with a brace and possible tendon transfer surgery down the road if it does not improve over a year. The leg is unlikely to ever fully improve after this. Other major nerves include the femoral nerve, which if stretched, can cause leg buckling, falls, and inability to straighten the knee. This will also require a brace and can take 9 months to a year to fully resolve. Any nerve injury can be temporary or permanent.

11. Instability and Dislocation

  • a. Knee replacements can feel unstable after joint replacement. Often times, patients complain of buckling, giving way, or a sense of untrustworthiness with the knee. While this is rare in Dr. Ramkumar’s practice, this can certainly happen. Sometimes this is due to how the bones were cut and how the implants were placed. Sometimes this is due to underlying lower back arthritis. Sometimes this is due to muscular atrophy that can be rehabilitated with a focused program.
  • b. Hip replacements can dislocate. This happens if you break “anterior hip precautions” during the first 3 months. This means you cannot bridge, you cannot thrust your pelvis forward, you cannot bring your operative leg behind your body (like winding up to kick a soccer ball), and you cannot turn your foot outwards excessively.

12. Stiffness

  • a. Hip replacements can and will certainly feel stiff up to 6 months after surgery. This almost always improves and almost never requires repeat surgery. Soft tissue work like massages and strength training in the gym can help with this.
  • b. Knee replacements can and will certainly feel stiff up to 12 months after surgery. For most patients, you can expect range of motion from 2°- 125°. You may be able to achieve more, but I would not expect this. Range of motion is most heavily influenced by your preoperative range of motion. Therefore, waiting on a stiff knee for years can negatively influence your outcome after a knee replacement.

13. Hip replacements can certainly create a leg-length discrepancy. Half the human population has a leg length discrepancy up to 1cm, and they don’t even know it! This goes to show that the human body can adjust up to a 1cm discrepancy. Experiencing a leg length discrepancy can arise from the hip joint, spinal scoliosis, and/or abductor muscle dysfunction/weakness. Dr. Ramkumar will try to get your legs even within 5-6mm, but he will also choose stability over discrepancy. Hips are generally more stable when the leg is longer. If you do have a leg length discrepancy beyond 1cm that you cannot live with, you may be referred to a podiatrist for a shoe lift. For major discrepancies beyond 2-4cm, you may require a revision procedure. Knee replacements do not cause leg length discrepancy, although in cases with extreme deformity, your leg will usually be longer.

14. Hardware concerns can certainly occur. The implants are made of titanium, plastic, and cobalt chromium. These implants are well tolerated by the body and “metal allergy” has recently been debunked as a source of persistent pain and inflammation. However, if you are worried about metal allergy, you may request a Nickel-free implant with the understanding no implant will be free of trace metals (including nickel). These implants can wear or loosen over time. If this mechanical failure occurs, this always requires additional surgery to restore mechanical stability. However, these implants are expected to last 30 or more years given their increased ability to integrate with the body using cementless technology. In some cases, like severe osteoporosis, cemented implants may be necessary.

15. Robotic assistance is commonly used to improve component accuracy, which has been associated with less pain and a faster recovery. This almost always requires a second small incision. In knee replacements, this second incision is in the middle of the shin bone below the main incision. In hips, this is on the pelvic brim but on the opposite side of your main hip incision.

16. Reoperation can occur. As you just read, there are many ways in which additional surgery can occur. Infection is the most common. You need to know future surgery can certainly occur. Getting a joint replacement does not always mean “one and done.”

17. Although rare, blood transfusions may be necessary to save your life. This can create side effects ranging from minor to serious considerations, including transmission of hepatitis or HIV.

18. There exists a risk of common medical complications during the surgical procedure under anesthesia. This ranges from hoarseness, hiccups, and vocal cord injury to heart attack, stroke, or even death. We try to use spinal anesthesia to help lower these risks and to enable a faster recovery.

19. Persistent pain or failure of the proposed procedure may occur. This commonly occurs when there is a coexisting source of the pain, most commonly the lumbar spine. Specifically, L2 and L3 disc herniations can mimic hip pain. L3, L4, and L5 disc herniations can mimic knee pain. Patients who have shooting pain into the foot and ankle or have numbness/tingling in their foot or ankle are at highest risk for this given that they may have a lumbar issue as well as a hip or knee issue.

20. For patients undergoing revision joint replacement, the risk of aforementioned complications and reoperation is at least double. Revision arthroplasty can be best compared to limb-saving surgery given the complexity, risks, and invasiveness of the operation compared to primary (first-time) hip or knee replacement.