Martin Anderson, MD

Martin Anderson, MD
Tahoe Fracture Clinic
1104 North Division Street
Carson City, Nevada 89703
775-884-5470
http://orthodoc.aaos.org/MartinAnderson
Physicians Line: 775-884-5472
FAX 775-884-5463
contents
Arthritis, Activities, Weight Loss
Glucosamine and Chondroitin Sulfate
Viscosupplementation (Rooster Comb Injections)
Cortisone Injections
Tylenol™ and Arthritis Medicines
Topical Ointments and Balms
Narcotic Pain Medicines
Braces
Nontraditional Therapies
Arthroscopic Surgery
Osteotomy (Bone Realignment)
Fusion Surgery
Total Joints (General Information)
Canes, Wheelchairs, and Scooters
Total Knee Replacement
Total Hip Replacement
Frequently Asked Questions – Joint Replacement
Photos (Martin Anderson, MD & Chip Nuttall, PA-C)
Schedule for Joint Replacement
Risks from Banked Blood
Total Joint Infection Surgery
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Arthritis affects 45 million people in the United States. The most common form is
osteoarthritis, a form ascribed to aging, although in reality it is a disease (the cause of which
is unknown) that effects people of all ages to varying degrees and does not affect others,
including the very elderly. There over 150 known causes of arthritis and it affects one third
of all adults to one degree or another. Osteoarthritis is a disease of cartilage that leads to
pain in the joints. Osteoporosis is a disease of bones that makes them brittle and leads to
fractures (broken bones). Osteoporosis does not preclude good results with joint
replacement surgery.
Osteoarthritis may be separated from post-traumatic arthritis, rheumatoid arthritis, systemic
lupus arthritis, enteropathic arthropathy (associated with Crohn’s disease or ulcerative
colitis), Reiter’s syndrome (associated with chlamydia genitourinary infection and infectious
diarrhea), psoriatic arthropathy (associated with psoriasis, a skin condition), rheumatic fever
(associated with strep infections and which may damage the heart valves), Lyme disease
(associated with infections from tick bite and which may lead to neurological problems), and
a myriad of infectious causes which either damage the joint directly or cause inflammation
from the deposition of immune complexes in the joint. The medical management of these is
other diseases is different from that of osteoarthritis and is sufficiently complex that a
subspecialty of internal medicine, rheumatology, has evolved. The surgical treatment of
end stage arthritis is not markedly different, no matter what type of arthritis you have.
Osteoarthritis is a disease of the cartilage although it eventually causes changes in the bone
such as bone loss, bone spur and cyst formation. There is no cure for osteoarthritis and
there is no way to accurately predict how fast it will progress. Only a small percentage of
patients will develop arthritis so severe as to require surgical intervention and when
osteoarthritis is this severe it is not easily confused with other diseases. We are now
replacing 245,000 knees and 138,000 hips in the United States each year. These numbers are
expected to increase to 454,000 and 248,000 by the year 2030.
Osteoarthritis Treatment Options
1.
Activity modification: limit activities prudently. This is not to say give up exercise,
which is important in maintaining cardiovascular conditioning and emotional and physical
well-being. It may be prudent to substitute walking or bicycling for jogging with mild
arthritis. Swimming or water aerobics are better tolerated for patients with severe arthritis of
the weight bearing joints. In all instances exercise should be prudent, with adequate periods
of rest. Listen to your body: if an exercise is consistently resulting in pain and swelling
afterwards, omit it from your routine and try another one. Cardiovascular conditioning
should be discussed with your primary care provider, especially if you have risk factors for
cardiovascular disease, such as smoking, high blood pressure, diabetes, high cholesterol,
obesity, or a family history of heart disease. There is a body of evidence that suggests that
weakness of the muscles around the arthritic join may accelerate the progression of arthritis.
The bottom line is that it is our role, as physicians who specialize in the treatment of
arthritis, to keep you active.
2.
Weight Loss: Weight loss will benefit overweight patients as many activities of daily
living place several times the body weight across portions of the knee or hip. The benefits
of weight loss are exponential but there has not been historically a safe and effective medical
treatment for obesity that has withstood scientific scrutiny. There is a new surgical
treatment available for patients who are morbidly obese, although previous bypass
operations were unsuccessful. The subspecialty of general surgery that provides surgical
treatment of morbid obesity (severe enough to poses risks to life) is bariatric surgery.
3
Obesity, in itself, does not preclude a good result from arthritis surgery but is associated with
higher rates of blood clots, joint instability, infections and wound healing problems. The
surgery is more technically demanding for your surgeon. Historically, many surgeons have
refused to operate on morbidly obese patients and, even now, you should understand that
many surgeons do not have the skill to operate on very large patients and may recommend
that you seek surgical care from a sub specialist. Only about one in four patients loose
significant weight after joint replacement. Just because you are able to resume a more active
lifestyle is no guarantee that you will become more active after surgery. It is hard to change
the behaviors that you have adopted to cope with your arthritis and if you have always been
sedentary, you will need motivation other than a new joint to make you more active.
3.
