DEAR MAYO CLINIC: I need to have a joint replacement, but I'm really nervous. What questions should I ask my orthopedic doctor?

ANSWER: Knee and hip replacements have changed so much due to advanced surgical techniques, making them far different from those even five years ago. From multiple-day hospital stays, total joint replacement has advanced to a one-night stay or even going home the same day as surgery.

Questions from my patients usually fall into three categories:

• How do I know it's time for surgery? 
• What will happen during surgery? 
• What will recovery be like?

Let's start with the "when" question. Patients undergoing replacement surgery have arthritis in the joint. Arthritis is the loss of the protective cartilage layer between bones, and when that cushioning is gone, you have bone-on-bone contact, pain and swelling. Physical therapy, over-the-counter medications and injections can help for a while. 

Eventually, the pain and discomfort affect your mobility and activities of daily living, whether it's walking the dog or playing with grandkids. That's when you may decide it's time.

But joint replacements aren't only for older patients. Total joint replacement in people in their 50s is no longer uncommon.

Deciding on surgery

Once you've decided on surgery, the next step is preparation, particularly making sure any chronic conditions like diabetes or high blood pressure are under control. To reduce your risk of infection, stop any steroid injections at least three months before surgery. You'll also need to address dental work, such as cleanings.

Your orthopedic care team will provide you — through classes and printed guides — with a wealth of information on how to prepare, including:

• Required preoperative tests and exams.
• Adapting your home for recovery.
• Arranging for care when you return home, such as having a support person with you through the early weeks.
• Setting up transportation to and from physical therapy and medical appointments. 
• Requesting a temporary accessible parking permit.

If you have questions or concerns, be sure to ask your care team so that you feel ready for surgery and recovery.

Your surgeon also will be preparing. This includes using X-rays or CT scans to study your bones and anatomy. 

If your surgeon is using robotics, they're able to make a 3D model of the joint to assist with planning your joint replacement. In knees, this lets them correct issues caused by arthritis, such as bow-leggedness or knock knees.  During your surgery, the surgeon will map your knee in the operating room to the 3D model on the computer built from your preoperative CT scan. Your surgeon will use the robot to collect information on ligament balance and alignment so they can determine the best position to place your implants. 

While robotics makes total joint replacement more accurate, it doesn't make it less invasive. It helps achieve a more precise balance, which can lead to less pain and wear and tear on the implant.

When it comes to hip replacement, there are multiple surgical approaches available. The two most common approaches are the posterior and the direct anterior. The direct anterior approach is a more recent surgical technique that has gained popularity over the last decade. The anterior approach is considered "muscle-sparing" because the surgeon is working between the muscles. As a result, patients tend to recover faster, and there's less risk of dislocation.

For both knee and hip replacements, don't hesitate to talk with your surgeon about the techniques they'll be using.

After surgery

After surgery, knee and hip recovery differ:

• Knees. For the first two weeks, there's pain and swelling, but also the need to regain range of motion to minimize stiffness and scar tissue. Therapy is a big focus of early recovery. At-home physical therapy is every day; in-person is typically twice a week. 
• Hips. The first few weeks are for letting the incision heal and reducing pain and swelling. That means gradually increasing activity, using a walker, then a cane. Most patients do home-based therapy but not in-person therapy.

Whether you've had a knee or hip joint replacement, you're able to return to your regular activities within three months. However, there may be some restrictions. For the hips, these may include avoiding extreme positions, such as deep squatting and certain yoga poses, to decrease dislocation risk. For knees, kneeling may be uncomfortable and often isn't recommended. Also, don't be alarmed by clicks and pops from your implants — they're normal. 

Overall, patients do well with total joint replacement. This is a long journey, so an incredibly important part of your success is the relationship with your surgeon and care team. They'll be with you from beginning to end to ensure you have the best possible outcome.

Kariline Bringe, M.D., Orthopedics and Orthopedic Surgery, Mayo Clinic Health System, La Crosse, Wisconsin

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