The Physical and Psychological Demands of Total Joint Surgery: How New Models of Care Can Alleviate Patient Worry & Stress & Enhance Outcomes

Total joint surgery, including knee and hip replacements, can be a life-changing procedure for patients suffering from severe arthritis and other degenerative joint diseases. It can give them back mobility, reduce debilitating pain, and restore quality of life. In other words, the outcomes can be truly life-altering.

However, the physical and psychological demands of this surgery (or any major surgery) are immense, particularly for older patients and those with health challenges such as obesity, malnutrition, or comorbidities like diabetes and cardiovascular disease. Understanding these patients' unique challenges underscores the need for careful preoperative preparation and a multidisciplinary approach to improve outcomes.

This is why Mend has developed the transformative Upgraid platform – a proactive, hands-on, real-time coaching, monitoring, and readiness/recovery support platform with precision care pathways and embedded evidence-based nutrition. There are specific care pathways for patients with obesity to ensure that we are addressing their modifiable risk factors and preparing them for a successful surgery. This is not a standard weight loss program but a surgical optimization obesity management program. We believe automated text message push notification-based programs are insufficient. We need real behavioral support from real clinicians supporting the patient through the episode of care with sophisticated care plans that address the whole person and biopsychosocial needs.

Physical Demands of Total Joint Surgery – Like Running One and A Half Marathons

Undergoing total joint surgery, particularly a total knee or hip replacement, is comparable in the physical toll and metabolic demands on the body of running one-and-a-half marathons due to the immense stress, where a typical person can burn up to 5000 calories. The body needs to heal from the invasive surgical procedure, regenerate tissue, regain mobility, and rebuild strength through rigorous rehabilitation, which can take months. Studies have shown that patients may experience elevated heart rates, high levels of fatigue, and muscle soreness after surgery.

Is it reasonable to ask anyone to run a marathon without proper preparation and training? Without proper nutrition?? Is it reasonable then to ask a 70-year-old with compromised health to go into surgery with similar physical and mental demands without preparation, readiness, and a recovery plan?

The level of physical conditioning required to recover successfully highlights the need for strong cardiovascular and musculoskeletal health before surgery. This is especially challenging for elderly patients or those with comorbidities, who may face longer recovery times and higher rates of complications.

Total joint surgery places a significant burden on the body, especially in the postoperative period. The procedure involves removing damaged joint surfaces and replacing them with prosthetic components, which requires substantial physical recovery and rehabilitation. For older adults or patients with underlying health conditions, the demands of recovery can be incredibly daunting.

1. Age-Related Factors: The average age of patients undergoing total joint replacement surgery, particularly hip and knee replacements, is typically in the mid-to-late 60s. According to the American Joint Replacement Registry (AJRR), the average age for total knee arthroplasty (TKA) is around 66 years, and for total hip arthroplasty (THA), it is approximately 65 years. This reflects the high prevalence of degenerative joint diseases like osteoarthritis in older adults. Many patients are having the surgery at more advanced years – my mother had her knee replaced at the age of 79 (I made sure she was guzzling her Mend pre and post-surgery on an Upgraid protocol). As patients age, they experience a natural decline in muscle mass (sarcopenia), bone density, and overall physical resilience. This makes recovery from total joint surgery more challenging. Older patients often have reduced strength, delayed wound healing, and slower postoperative mobilization, which is critical for avoiding complications like deep vein thrombosis (DVT) or pneumonia. Studies show that elderly patients (aged 75 and older) have higher rates of postoperative complications and slower functional recovery compared to younger patients.
2. Obesity and Its Impact on Recovery: Obesity significantly complicates total joint surgery. Most surgeons that we speak to suggest that 70% or more of their patients exceed the obesity threshold of 30 BMI or higher. At a national level obesity is at roughly 50% with another 20-30% of the population being overweight. Despite the GLP1 craze, obesity is set to increase sharply in the next five years. Excess body weight increases the mechanical load on the newly implanted joint, raising the risk of early implant failure. Each additional kilogram of body weight adds approximately four kilograms of pressure on weight-bearing joints, exacerbating joint stress post-surgery. Moreover, obesity is linked to a higher incidence of complications such as surgical site infections (SSIs), delayed wound healing, and venous thromboembolism (VTE). A 2020 study found that obese patients were more likely to experience postoperative complications and had more extended hospital stays compared to non-obese patients.
3. Malnutrition and Frailty: Large-scale hospital studies suggest that malnutrition is widespread, and it is not just limited to the frail person but also the obese person as measured by their skeletal muscle. Muscle is the metabolic reserve for key amino acids mobilized to fuel the immune system and the healing response. Malnutrition impairs wound healing, weakens the immune system, and increases the risk of infections. A 2019 study published in The Journal of Arthroplasty highlighted that malnutrition was associated with a 2-3 times higher rate of postoperative infections and a greater likelihood of prolonged rehabilitation periods. Frailty, which often accompanies malnutrition in elderly patients, further complicates recovery, as these patients may lack the physical reserves needed to withstand the demands of rehabilitation.
4. Comorbidities: Patients with multiple chronic conditions, such as diabetes, hypertension, and cardiovascular disease, face higher surgical risks. Studies show that around 70-80% of patients scheduled for total joint arthroplasty (TJA) have at least one significant comorbidity. Common comorbidities include hypertension (40-60% of patients), diabetes (10-20%), cardiovascular disease, chronic pulmonary conditions, and kidney disease. Diabetes, for example, is associated with poor glucose control, which increases the risk of infections and delays wound healing. Cardiovascular disease can complicate anesthesia and raise the risk of perioperative heart attacks. These comorbidities can lead to longer recovery times and a higher likelihood of adverse outcomes. Data indicates that patients with diabetes are at a significantly higher risk for complications such as deep joint infections following total joint replacement.