Glucosamine/Chondroitin Sulfate: These simple over the counter medicines are
the only ones that have been shown to slow down the progression of arthritis. There is
experimental evidence that these medications improve the health of cartilage cells in animals
but no evidence that they restore lost cartilage cells or make them reproduce faster. There is
a study that showed that long-term use of glucosamine did slow the progression of
osteoarthritis (Pavelka K, Gatterova J, Olejarova M, et al., “Glucomasamine sulfate decreases
progression of knee osteoarthritis in a long-term, randomized, placebo-controlled,
confirmatory trial,” #1908, The American College of Rheumatology, 64th Annual Scientific
Meeting, 10/28-11/2/2000, Philadelphia). Glucosamine is as effective as over the counter
ibuprofen in treating arthritis pain. It is safer than anti-inflammatory medications. Only
rarely are allergic reactions seen, typically in patients allergic to shellfish.
Cosamin DS™ has been my brand of preference for combination therapy as the
manufacturer maintains tight controls over its purity and this brand has done a great deal of
research to prove their product’s efficacy. This brand cost $50-75 for a two month’s supply
and is not covered by most insurance plans because it is an over the counter nutritional
supplement. Dona™ glucosamine sulfate (Rotta Pharmaceuticals, Inc) is the brand used in
the study showing slowed progression of arthritis and appears to be a good choice for single
agent (glucosamine alone) therapy and appears promising. As they have few side effects, I
recommend these medications enthusiastically for patients whose arthritis is not yet severe
(bone on bone). There is legislation pending to guarantee the purity of glucosamine and
other medicines sold as nutritional supplements. This will allow patients to shop for cheaper
medicines.
4.
Viscosupplementation: Artificial joint fluid improves pain in 70% of patients for
at least six months, by most industry-sponsored studies.
Clouding the issue is less favorable results in studies not
supported by the companies that manufacture these
products. The treatment consists of a series of three to five
injections given roughly one week apart and is used primarily
for the knee joint. While this is very expensive and may not
prevent arthritis progression, it may buy time before surgical
options are considered. It may make remaining cartilage cells
healthier but does not cure arthritis. I usually refer patients
with mild to moderate arthritis of the knee without severe
mechanical problems such as meniscal tears to a
rheumatologist for this treatment. I have consistently been
disappointed with the results for severe arthritis (bone on
bone changes on X-ray).
4
This treatment is expensive and if your insurance doesn’t approve the use of the treatment,
your cost may be in excess of $1000. If insurance doesn’t cover this or if arthritis is severe
(bone on bone), injection of cortisone-type medications may be more prudent as some
studies show no improvement in the results of viscosupplementation over simple cortisone
injection. This treatment may cause a local allergic reaction severe enough to be confused
with an infection (about 1% of the time with the first series and 10% of the time with the
second series). This may require aspiration of the knee, injection of cortisone and
occasionally arthroscopic surgery to remove the lining of the knee joint (synovectomy).
Allergies occur because these preparations are made from rooster combs and this material is
foreign to our immune systems. Infection risk is 1/10,000 with injections of the knee. An
infection makes total knee replacement inadvisable for a period of two years due to the risk
of recurrent infection. This treatment is FDA approved for the knee only. Its use in other
joints is under study but the hip joint usually requires injection by a radiologist using a
fluoroscope.
5. Injection of cortisone: This treatment may actually modify the disease activity in
rheumatoid arthritis but does not do so in osteoarthritis. It was first used at the Mayo Clinic
in the 1940’s. It provides pain relief for hours to months, depending on how much
inflammation is associated with the arthritis and, like other medical interventions, works well
when arthritis is not severe (bone on bone). I find that the first injection for osteoarthritis
often lasts several months, the second lasts several weeks, the third lasts several days and the
forth lasts several hours. It may cause softening of any remaining healthy cartilage, as seen
in studies of dogs undergoing injection, and is not recommended more than four times
yearly nor is it recommended more often than once a month. It carries a risk of about
1/10,000 of causing an infection in the knee joint and may temporarily cause significant
increases in blood sugar in diabetic patients. I do not recommend cortisone injection for
mild arthritis due to uncertainty about how the medications may affect the remaining
cartilage based on the research done on dogs.
6. Tylenol™: If you do not exceed 650mg every 4 hours, this is a very safe treatment for
pain. If you do exceed this dose, liver damage may occur. Remember that many narcotic
preparations (Darvocet™, Vicodin™. Lortab™, Percocet™) contain Tylenol™ and should
not be supplemented with additional Tylenol™ (acetaminophen). The safety of this
medicine is second only to glucosamine and I recommend its use enthusiastically.
7. Anti-inflammatory medicines: these medications may decrease pain and inflammation
when it occurs in inflammatory osteoarthritis but carry the risks of potentially fatal bleeding
ulcers, liver damage and kidney failure
and require laboratory monitoring. The
first step is to use over the counter
medicines (Aleve™, Advil™, etc.)
except for patients with a history of
ulcers or allergies who should avoid this
class of medicines. The next step is to
use the new class of the medicines
(COX2 inhibitors, Vioxx™ and
Celebrex™), which are much less likely
to cause bleeding ulcers.
The medicine, Arthrotec™ contains a
medicine that protects the GI tract from
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ulcers very well but may cause 2-3 days of mild nausea or diarrhea as your stomach adjusts to
it. The stomach may require periods of rest from this medicine every couple of years to
prevent gastric cancers as in the case of its cousin, the ulcer medicine cytotech™. It does
thin the blood somewhat and is one of the most effective anti-inflammatory medications
available to us. It is my favorite anti-inflammatory but it is expensive. The medicines
Bextra™, Mobic™, Relafen™, and Lodine™ are COX2-selective and are safer on the GI
tract than prescription strength medicines that are not either selective or specific blockers of
inflammation in the joints. Close monitoring for GI ulceration is required as it is estimated
that 16,500 arthritis patients die taking these medicines in the U.S. annually from bleeding
ulcers and these medications are also a leading cause of kidney failure and can also damage
the liver. (Singh, Am J Med 1998: 105(1B): S31-8).
