Dr. Lee’s mission is to be a caring, compassionate physician and surgeon and to provide successful outcomes for his patients, and takes a holistic approach to orthopedics. Surgery is considered a last resort. A complete history and physical exam will be performed prior to suggesting treatment options. He looks at the whole picture, not the individual problem or x-ray findings.
Dr. Lee spends ample time with patients. Because of this, as well as the challenging environment and the number of patients Dr. Lee sees, the office may run behind schedule. Be prepared for this, bring a book, e-book, or magazine. When your time to be seen comes, you will get the time you need, so please be considerate of others who need Dr. Lee’s time and expertise.
- Dr Lee Total Hip Replacement Exercise Guide
- Dr Lee Activities After Hip Replacement
- Dr Lee Total Knee Replacement Exercise Guide
- Knee Conditioning Program
- Dr Lee Activities After Knee Replacement
After your consultation with Dr. Lee, through shared decision making, you may have both agreed that your arthritic hip or knee pain has not been adequately relieved by nonoperative treatments, and joint replacement is a reasonable option for you.
Proceeding with surgery is an important decision to make and one that you should spend as much time as is needed to reach a definitive conclusion.
If you have chosen that is the best option for you, you will have been in touch with the office scheduler to find a surgery date.
You will need to consult with your regular doctor to make sure you are in a state of health that will allow you to undergo a hip or knee replacement. This should be a preoperative clearance letter made available to our office.
If you see a heart specialist (cardiologist), you will need to obtain a clearance letter from this doctor as well.
Other specialists who you see on a regular basis should also provide their clearance for you to proceed with surgery.
6 WEEKS BEFORE SURGERY
Start arrangements for care after your surgery. Most patients can go HOME the day of surgery (outpatient) although some will require an overnight stay at the hospital. It is important to have someone around if planning to go home so will not be all alone. A stay in a rehabilitation facility is not needed in most cases and studies show it is generally safer to go home. Discuss this with loved ones so they can support your recovery process. Home health services will be arranged for you in your home. (nursing and physical therapy).
Make sure to eat a healthy diet, with abundant protein which is important for wound healing and avoiding infections. Limit alcohol use to no more than 1 drink daily.
Lose weight if required. We look at Body Mass Index (BMI) as an indicator of risk for surgery. It is easily calculated by entering in your height and weight into a BMI calculator widely available on the internet. BMI of 30 or more is considered obesity and is associated with increased risk of complications with surgery. BMI of 40 or more is too unsafe to have surgery. If trying to lose weight make sure to continue to eat protein (see 2 above) as many obese patients are also malnourished.
It is important to stay active. The better shape you are in going into surgery will make your recovery easier and quicker. Exercises generally well tolerated including upright or recumbent stationary bikes, elliptical trainers, NuStep Machines, pool exercises or even just walking. Use pain as a guide. A little discomfort is ok, but if severe pain occurs find another activity. The worst thing to do is nothing.
Work on functional limitations identified. The best predictor of function after surgery is function before surgery. So, if your hip doesn’t flex or your knee doesn’t straighten or bend properly, surgery will not fully solve that. Those are functional issues that you need to work on. We recommend a preoperative physical therapy evaluation to identify and issues and be taught a home exercise regimen (PREHAB).
Optimize oral health. It is highly recommended to make an appointment with your dentist to make sure oral health is optimized, especially if there is any concern for loose or infected teeth, as this can be a potential source to infect your new joint replacement.
Obtain screening bloodwork. We will order some initial bloodwork which will screen to make sure blood counts, nutritional status, glucose control and other health conditions are optimal.
This should be obtained as soon as possible to ensure there is time to correct if there is an issue.
If you are found to be MALNOURISHED, supplement protein. We will check your albumin level in your blood which assesses your nutrition level. If this is low (below 3.5), then generally protein supplementation (eg. Ensure shakes) will be recommended.
Manage anemia (low blood count). If you are found to be ANEMIC (hemoglobin level too low), an Iron supplement may be recommended and/or a hematology consult may be obtained.
Manage diabetes/blood sugar. If you are DIABETIC, make sure to eat healthy diet and maintain close glucose control. We will check your HgbA1C test and if above 7, surgery should be delayed until better control of blood sugar is achieved. HgbA1C above 7 is associated with a higher risk of infection.
Quit smoking. If you are a SMOKER, make sure to quit immediately. Studies show that smoking/nicotine use significantly elevates your risk of basically all complications including infections and blood clots which can be fatal. This includes all tobacco and nicotine products. We will test to ensure you have ceased use of nicotine products. Please discuss quitting with your primary care doctor and ensure this occurs or surgery will be cancelled. There can be now tobacco use for 6 weeks prior to surgery.
