For many patients with hip or knee arthritis, the hardest question is not whether joint replacement works. It is deciding when the time is right to actually have surgery.
In Episode 55 of The Joint Replacement Podcast, I sat down with Dr. Randall Schultz, a board-certified orthopedic surgeon at Texas Orthopedics in Austin and creator of The Surgeon Unmasked. Dr. Schultz has practiced orthopedic surgery for more than three decades and has performed thousands of joint replacements.
But he also brings a perspective that relatively few joint replacement surgeons have: he has undergone a knee replacement himself.
That experience changed how he thinks about surgery, recovery, patient expectations, and even how patients should choose their surgeon.
When does arthritis become bad enough for joint replacement?
One of the most important themes in our conversation was that the decision to have joint replacement is not based on an X-ray alone.
Dr. Schultz described how his own arthritis gradually reduced what he was willing and able to do. He could still exercise on a stationary bike, but walking more than about 5,000 steps could leave him awake at night with pain. Eventually, he realized his “world” had slowly become smaller.
That is something I hear from patients frequently.
You may stop taking long walks.
You may turn down trips because you are worried about how far you will have to walk.
You stop golfing, gardening, exercising, shopping, or playing with your grandchildren.
Often, these changes happen gradually enough that patients do not recognize how much they have adapted their lives around their arthritis.
Current ACR and AAHKS guidelines emphasize a similar concept. For patients with moderate-to-severe radiographic arthritis, significant pain or loss of function, and unsuccessful nonsurgical treatment, the decision to proceed with joint replacement should be made through shared decision-making between the patient and surgeon. Once an appropriate patient has decided on surgery, the guideline conditionally recommends against requiring additional ineffective nonsurgical treatments simply to delay surgery. AAHKS | Educate. Advocate. Investigate.
Do you have to be “bone on bone”?
Not necessarily, but the amount of arthritis on imaging matters.
Dr. Schultz made an important point during our discussion: the less obvious the arthritis is on X-rays, the more carefully he thinks about whether joint replacement is likely to produce a meaningful improvement.
Joint replacement is designed to treat pain and disability arising from a damaged joint. If the joint does not look severely damaged, surgeons have to consider whether something else could be responsible for the patient’s symptoms.
That is one reason I often think about the potential change between a patient’s preoperative and postoperative function rather than simply asking whether arthritis is present.
The goal is not just to replace a joint.
The goal is to make someone meaningfully better.
Can you wait too long for a hip or knee replacement?
Sometimes.
Joint replacement is elective surgery, and patients generally should not feel pressured into having an operation before they are ready.
But waiting indefinitely may have consequences in certain patients.
Dr. Schultz highlighted several concerns that can develop over time, including progressive stiffness, worsening deformity, declining fitness, loss of bone quality, and increasing age.
For knees in particular, severe deformity or stiffness can eventually make reconstruction more complicated.
That does not mean there is a specific birthday or X-ray finding when everyone should have surgery. Instead, the decision should consider the trajectory of the disease, the patient’s function, their overall health, and how much arthritis is interfering with the life they want to live.
What should patients try before surgery?
We also discussed the nonsurgical treatments available for arthritis.
Exercise and maintaining strength remain extremely important. Weight loss can substantially reduce the load placed across an arthritic hip or knee in patients who are overweight.
Other options may include:
- Physical therapy and strengthening
- Activity modification
- Anti-inflammatory medications when medically appropriate
- Corticosteroid injections
- Selected use of hyaluronic acid injections
- In some patients, biologic treatments such as platelet-rich plasma
The strength of evidence varies considerably between these treatments, and not every option is appropriate for every patient.
Importantly, once a patient has significant symptomatic arthritis and reasonable nonsurgical treatment has failed, repeatedly requiring additional treatments may simply delay definitive care. That principle is reflected in the ACR/AAHKS guideline on timing of hip and knee replacement. AAHKS | Educate. Advocate. Investigate.