This class of medicines is useful to decrease inflammation, shorten the duration of
symptoms and treat pain. They decrease inflammation in diseases and injuries and are useful
when inflammation does not play a constructive role. These medicines are not a substitute
for activity modification, therapy or surgery when it is required and may hinder healing when
inflammation is useful (as in fracture healing and in bone ingrowth after cementless total
joint replacement).
The older, cheaper medicines cause ulcerations in the GI tracts of about 15% of long-term
users and bleeding ulcers requiring hospital admission in approximately 1% of regular users
annually. All of these medications can cause edema (swelling) in 4-8%, worsening of
hypertension (blood pressure) in 4-8% of patients. Kidney failure, or liver injury may occur
although this is rare and usually occurs in those who already have some degree of kidney
failure, liver disease or heat failure. The older medicines may interfere with platelets (blood
clotting) and are unsafe before surgery and unsafe when the blood thinner coumadin™ is
being used. The older medications may provide some protection from heart attack and
stroke however. All of the medicines work to inhibit the enzyme in the body called
cyclooxygenase (COX). There are two sites: COX1, in the stomach, kidneys, liver, and the
platelets and COX2, in the kidneys and in bones, joints and tendons. The recent
breakthroughs are in the development of COX2 selective drugs (Bextra™, Relafen™,
Lodine™, and Mobic™) and the newest class of drugs that are COX2 specific (Celebrex™
and Vioxx™). These medicines are much safer on the GI tract unless taken with aspirin.
Those with sulfonamide (“Sulfa”) allergies may have severe allergic reactions to Celebrex™
or to Bextra™. Those with NSAID or aspirin allergies should not use any of these
medicines, if it is determined to be a true allergy. Those with asthma, urticaria (hives from
environmental allergies), or nasal polyps should discuss the risks of the medicines with their
doctor before using them. With risks for kidney failure the doctor will need to check a
blood test to calculate the risks of using this medicine. The important things to know are
that these medicines are all about as safe as aspirin. If they bother the stomach, or cause
abdominal pain, stop them. If you have blood in the stool, black tarry stools, vomiting of
material that looks like coffee grounds, swollen legs, dark or excessively foamy urine or just
feel bad stop the medicines and seek medical care immediately. Remember that GI
bleeding may occur without pain or other warning symptoms.
COX2 selective inhibitors do not protect you from heart attacks stoke and blood clots. This
is expected, as they do not thin the blood. They change clotting mechanisms in complex
ways. If you have risk factors (previous MI or stroke, known coronary carotid or peripheral
vascular disease, smoking, worrisome family history, high cholesterol, sedentary lifestyle, etc)
you should take a baby aspirin to decrease these risks. The use of aspirin negates much of
the protective effect of these medicines on the GI tract, however. Some selective inhibitors
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have been shown to be associated with more heart attacks strokes and blood clots than the
nonselective inhibitors presumably because they do not thin the blood, although the exact
reasons for this are under investigation at the time of this writing.
Often, the medications which are safest on the GI tract are the most expensive:
Med
Monthly Cost (generic if available)
Motrin™ 800mg TID
$27.69
Naprosyn™ 500mg BID
31.16
Relafen™ 750mg BID
114.45
Lodine™ 400mg QD
41.45
Celebrex™ 200mg QD
90.37
Vioxx™ 25mg QD
90.34
Arthrotec™ 75mg BID
106.20
(Source: Michael's Pharmacy 1007 N. Curry St. Carson City, NV)
The costs of treating an ulcer are monumental compared to the costs of the safer
medicines.
The Merck Corporation has a toll-free number for assistance with the costs for those who
make less than $18,000/yr ($24,000/yr for the household) and selected others. They
manufacture Vioxx™. That number is 800-727-5400.
For long-term use of anti-inflammatory medicines I require periodic lab testing to ensure
that no problems are occurring, at 3-4 months after starting the medicine and yearly
thereafter. These include three stool hemetest cards, BUN, creatinine, urinalysis and liver
functions. Your blood pressure should also be monitored closely as should the INR test for
blood thinning if the blood thinner warfarin (coumadin™), if it is used. If you are on
coumadin you need to have an INR lab test 3-5 days after beginning the new medication.
8. Topical preparations: anti-inflammatory medications can be complexed into gels by
the pharmacist allowing some medication to be absorbed across the skin without the risk of
systemic problems (except allergic reactions). I usually have the pharmacist mix 10%
ketoprofen gel. These formulations have a short shelf life and won’t work after they are old.
There is special training required for the pharmacists in this instance and you may not be
able to use your usual family pharmacist for this prescription. The medication, capsaicin, can
both block the transmission of pain through nerve fibers and can block formation of a pain
transmitter (substance P), thereby alleviating pain. Its use, however, is limited by its
tendency to cause a burning sensation in warm weather or when exercising.