4 WEEKS BEFORE SURGERY
Preoperative medical evaluations. Make sure you have an appointment with your primary care doctor and other necessary doctors so that all preoperative medical tests are completed prior to your surgery date. Do not wait until the last minute as they may require additional tests which could delay your surgery. These evaluations are required to proceed with surgery.
2 WEEKS BEFORE SURGERY
Follow up on medical evaluations. Make sure the preoperative evaluation and testing process is moving along and that all doctors visits are either complete or scheduled. Keep copies of all testing and office visits and bring these with you to your preoperative visit at our office and also the hospital preoperative visit, which will occur within the two weeks before surgery.
Hospital preoperative visit. (NOT APPLICABLE IF AT SURGERY CENTER) If you are having surgery at the Hospital, you will have a preoperative visit where your medical evaluations and conditions will be reviewed. You will have screening to see if you are a carrier of MRSA/MSSA. If you are, you will be called and started on a nasal antibiotic. You will also be given a special soap to wash with.
Office preoperative visit. If you are having surgery at the Hospital or Surgery Center, you will have a preoperative visit at our office. This will review all of your questions and make sure you are ready for upcoming surgery. Your postoperative medications will be reviewed and prescriptions given.
Make a list of all your medications, the doses, and when they are taken. It is important to review this at your visit with your primary care doctor and also at your preoperative visit at our office and the hospital. Some medications may need to be stopped and others may be important to continue for your safety.
Finalize arrangements for any family members who will be assisting you after surgery. It is helpful if they come to the preoperative visit at our office in case they have questions or concerns about being a caregiver. If you have no help or live in a situation where you can not return home after surgery there is the option of going to a rehabilitation facility. An alternative would be to hire an aide to be with you at home for a few days. The case manager at the hospital can facilitate and provide options.
Please eat healthy foods, cut down on alcohol intake to no more than 1 serving daily.
Avoid any cuts, accidents, injuries or procedures which damage your skin. Your skin is your most important barrier to infection. If there is any damage or rashes on your skin alert our office so can be examined and determine if postponing surgery is safer for you.
Make sure you are clear on which medications and supplements you are taking should be stopped. The following are good general guidelines:
- Non-steroidal anti-inflammatory drugs (NSAIDs) should be stopped at least 1 week prior to surgery, but preferably two weeks. These drugs include: ibuprofen (advil and motrin), naprosyn (alleve), meloxicam (mobic), diclofenac (voltaren) and other drugs in this class. The exception is Celebrex, which may be taken right up to the surgery as this is the only NSAID that does not increase the risk of bleeding considerably.
- Acetaminophen (Tylenol) is a safe choice for pain relief, as long as no liver disease. Can take 1000mg up to 3 times per day, but not more.
- Narcotics are not recommended preoperatively and will make your recovery more difficult. If you are taking narcotics you should work with your prescribing doctor to stop.
- All herbal and diet supplements should be stopped 2 weeks prior to These are not regulated by the FDA and many have impurities that can thin your blood or cause other reactions with medications/anesthesia you may be given.
- Any supplements containing Vitamin E or Fish Oil should be discontinued 2 weeks preoperatively. These are potent blood thinners and will increase bleeding risk.
- Vitamin C is potentially helpful to take and the recommended dose is 1000mg
- Probiotics pills are not recommended, but greek yogurt or a yogurt culture drink like DanActive or Activia may be helpful for your gut as well as provide
- If you are normally on blood thinners (Aspirin, Coumadin, Plavix, Xarelto, Eliquis, Prodaxa, etc) it is important to discuss a plan with your doctors so you know the risks of stopping these and the appropriate timing of when to stop these.
1-2 Weeks Prior to Surgery Date
You will see Dr. Lee at least one more time, 1 to 2 weeks before your scheduled operation. At this visit, we will go over the details of the surgery and an informed consent process.
You will also attend a preoperative joint replacement class at the hospital, a group session with other joint replacement patients, to go over the perioperative days' workflow and the do's and don'ts prior to and immediately following surgery. It is important that you bring your "coach" to this preoperative education class.
Night Before Surgery
Prior to midnight, on the night before your surgery, drink plenty of fluids. This has been shown to accelerate your recovery process.
Do not eat or drink anything after midnight the night before your surgery. The anesthesiologist may refuse to proceed with your case if he/she feels there is material risk for aspiration and the blocking of your airway.