Hip replacement and knee replacement are different recoveries
One of the most useful parts of the episode was hearing Dr. Schultz describe recovery from the perspective of both surgeon and patient.
He tells patients that after hip replacement, many people will appear largely recovered to others at roughly six weeks, although the hip may continue improving for six to twelve months.
Knee replacement is different.
His advice is to expect the first couple of weeks to be difficult, expect approximately six to eight weeks before beginning to feel much more normal, and recognize that the final result may continue evolving for a year or even longer.
That matched his personal experience. After undergoing knee replacement himself, he felt his knee continued improving for approximately two years. Pasted text
That is an important message because patients can become discouraged when they compare themselves with highly edited recovery stories online.
Recovery is rarely a straight line.
Should patients push harder after knee replacement?
We also discussed the growing interest in the so-called “quiet knee” concept.
Historically, patients were often encouraged to aggressively increase walking and range-of-motion exercises immediately after knee replacement.
More recently, some surgeons have questioned whether excessive early activity creates additional swelling and inflammation that actually makes recovery more difficult.
A 2026 study from Hospital for Special Surgery evaluated a quiet-knee rehabilitation protocol after primary total knee replacement and found lower opioid exposure without evidence of increased risk in the studied population. The authors proposed that limiting aggressive early rehabilitation may help reduce inflammation and pain while still allowing successful recovery. PubMed
The concept is interesting, but it should not be interpreted as meaning every patient should simply stop moving after surgery. Patients with significant preoperative stiffness or early postoperative motion problems may require a different strategy.
Rehabilitation should remain individualized.
Does the type of knee replacement matter?
Dr. Schultz and I also had an interesting discussion about partial versus total knee replacement.
Partial knee replacement can be an excellent operation in appropriately selected patients because it preserves more of the native knee. However, it also requires careful patient selection and technically precise execution.
Historically, registry and meta-analysis data have generally demonstrated higher revision rates after unicompartmental knee replacement than after total knee replacement, although outcomes vary significantly based on implant, surgeon volume, patient selection, and surgical technique. One large meta-analysis reported annual revision rates of approximately 0.49% for total knee replacement compared with 1.07% for medial unicompartmental knee replacement. PubMed
This is one area where technology may also play an important role. Robotic assistance was originally developed extensively around partial knee replacement, where relatively small differences in implant positioning and ligament balance may matter.
Are robots actually better?
One of the liveliest parts of our discussion involved robotics and computer navigation.
Dr. Schultz uses computer navigation and sees value in obtaining more precise information during surgery, but he also emphasized an important distinction:
Precision does not automatically mean a better clinical outcome.
Robotic and navigation systems can tell a surgeon very precisely where implants are positioned and provide information about alignment and ligament balance. But surgeons still have to decide what the correct target should be.
That remains one of the biggest unanswered questions in modern knee replacement.
Different surgeons may favor mechanical alignment, restricted kinematic alignment, functional alignment, or other personalized strategies.
The technology may help us execute a plan more accurately.
Determining the ideal plan for each individual patient remains an evolving area of research.
How much does the implant brand matter?
Patients frequently arrive at appointments having researched specific implant companies and designs.
Dr. Schultz’s answer was memorable: for most patients, the specific major implant brand matters far less than they think.
Modern implants from established manufacturers have generally evolved substantially, particularly with improvements in bearing materials such as highly cross-linked polyethylene.
Large registries such as the American Joint Replacement Registry track implant performance, revision rates, surgical techniques, and outcomes across hundreds of thousands of procedures and remain important for identifying meaningful differences over time. American Academy of Orthopaedic Surgeons
For an individual patient, however, choosing an experienced surgeon who is comfortable with a well-established implant system is generally more meaningful than selecting a surgeon because of a particular brand advertised directly to consumers.
Does the surgical approach matter?
We also discussed one of the most common questions patients ask before hip replacement:
Anterior or posterior approach?