9. Pain medications: the prescription medications Ultram™ and Ultracett™ are not
believed to be as habit-forming as narcotics but pain medications must be used with caution
and long term use is usually supervised by a physician who specializes in the treatment of
chronic pain if they are to be used for more than a few days. Narcotics can cause addiction,
depression, and mental status changes and typically require increasingly higher doses as your
body becomes tolerant to them. These medications impair judgment and reaction time and
must not be used within 8 hours of driving or operating machinery. It is just as illegal to
drive while taking these medications as it is to drive drunk but the decision about driving
must be made with your pain specialist, usually a physiatrist (Physical Medicine and
Rehabilitation). The use of a pain pill “now and then” is no safer than smoking a cigarette
now and then from the standpoint of addiction. It can be a starting point for addiction.
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10. Braces: Some people get relief from a wrap worn around the knee although there is no
evidence that knee sleeves, with or without magnets, will benefit their arthritis. So long as
they are not worn so tightly as to cause swelling or blood clot formation, they are safe.
Unloading braces have been shown to benefit arthritis pain when the arthritis is limited to
only part of the knee. My patients ask me to prescribe these several times a year but the
majority of them are disappointed with the result. Some scientific studies of these braces
have shown improvement in the gait pattern but other studies have shown no improvement
in pain relief over a simple knee sleeve obtained at a much lower cost and without a
prescription from the doctor. Custom-made arthritis braces are expensive, cumbersome to
wear, and may make the knee pain worse, although the occasional patient experiences relief
from these devices in my experience.
11. Non-traditional therapies: My role is to prescribe only treatments that can be shown
conclusively to benefit patients and this limits my ability to recommend therapies not listed
in this handout. There is testimonial evidence to support everything from faith healing to
copper bracelets and rum-soaked raisons. The best guide to these is found in The Arthritis
Foundation’s Guide to Alternative Therapies (J. Horstman, Ed., Arthritis Foundation,
Atlanta, GA, 1999) that lists 64 alternative treatments. I support whatever safe interventions
that you and your nutritionist or naturopathic provider agree on, so long as they are safe. I
have no personal expertise is this area and will not be able to make recommendations
regarding alternative therapy to you in good conscience. I am opposed only to treatments
that are dangerous or that are expensive when there is little or no evidence that they work.
12.
Arthroscopic surgery of the knee: this works best for patients who have
symptoms of short duration with mechanical derangements such as meniscal tears, central
osteophytes (bone spurs), or loose bodies in the joint, affording at least two years of relief
for 80% of patients that fit these criteria and do not have severe arthritis. Repeat procedures,
arthroscopy for severe arthritis (bone on bone) and procedures for patients with symptoms
which came on slowly, have persisted a long time and who don’t have meniscal tears is less
rewarding. Just running large amounts of fluid thru the knee (arthroscopic lavage) may
provide some degree of
relief for a percentage of
patients. Surgery to
replace cartilage
(mosaicplasty and
autologous chondrocyte
implantation) is
appropriate to repair holes
Torn
Tear
in
cartilage,
not
huge
Meniscus
Removed
surfaces of absent cartilage
such as occur in severe osteoarthritis. Our problem is that cartilage cells do not adhere to
bone as they would in a normal knee due to the loss of the supporting collagen framework
present in normal joints. A procedure used to induce new scar cartilage (fibrocartilage) to
form in small defects has been very successful. This procedure, the microfracture technique
pioneered by Dr. Dick Steadman, is easily performed and allows stem cells inside the bone
marrow to differentiate into cartilage cells. It may work much better for younger patients as
the population of stem cells which can make cartilage decreases dramatically with age.
8
To draw an analogy from road repair, we can repair potholes with cartilage ingrowth
and transplantation technology but we can’t create a whole new highway. We can
grow abundant cartilage in cell cultures but, without collagen to attach the cartilage to the
bone, this technology is helpless against severe arthritis. Arthroscopic surgery does offer
many patients relief, especially if done before arthritis becomes severe. To estimate the
likelihood of a successful result with the lesser surgery, the surgeon weighs the following
factors:
FACTORS WHICH PREDICT SUCCESS WITH ARTHROSCOPIC SURGERY
Short duration of symptoms
Recent injury
No previous surgery to the knee
Locking of the knee
No pain at rest
No malalignment
Effusion (fluid on knee)
X-ray not “bone on bone”
(Yang, Niconson CORR 316: 50-58, 1995)
For severe osteoarthritis, arthroscopic surgery may be no better than placebo therapy;
although when there is doubt about the extent of arthritis arthroscopic examination may be
appropriate:
”A randomized, placebo-controlled trial involving patients with
osteoarthritis of the knee, found the outcomes after arthroscopic lavage or
arthroscopic debridement were no better than those after a placebo
procedure. A total of 180 patients with osteoarthritis of the knee were
randomly assigned to receive arthroscopic debridement, arthroscopic lavage
or placebo surgery. Patients in the placebo group received skin incisions
and underwent a simulated debridement without insertion of the arthroscope.
Patients and assessors of outcome were blinded to the treatment-group
assignment. Outcomes were assessed at multiple points over a 24-month period
with the use of five self-reported scores-three on scales for pain and two
on scales for function-and one objective test of walking and stair climbing.