Behind the Scenes
If you are curious about the surgical planning behind the scenes, we've outlined the process below. Surgical planning begins based on your preoperative X-rays. If your case is a complex one (that is, not a routine, first-time hip or knee replacement), your case will be discussed with and presented to a group of Harvard-trained joint replacement surgeons, where the best treatment plan will be agreed upon and described to you.
Total Hip Replacement
The dimensions of your pelvis and hip are carefully examined, and preoperative templating of how the implants will be placed at your joint is overlaid onto your X-rays.
Considerations are made for implant size, geometry, placement location, as well as the resulting force across your new joint, what your range of motion, risk of impingement, and ultimate leg length will be.
Hip Intra-Operative Fluoroscopy
During your surgery, low-dose X-rays are obtained to visualize the positioning of the implants, and to see how it matches up to our preoperative templating plan.
Total Knee Replacement
Careful attention is placed on the alignment of your knees. Standard knee replacements with Dr. Lee are cemented components, but your X-rays are thoroughly reviewed and consideration is given to whether your bone density and age make you a candidate for cementless implants. Templating of the implant sizes allows for a smooth intra-operative workflow.
Day of Surgery
The morning or day of the surgery, the anesthesiologist will meet you in the preoperative holding bay. A preoperative nurse will be taking care of you and collecting your history, reviewing your allergies, placing an IV, and providing you with preoperative medication. Dr. Lee will meet you there, and place a marking on your operative site.
If no contraindications exist, you will be given a cocktail of medication to help you relax and to provide enhanced analgesia through the operation and postoperative period. These include Tylenol, a nonsteroidal anti-inflammatory pill (Celebrex), a nerve-blunting pill (gabapentin), and a narcotic pill (oxycodone).
You will then be taken to the operating room, OR, where if deemed appropriate, you will be given a spinal anesthetic injection by the anesthesiologist. Patients often request to not be conscious for the actual operation, and additional sedatives can be administered to help you fall asleep during the procedure.
No surgery exists without complications, and total hip/knee replacements are no exception. If you are proceeding with a joint replacement operation, it is important to understand the potential complications.
Total Knee Replacement
- Incomplete pain relief. The most common scenario after a total knee replacement is a significant improvement in knee pain, albeit with some degree of lesser tolerable pain that no longer interferes with a basic level of ambulatory activity. The vast majority of these patients are very glad they had the surgery and report high satisfaction with their procedure. However, across the nation, there is a small but notable minority of patients who do not derive the level of pain relief they expected and are unsatisfied with their result. Dr. Lee believes the most important factor in maximizing your chances of satisfaction are to help you understand and manage expectations surrounding the replacement surgery.
- Instability. Knee instability can be an immediate result of surgery, but it is far more commonly encountered years after the operation. This may occur as a result of the stabilizing ligaments being stretched out, or replacement components wearing out, subsiding within the bone, loosening, or a combination of all of the above. In some cases, this may become severe enough that it is difficult to trust the knee, and in select cases, a second operation may be warranted to tighten up the knee.
- Stiffness. Knee stiffness can result after a total knee replacement if range of motion exercises are delayed too long during the recovery process. In particular, full knee extension (getting the knee fully straight) is very difficult to recover if not achieved and maintained early in the rehabilitation process. It is important to work on regaining your range of motion within several weeks after your operation. The best predictor of your maximum range of motion postoperatively is your range of motion preoperatively. That is, if you start with a stiff knee, there is a higher likelihood you will remain with some stiffness in your knee compared to someone with full range of motion. If you are unable to regain your range of motion in the first 6 weeks, you may benefit from a secondary procedure to stretch your knee out.
- Loosening. Component loosening most commonly occurs years after your operation. It can become a source of pain. The term loosening in this context usually refers to microscopic motion. That is, the components are not typically grossly loose, but even micro-motion can be a source of pain. The most definitive solution for this issue is a revision total knee replacement.
- Infection. Infection is the most dreaded outcome of any joint replacement surgery. In most cases, the preferred treatment is surgical removal of the existing implants, with temporary implantation of antibiotic-loaded cement, intravenous antibiotics through a long-term IV line, and subsequent re-implantation of final components once the infection has been cleared. These can be long processes for patients and their families, therefore Dr. Lee takes very deliberate measures to make sure your risk of infection is minimized. In some cases, less invasive options may be pursued, but these are highly dependent on the clinical scenario.
- Fracture. Patients undergoing joint replacement often have a co-existing condition called osteopenia, or poor bone quality. In this setting, even minor falls can lead to lower extremity fractures. If this occurs, there are several potential treatments, depending on the scenario, which include nonoperative treatment, operative fixation with plates and screws or a rod, or removal of your existing joint replacement and placement of new larger components that stabilize across your fracture site.