Psychological Demands and the Impact of Preoperative Health

The psychological burden of preparing for and recovering from total joint surgery can be overwhelming, especially for older patients or those with chronic health conditions and who are perhaps faced with a level of social isolation. Factors such as preoperative anxiety, fear of surgery, and postoperative depression are well-documented in this patient population. Studies indicate that between 20-40% of patients experience significant psychological distress in the form of anxiety or depression before surgery.

Anxiety is particularly prevalent, with around 20-30% of patients reporting heightened levels of preoperative anxiety related to concerns about the procedure, pain, and recovery. Depression is also common, affecting up to 25% of total joint replacement patients, and is often associated with chronic pain, reduced mobility, and diminished quality of life before surgery. The impact of stress and worry don’t always show up in the quality and outcomes scores but cause significant suffering that can be alleviated and reduced through the right care models.

1. Preoperative Anxiety: Older adults or individuals with significant comorbidities often experience heightened anxiety about surgery due to concerns about pain, complications, long recovery times, or loss of independence. Preoperative anxiety can negatively impact surgical outcomes, as it is associated with increased postoperative pain perception and more extended recovery periods. A study published in The Journal of Arthroplasty showed that patients with high levels of preoperative anxiety were more likely to experience prolonged pain and slower functional recovery.

2. Postoperative Depression: After total joint surgery, patients often face physical limitations, pain, and prolonged rehabilitation, which can contribute to feelings of frustration, helplessness, and depression. Older adults, especially those with limited social support, may be at higher risk for postoperative depression, which can impede their willingness to engage in rehabilitation exercises essential for successful recovery. Depression has been shown to delay recovery and increase the likelihood of poor functional outcomes in joint replacement patients.

3. Cognitive Impairment: In older patients, cognitive decline or dementia can make the recovery process even more challenging. These patients may have difficulty following postoperative instructions, remembering to take medications, or engaging in rehabilitation exercises. This can lead to poor outcomes, including delayed recovery and reduced joint mobility. Studies indicate that patients with cognitive impairments have significantly higher rates of postoperative complications, hospital readmissions, and longer recovery times.

Addressing the Challenges: The Importance of Prehabilitation and Multidisciplinary Care with Upgraid – A Transformational Shift in the Care Paradigm

Given the significant physical and psychological demands of total joint surgery, preparing patients thoroughly to optimize outcomes and support and monitor them in the postoperative period is crucial. Upgraid is a precision approach to readiness and recovery, utilizing technology and an adjunctive care delivery approach to transform how we support patients in the pre and post-operative period.