A total of 165 patients completed the trial. The study, which appears in
the July 11 edition of the New England Journal of Medicine, was conducted by
J. Bruce Moseley, MD, and colleagues at the Houston Veterans Affairs Medical
Center. Dr. Moseley, an orthopedics professor at Baylor University, told
UPI, "I was initially surprised. I could not imagine anybody suggesting that
anything we do in surgery would be beneficial from a placebo effect. I
associate placebo effect with pills." Dr. Moseley said, "In my simple
surgeon's explanation of this, the magnitude of placebo effect is directly
proportional to the patient's perceived intervention." New England Journal
of Medicine, UPI July 10, 2002” (AAOS news 7/10/02)
the abstract is at:
http://content.nejm.org/cgi/content/short/347/2/81
It is rare to recommend arthroscopic surgery for arthritis in joints other than the knee and
shoulder but occasionally the ankle, elbow, wrist and rarely the hip will be benefited by
arthroscopic surgery in the setting of arthritis. For a very young or very active patient with
arthritis it may be worth the risks and limited goals of arthroscopic surgery to attempt to
postpone joint replacement surgery even if there are factors that may predict limited success
as outline above.
9
13. Osteotomy (bone realignment) surgery: Occasionally used for young patients with
hip arthritis, this is a much more commonly
done operation for younger patients with knee
arthritis limited to one compartment of the
knee. This goal is to realign the knee to allow
more weight to be borne through the
remaining healthy compartment to bear more
of the brunt of the loading of the knee. It may
complicate future total knee replacement but
remains an excellent option for patients
Pelvic
between the ages of 40-65 who are not obese,
Osteotomy by
Tibial Osteotomy by
who have at least 90° of motion and who do
Jeff Mast,
Mike Edmunds, MD
MD
not have a significant deformity (>15° varus).
It appears to have slightly better results in women and less active men,
with 75% of all patients reporting a satisfactory result at 7 years
(Morrey BF: upper tibial osteotomy for secondary osteoarthritis of the
knee. JBJS 71B: 554, 1989). It has the advantage over joint
replacement of not requiring the implantation of a prosthesis and, in our group, is often
done with an external fixator, which leaves no hardware in the body after the surgery. The
major risks of this surgery are failure to relieve the pain in 25% of the patients, infection in
1%, pin tract infection if an external fixator is used, failure of the bone to heal, scarring of
the tendon below the kneecap resulting in a low-riding kneecap (patella infera), loss of the
blood supply to the top of the tibial bone (avascular necrosis), the cosmetic deformity of a
valgus knee (this operation is designed to make the knee knock-kneed for patients with
arthritis in the medial compartment of the knee), injury to nerves and blood vessels, blood
clots in the legs which may travel to the lungs and become life-threatening, and failure of the
hardware placed.
Usually when the outer (lateral) compartment of the knee is selectively worn out, the end of
femur (thigh-bone) is moved, when the inner (medial) compartment of the knee is selectively
worn out, the top of the shin bone (tibia) is moved.
Osteotomy of the bones around the hip joint can be very effective when the hip joint has
failed to form correctly (congenital hip dysplasia) or when it has been damaged from certain
childhood diseases. This surgery is done to halt the progression of arthritis and is usually
not done after the age of 40. There are few surgeons experienced at pelvic osteotomy
surgery.
Knee joint fused
with IM rod
13. Fusion surgery: This is an underrated operation for very
young, very active patients with severe hip arthritis. When
done correctly (with the hip in good position: flexed 30°,
abducted 0°, and externally rotated 5°), it results in a
minimal limp and provides relief for 20 years or longer.
When it does fail, it usually does so by causing back and
knee problems. (Callaghan JJ, Brand RA, Pedersen DR:
Hip Arthrodesis. JBJS 67: 1328, 1985). It can often be
converted to a total hip replacement years later. It does
limit the ability of a patient to spread their legs and this can
be a detriment to sexual relations. Hip fusion may shorten
the leg and require a built up shoe. Failure to fuse is not
uncommon and would require additional surgery.
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Knee fusion surgery is also effective but most patients are annoyed by the fact that the knee
is straight when sitting, requiring special seating arrangements on airlines and tripping other
patrons in movie theaters. It often results in enough limb shortening to require a shoe buildup. Knee fusion is associated with a more noticeable limp and is much more difficult to
convert to a total joint replacement in later years than is hip fusion. Knee fusion surgery is
still the recommended procedure when an incurable bone infection or when severe soft
tissue loss is present around the knee.
Fusion surgery is widely used for hand, wrist, foot, ankle and spine arthritis but its
applications to other joints in the body is limited. Fusion removes the motion from the joint
but a successful fusion is almost always painless.
15. Total joint surgery: This is clearly the gold standard in the treatment of severe
arthritis of the hip, knee, shoulder, and elbow. Results from replacement of the ankle, wrist,
and toes are too variable in most surgeons’
Total Knee Replacement
hands to recommend them in most instances,
although special circumstances occasionally
warrant their consideration in low-demand
patients with severe arthritis. In general,
good (minimal pain) or excellent (no pain)
results are obtained in over 95% of all
patients. This still leaves a few total joint
patients dissatisfied with the result to one
extent or another but it is rare to have a
patient report that they are worse off then
they were before surgery.
A total joint replacement will eventually wear out and require repeat (revision) surgery. Hip
replacement surgery affords good pain relief early on; knee replacement surgery will require
several weeks to gain good pain relief and will continue to improve over the entire first year
after surgery.
Results from joint replacement vary from surgeon to surgeon and from center to center but
complications can occur in anyone’s hands. The complication rates are lower among
surgeons and centers that do more of this surgery than by those that only do this surgery
occasionally. The most common complications are changes in leg length with hip surgery,
dislocations of the hip joint or kneecap, infections (requiring at least temporary removal of
the implants for deep infection or fusion if infection is severe), potentially fatal blood clots
(requiring blood thinners for a period of time after surgery), loosening, fractures of the bone,
and continued pain or loss of motion with or without soft tissue calcification (heterotopic
ossification). Please refer to the detailed sections on hip and knee replacement.