- Blood clots. Blood clots are a serious complication of joint replacement surgery. Deep vein thrombosis, the most concerning type of blood clot, has the potential to dislodge and travel to your lungs, impairing the ability of blood oxygenation, and can be a catastrophically lethal complication. Because of this, we always recommend blood thinning anti-coagulation agents for a period of time after your surgery and encourage early and aggressive mobilization.
Total Hip Replacement
- Residual pain. Total hip replacement is an effective pain relief surgery. Despite this, it is not uncommon to have a minor degree of soreness postoperatively. Most frequently, the level of discomfort is not prohibitive and patients are very satisfied with the degree of pain relief when asked at subsequent follow-up visits.
- Leg length discrepancy. Arthritic hips have by definition loss of joint space and cartilage. Sometimes this erosion is so severe that it can cause shortening of the diseased limb. When this happens over many years, it is easy to grow accustomed to this shortened length. During surgery, in most instances, an attempt is made to restore your natural limb length, which can be noticeable. In addition, there is a technical trade-off between limb lengthening and risk of hip instability/dislocation. A further detailed discussion and operative plan is made on an individual case-by-case basis.
- Dislocation. Dislocations are a dreaded complication of total hip replacement. This occurs when the ball pops out of the socket and needs to be placed back into the socket. The causes of dislocation can be multifactorial, including a breach of hip range-of-motion precautions, technical considerations at the time of surgery, mechanical impingement due to patient's natural anatomy, and a stiff spine.
- Bursitis. Hip bursitis can occur after a hip replacement when the soft tissue are placed under greater tension by having newly implanted parts. This is often a self-limited condition and can be a necessary trade-off to achieve a stable hip to minimize the risk of dislocation.
- Tendonitis. The most common tendon irritation after total hip replacement is psoas tendinitis. This tendon passes through the pelvis and helps flex the hip (the action your leg undergoes when you bring your knee up toward your body). If the tendon grinds against the new socket of a total hip replacement, it can lead to psoas impingement. This condition can have a spectrum of severity, ranging from no action needed, to injections, hip scope surgery to release the tendon, to full revision hip surgery.
- Metallosis. Metallosis occurs when microscopic metal debris is generated from the prosthetic implants. This was one major reason why metal-on-metal hip replacements failed in the early 2000s. Most hip replacements performed today are metal-on-plastic or ceramic-on-plastic. However, even these replacements have an interface that can potentially generate metal debris. The metal debris can cause a local tissue reaction and cause pain, muscle weakness, and, in high enough concentrations can cause systemic toxicity. Metallosis is not a common complication but is still encountered on a daily basis by busy joint replacement surgeons.
- Wear. Wear refers to erosion of the plastic parts that house the ball inside the socket of a hip replacement. Wear can cause plastic particulate debris that causes bones to be resorbed and weaken, and when very severe, can cause dislocations and implant loosening. In the early 2000s, several ways to overcome this problem were introduced, including metal-on-metal hip replacements, which have not borne out to be a great solution due to metal debris particles (see above). Another more lasting solution was highly cross-linked polyethylene. This was a treatment of the plastic molded parts that enhanced their wear properties. Many of these plastic parts that were implanted 20 years ago appear to have promising wear characteristics. Thus, these improved plastics parts are routinely used today.
- Loosening. Although the vast majority of implants are consolidated and become integrated with the host bone, in a minority of cases, components can loosen over time. This can lead to activity-related weight-bearing pain. If this is the case, X-rays and bone scans can help diagnose the condition. The only definitive treatment for component loosening is a revision operation.
- Infection. Infection is the most dreaded outcome of any joint replacement surgery. In most cases, the preferred treatment is surgical removal of the existing implant, with temporary implantation of antibiotic-loaded cement, intravenous antibiotics through a long-term IV line, and subsequent re-implantation of final components once the infection has been cleared. These can be long processes for patients and their families, therefore Dr. Lee takes very deliberate measures to make sure your risk of infection is minimized. In some cases, less invasive options may be pursued, but these are highly dependent on the clinical scenario.
- Blood clots. As mentioned previously, blood clots are a serious complication of joint replacement surgery. Deep vein thrombosis, the most concerning type of blood clot, has the potential to dislodge and travel to your lungs, impairing the ability of blood oxygenation, and can be a catastrophically lethal complication. Because of this, we always recommend blood thinning anti-coagulation agents for a period of time after your surgery and encourage early and aggressive mobilization.