1. Nutritional Support: Addressing malnutrition and ensuring patients receive adequate protein and calories in the weeks leading up to surgery can significantly improve healing capacity and reduce the risk of infections. Supplementing with Mend’s evidence-based medical food products, like Mend Joint Replacement, patients are provided nutritional support that is clinically proven (published in randomized trials and mechanistic studies) to enhance muscle, enhance return to function, reduce post-operative inflammation, and sustain long-term muscle health and function benefits. Patients know and understand that nutrition is important to their healing - in a survey study done by Mend of roughly 1300 patients, 92% of patients stated that nutrition is very important to healing and recovery from injury and surgery. A proven nutrition product also contributes to the overall patient experience ("I'm receiving something that will make my recovery easier") and alleviate some of the worry and stress.

2. Coaching and monitoring: a team of clinicians remotely support and monitor the patient through developed precision care pathways referencing the programs with the best national numbers of outcomes. Patients are guided daily on key instructions pre-operatively and post-operative, and in-home devices such as body composition scales and Fitbits allow our clinicians to monitor critical biomarkers and train the patient on new approaches to managing their overall health.

3. Psychological Support: Mend’s program can screen patients who are experiencing anxiety, depression, or other mental health issues and refer them to our network of mental health professionals.

4. Comorbidity Management: A multidisciplinary approach in a connected and coordinated care model allows us to monitor comorbidities and guide the patient to additional care when clinically necessary.

A Better and More Thoughtful Model

Total joint surgery is a demanding procedure, both physically and psychologically, particularly for patients who are older, malnourished, obese or have comorbidities. By recognizing these challenges and emphasizing the importance of prehabilitation, nutritional support, and psychological readiness, we can significantly improve patient experience and outcomes and enhance recovery. Preparing for total joint surgery is not unlike training for a marathon, and both patients and healthcare teams must work together to ensure the patient has the support needed for minimized stress and support full and rapid healing and recovery.

Since we all care about patient satisfaction and net promoter scores, let's see what patients are saying about this approach.

“Outstanding team members for UPGRAID. Alicia was exceptional and gave outstanding advice as well as solid medical information. She was great!”

“I’ve never seen this kind of care. I'm so proud to have been a part of this wonderful experience. My husband had no care at all compared to what you’ve done for me.? We both thank you all very much and you will probably see me one more time with my other one. I wouldn't let anyone else touch me.”

“Excellent rapport and every day contact by texting was easy.”

“I’ve already told two other people about this program that are going to have hip replacement in the next two months.”

“I’ve had several surgeries and I’ve never experienced such an abundance of trained people caring for and helping me get my health back to good.”

“I have really loved being on this journey with your team. I felt very supported and learned a lot!”

“I think the program and its products were great and I also believe that they had a significant part in my quick recovery.”

"My sister in law is on the Upgraid program and insisted that I utilize it. She said it's been truly helpful and she looks forward to the recovery process knowing that there's team there for her."

"Oh my goodness, you have no idea how much relief this gives me. Hearing about the program gives a wave of relief. I have never heard of anything like this and wish I had known about something like this before. THANK YOU and god bless you."

"I really appreciate all of your support. You guys really help me feel encouraged. I don't know where I'd be without? you guys keeping me on track. I feel really cared for and have confidence in myself because of you all."

“I’m really pleased with Mend’s surgical readiness program and that my surgeon and his staff are proactive about care.”

“Seemed to be a great improvement over my first surgery without Mend.? Enjoyed meeting with the dietician…All of the supplements were high quality and contributed to my recovery.”

“This is very helpful to me. Thank you; and these are the kind of things that I am trying to work on to keep my kidneys functioning properly.”

“I am 8 weeks post LKR and doing awesome. I am finding MEND products to be making a major difference!? I have a friend who had surgery by Dr Peters ...not on the MEND program, and had a lot of pain and difficulty post-op.. that speaks volumes.”

“... would like to thank everyone involved with the MEND Program for helping me....surgery such as a total knee replacement; takes a toll on your mental health + physical health...MEND played a very strong role on my support team; and I'm very grateful …”

“Best care team possible.”

“Thank you… you really have helped me... For the first time in probably 20 years...I’ve been able to walk into a store, pick something off the rack, and be able to wear it.... I’m thankful that this program exists.”

“I have really loved being on this journey with your team. I felt very supported and learned a lot!”

“I enjoyed speaking with Stacey regarding the nutrition. The nurses were great as well.”

“It was very reassuring to know that there are professionals looking after my progress after surgery.”

“...I have been so impressed with Upgraid. I've had a lot of other surgeries before and I have never had anyone call and talk to me about specific things that I need to know... it's so hard to get ahold of the doctor so it's nice to feel like I have support if I have any questions.”