In spite of the risks taken up front with joint replacement surgery, it is cost-effective (when
considering quality of life modifiers it is more effective than many cardiac procedures), safe
and effective.
Joint replacement is not recommended for mild arthritis, when active infection is present,
and when other active medical problems create unacceptable risk. Age is not an absolute
contraindication to this surgery, which I have done in patients as old as 102 and as young as
19. The surgery can be safely done even when there are other medical and cardiac problems
with appropriate preoperative evaluation if certain precautions are followed.
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Joint replacement can usually be performed in 45-90 minutes. It may require a transfusion.
The hospital stay is usually about 24 hours, and most patients will benefit from an additional
stay in a rehabilitation hospital. This is a consideration that varies depending on your
insurance coverage and ever-changing CMS (Medicare) regulations. Almost all patients are
independent in their home by one week, able to drive in three weeks, and able to return to
work that requires prolonged standing by six weeks.
Often overlooked in joint replacement surgery is the importance of a positive mental
attitude. If you are not certain that the benefits outweigh the risks or if you are
uncomfortable with your hospital or surgeon, it is best to defer total joint surgery.
Arthritis patients who are optimistic that an upcoming hip or knee
replacement operation will remedy their pain are more likely to get better
relief than patients with low expectations about what surgery can do for
them, according to Dr. Nizar Mahomed, an orthopedic surgeon at University
Health Network in Toronto. The most likely explanation, he said, is that
patients with a positive attitude are more willing to devote time to
rehabilitation after surgery. The finding, reported in the June issue of the
Journal of Rheumatology, is based on a study of 103 patients who underwent
total hip replacement surgery and another 89 who had a knee replacement.
Before surgery, participants completed questionnaires about their overall
health, physical functioning, level of pain and expectations about
treatment. They were questioned again about their health six months after
surgery. Overall, patients experienced less pain and better physical
functioning after surgery, but the three-quarters of patients who expected
complete pain relief following their operation reported less pain and better
functioning six months after surgery than their counterparts with lower
expectations. Reuters Health July 10, 2002 AAOS Newsletter 7/10/02
Source: Journal of Rheumatology 2002;29:1273-1279
12
Technologies in Joint Replacement
There are several exciting technologies available in joint
replacement surgery. For patients with partial involvement
of the knee, a unicompartmental arthroplasty can be done
through a smaller incision. This involves resurfacing only a
portion of the knee. There is evidence to support the use
of mobile bearing knees, which may feel more like a normal
knee and be very durable. There is now a surface ceramic
knee that demonstrates an 85% wear reduction in the
laboratory. We are hopeful that this may translate into a
knee replacement that will be more durable than previous
designs. There are also designs that do not require the
routine resurfacing of the patella (kneecap). The operation
done in this fashion may allow for better results in revision
(redo) surgery if the knee replacement wears out or becomes loose. This type of surgery
may also decrease the risk of breaking the kneecap in a fall.
Hot Topics in Total Knee Technology
• Mobile bearing knees
• Surface ceramics
• Preservation of the kneecap (patella) without resurfacing
• Small incision surgery (so-called “minimally invasive”)
• Patellar augmentation for previous patellectomy
• Unicompartmental knee replacement
• Moderately cross linked polyethylene
Hip replacement technology has also evolved. We now have new bearing surfaces such as
highly cross-linked polyethylene, ceramics and the all-metal hip. One manufacturer
(Sultzer™) was recently the subject of a recall due to a manufacturing problem not related to
the all metal technology that has required that about 2% of these hip replacements be
revised. I do not recommend the all-metal hips, not because of the manufacturing problem
that led to the recall (which has been identified and solved) but because of the fact that we
do not know the biologic effects of this device. There are detectable metal levels in the
blood and urine of patients who have had these implants placed and we do not know if this
will result in long-term adverse effects nor whether they will prevent loosening or dissolving
bone (osteolysis) without long term controlled studies involving many additional patients.
We did not appreciate the fact that silicone breast implants could cause problems until they
had been used for many years. Any implant that introduces a material systemically must be
approached with caution. The effects of polyethylene have now been under scrutiny in large
numbers of patients for 40 years. The reports on all metal hips over that period have been
limited and have not had numbers large enough to make conclusions about these implants.
Ceramics are highly oxygenated metals combined with trace amounts of other substances to
improve their mechanical characteristics. The have ions on their surfaces that help to
introduce a layer of joint fluid and decrease friction in an artificial joint. They are harder
than their related metals and have less wear on the surfaces adjacent to them. They were
first introduced to hip replacement surgery to prevent wear debris which can cause the bone
to be reabsorbed around the implants (osteolysis). Any wear particle can cause this reaction
and some patients have far more trouble with osteolysis than others. All metal hips,
13
ceramics and highly cross linked polyethylene have found their way into our implants to
prevent these reactions. The volume of these particles and the surface area of these particles
correspond with the severity of bone resorption in the group of patients susceptible to this
reaction. The reactions to the peculiar sized debris from all ceramic and all metal hips are
under study as are the use of medicines to prevent or treat osteolysis. There is promise in
each of these technologies. The decision to use one of these technologies has to be
individualized until there is a long-term American experience with them.