Dr. Schultz performs direct anterior hip replacement but emphasized that both approaches can produce excellent long-term results when performed well.
The literature generally supports that interpretation.
Recent meta-analyses suggest that the direct anterior approach may provide advantages in some measures of early recovery or hospital length of stay, but differences tend to diminish with longer follow-up, and both anterior and posterior approaches can produce excellent outcomes. PubMed
This reinforces an important principle:
Choosing a surgeon who is experienced and comfortable with their technique may be more important than choosing an approach based solely on marketing.
How should you choose your joint replacement surgeon?
This may have produced the most surprising answer of the entire episode.
When I asked Dr. Schultz whom he would ask about the quality of a surgeon, his answer was:
An anesthesiologist.
His reasoning is compelling.
Anesthesiologists spend their careers in operating rooms. They see surgeons operate repeatedly. They see how surgical teams function, how surgeons respond when something unexpected happens, and how different surgeons approach difficult cases.
Dr. Schultz also cautioned against placing too much weight on online reviews.
Online reviews can provide useful insight into the patient experience, but they do not necessarily tell you how technically well a surgeon performs an operation.
He instead emphasized experience, appropriate fellowship training, and reputation among people who actually work with the surgeon. Pasted text
The biggest lesson: become an educated patient
Near the end of our conversation, I asked Dr. Schultz what he wishes every patient understood before undergoing joint replacement.
His answer summarized much of the episode.
Learn as much as you reasonably can.
Be cautious about marketing.
Prepare yourself physically.
Understand what recovery actually looks like.
And have realistic expectations about what surgery can and cannot accomplish.
Joint replacement can dramatically improve quality of life for appropriately selected patients, but deciding to proceed should be an informed decision between the patient and surgeon.
The question is not simply:
“Is my X-ray bad enough?”
A better question may be:
“Has my hip or knee started preventing me from living the life I want to live, and have reasonable alternatives stopped working?”
For many patients, that is when the conversation about joint replacement becomes much more meaningful.
Listen to Episode 55
How Do You Know When It’s Really Time for Joint Replacement? | Dr. Randall Schultz
Dr. Randall Schultz is a board-certified orthopedic surgeon at Texas Orthopedics and the creator of The Surgeon Unmasked, an educational platform designed to answer many of the questions patients have before and after joint replacement.
Subscribe to The Joint Replacement Podcast on YouTube, Spotify, Apple Podcasts or wherever you get your podcasts.
References
- Hannon CP, et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Journal of Arthroplasty. 2023;38:2193-2201. AAHKS | Educate. Advocate. Investigate.
- American Association of Hip and Knee Surgeons. Optimal Timing of Total Hip and Knee Arthroplasty. 2023. AAHKS | Educate. Advocate. Investigate.
- Afzal S, Bhatti P, Alschuler DM, et al. Quiet Knee Rehabilitation Protocol After Primary Total Knee Arthroplasty Is Associated With Lower Opioid Exposure and No Added Risks: A Retrospective Cohort Study. Journal of Arthroplasty. 2026;41(S1):S80-S84. PubMed
- Hansen EN, et al. Annual revision rates of partial versus total knee arthroplasty: A comparative meta-analysis. Knee. Evidence summarized from 124 studies including 374,934 arthroplasties. PubMed
- Ghandour M, et al. Direct anterior approach versus posterior approach in total hip arthroplasty: A systematic review and meta-analysis. Journal of Orthopaedics. 2025;65:233-250. PubMed
- Wang Z, et al. Clinical, functional and radiographic outcomes of primary total hip arthroplasty between direct anterior approach and posterior approach: a systematic review and meta-analysis. Orthopaedics & Traumatology: Surgery & Research. 2020. PubMed
- American Joint Replacement Registry. 2025 AJRR Annual Report. American Academy of Orthopaedic Surgeons; 2025. American Academy of Orthopaedic Surgeons