One type of ceramic used in hips (zirconia) was recalled in 2001 from multiple
manufacturers due to the risk of fracture from lots that were not manufactured to the usual
specifications. Two batches of ceramic heads manufactured in France broke with
frequencies of 15% and 3.4% and accounted for a total of 1200 prosthetic heads. The risk
of breakage from properly manufactured ceramic components is 0.04% and should not deter
us from using ceramics for younger, more active patients now that we are again confident in
the manufacturing process. The other type of ceramic in wide use (alumina) was originally
thought by most to be slightly less desirable than zirconia but has not had any recalls for
defects in manufacturing. Refinements in alumina have now led to equivalent properties to
zirconium and both are in wide spread use now. Ceramic on ceramic hips are made of
alumina and require unusually perfect technique to implant in a way that they will not chip or
fracture. With perfect technique they could last your lifetime but this statement cannot be
validated without long term follow up from large numbers of patients and surgeons.
Surface ceramic knees and hip heads are made of zirconium with the surface converted
to zirconia, its ceramic. They are as resistant to fractures but the thickness of the ceramic is
4 microns, a little less than the diameter of a red blood cell. The metal on the undersurface
of the surface ceramic material is not as satisfactory of a surface for bone ingrowth and this
led to a voluntary recall on the surface ceramic ingrowth knee prosthesis when the
manufacturer discovered failure to ingrow in 2% of these. In my experience, the results of
all knee replacements are better if all components are cemented, so this recall did not affect
any of my patients. There is less concern among many surgeons about the biologic effects
of ceramic than metal in long term use as implants. The use of highly cross-linked
polyethylene as a bearing surface appears safe and promising to increase the durability of hip
replacements.
In the era of John Charnley who pioneered modern hip replacement in the early 1960’s, the
components were cemented into the body. This technique is very safe and durable. We are
now on the second generation of cementless hip replacement and this is the method most
often used for of my patients. We are on our third generation of cementing techniques. I
believe that an implant which is ingrown by your bone with a bearing surface that is not
prone to cause bone loss (osteolysis) has the greatest potential for very long term survival.
There a certain patients that should have cement used, however. These patients should be
reassured by the fact that, to date, there are no long term studies that conclusively show that
an uncemented total knee or femoral stem in a total hip will last longer than cemented
components.
The new hip implants are typically made out of titanium, except for the bearing surfaces
where the motion occurs. Titanium is not as good of a bearing surface as is cobalt-chromemolybdenum or ceramics because titanium can burnish and produce wear particles.
Titanium is very inert to the immune system and rarely can cause an allergic reaction. It
provides better ingrowth for implants that are designed to heal to your bones without using
bone cement. It is lighter weight and more flexible than is stainless steel or cobalt-chromemoly. Tantalum, another element, may even improve on the results of titanium.
14
An exciting new development in hip implants is the Epoch™ stem for
Zimmer™. It was only released by the FDA in 2002 but has promise
to prevent two problems in hip replacement. Firstly, loss of bone
adjacent to large, stiff implants occurs due to stress shielding of bone
which no longer bears weight around the implant. The Epoch™ has
the similar flexibility to the bone around it and appears to greatly lessen
this undesirable effect. Secondly, when a stiff implant is placed in the
bone, it may cause thigh pain after hip replacement. This new stem
shows promise in preventing thigh pain.
A different metal, tantalum, may allow better bone ingrowth than even
titanium, and is now in use. I primarily use tantalum in revision (redo)
surgery at this point. I nearly always use cementless implants in
revision (redo) hip surgery and on the side of the cup. The new
developments in revision surgery are too numerous to list here.
Hot Topics in Total Hip Technology
• Alternative bearing surfaces :metal on metal, ceramic on ceramic, metals on highly
cross linked polyethylene, ceramic on highly cross linked polyethylene
• Flexible femoral stems
• Modular femoral stems
• Tantalum and compressible surfaces
• Resurfacing arthoplasty
• Small incision surgery
• Minimally invasive surgery
• Large head reconstruction
15.
Aids to Ambulation: The hip joint is
subjected to forces equal to 3 times the body
weight when walking, due to the
biomechanics of its muscle actions. These
forces can be offset about 20% by using a
cane in the other hand (about 120 lbs. each
step in a 200 pound person). A cane can
benefit knee pain to a lesser degree but is
handy to prevent falls should the knee buckle
with pain.
Use the cane in the hand opposite of your
bad hip but on the side of your bad knee
for best results.
15
Arthritis can be crippling but not everyone can undergo reconstructive surgery. In this
instance a wheelchair can be prescribed. Should you require a chair, deconditioning will
occur and may eventually rob you of you ability to make independent transfers and may
ultimately may require nursing home placement. It is not usually advisable to attempt total
joint replacement after more than six months in a wheelchair as the deconditioning may
make rehabilitation impossible. This decision is always individualized. A wheelchair can be
motorized but insurance will generally only cover this expense if you also have something
wrong with your arms that would preclude you from propelling yourself. I do not prescribe
scooters as I believe that they uniformly result in severe obesity. If a scooter is required it
should come from the doctor that will be treating the medical problems caused by obesity
such as death from sleep apnea, fatal heart rhythms, death from blood clots, diabetes,
infections, heart attack, stroke, high blood pressure and occlusion of the arteries to the legs.
This outcome is rare in this era of improved safety in reconstructive surgery with good
medical treatment of coexisting conditions. We are usually able to reconstruct patients who
have even grave coexisting medical conditions, such as recent open heart surgery. Some
conditions (kidney or liver failure, diabetes, and advanced AIDS) are clearly associated with
increased infection rates and the decision to have surgery should be more closely scrutinized.
16
Total Knee Replacement
The goal of knee replacement surgery is to restore function and
mobility and decrease or eliminate the pain from arthritis. It is an
operation to help you to live an independent and active life if knee
arthritis is threatening to rob you of this. While some patients are
too unhealthy to undertake this surgery, no one is too young or too
old. My youngest patient was 25 (juvenile rheumatoid arthritis) and
my oldest was 94 (87 for replacing both knees at the same surgery).
It is a safe, cost-effective tool in the management of arthritis of the
knee, decreasing long term risks of drug therapy and the long term
costs of the management of severe arthritis.
The usual incision is 7” long and is straight unless previous scars
mandate a curved incision. Ligaments are balanced to correct alignment and joint lines are
resurfaced. The resurfacing is similar to a crown on a tooth – a very accurate set of jigs is
used to precisely cap the knee joint surfaces. If the kneecap is severely damaged it too will
be resurfaced, otherwise it is left alone. In no case do I remove the kneecap (patella).
Usually all components are held in place with bone cement (polymethyl methacrylate). The
alignment of the knee is reestablished such that your previously crooked knee will be in line
with your hip and ankle (which gives the new knee a slight knocked-knee appearance).
Motion is restored in surgery but must be maintained in therapy. The hospital stay is usually
one or two days long, often followed by admission to a rehabilitation facility until you are
not independent enough to return home so long as your insurance or Medicare allows for a
rehab admission.
I believe that the hospital stay should be short to minimize exposure to other patients who
may have contagious diseases and drug resistant bacteria. It is estimated that 90,000 people
in the United States die each year from hospital acquired infections.
http://www.jcaho.org/news+room/news+release+archives/ic_standards.htm
The rehab hospitals would be happy to arrange tours or their facilities before your surgery.
The facilities that I use are in Carson City and Reno, Nevada. There is no way to predict
which one will have bed availability and best serve your needs until after the surgery when
your case manager precertifies the transfer with your insurance company. Transportation to
the rehab hospital is supplied. You need only get yourself to the hospital and home from
rehab.
Motion machines (CPM) may decrease the oxygen supply to the healing incision soon after
surgery and are used only two hours a day until staples are removed. You should have the
same motion machine in the hospital, the rehab hospital and at home. If the rehab
hospital is sending you home without your machine, please have them contact the
CPM specialist before you go home.
A healed
total knee
incision
X-Ray: front view
Side view
Skin is closed with staples which will be removed in
10-14 days. Motion machines will increase your
motion early but the final result (at one year) is not
improved with their use.
Bathing is permitted at any time if an occlusive
dressing is in place, otherwise it should be
postponed until two days after the staples are
removed. Swimming, using spas or hot tubs is best
deferred until 3 weeks after surgery. This is also
17
the time that you may resume driving, so long as you are not taking pain pills and have
reasonable motion (5-90°) and feel that you can brake safely and that you have regained
normal reaction time. You may return to work that does not require prolonged standing in 3
weeks and to usual standing and walking duties in 6 weeks. If therapy progress is very poor,
you will require anesthesia for a knee manipulation to break adhesions. This is
recommended if you do not have 90° of flexion 30 days after surgery although less than 1%
of knees require this.
In therapy, we expect that you will be at 5-90° by
one month and that you will have 0-125° by 6
months. It is important that you maintain the
ability to fully extend the knee as it takes more
energy to walk on a partially bent knee. For
Extension of knee should be
average height individuals, 120° of flexion will be
nearly full (0° = straight)
required to alternate feet when on stairs. If you
find that you are loosing the ability to fully
Flexion (in degrees
straighten your knee, do not sleep with pillows
from straight)
behind your knee as the healing process can cause
should be 125°
a flexion contracture from the long periods of time
that the knee is healing in a bent position. If your
knee is loosing extension, a knee immobilizer may
be prescribed for nighttime use. To improve
flexion outside of your physical therapy, use a
stationary bicycle and try to lower the seat a little each week. Pulling yourself around with
your feet on a wheeled chair or creeper will increase flexion and doing squats with both
hands on the kitchen counter (for support) will improve flexion. While many will regain
more than 125° of flexion some will not. In extreme preoperative knee disease, the
quadriceps will have developed shortening that will permanently limit the knees ability to
flex no matter how diligent you are in therapy. Remember that there is a balance in therapy.
Too much therapy will increase inflammation (swelling, redness and warmth) and lead to a
worse result. Too little therapy will lead to weakness and loss of motion as well as
deconditioning. Patients who struggle with physical therapy will take much longer to recover
from this surgery.
For one month after surgery you may be on the blood thinner, coumadin, to prevent blood
clot growth. Each Monday you should go to the laboratory and have a test (protime with
INR) drawn. The lab will fax this to my office at 775-884-5463 and we will call you with any
adjustments to keep your blood from becoming too thin or too thick by that Wednesday.
We adjust the lab (INR) to keep it around 2.0. Coumadin will be adjusted around each of
the medicines that you usually take but, because it has interactions with most other
medications, you should call our office of your primary doctor’s office, to discuss the use of
coumadin with the other medicine. This includes over the counter and herbal medications.
Occasionally, ulcers and growths in the colon or bladder may lead to blood in the stool,
black stools or blood in the urine. Should this occur while you are taking coumadin, stop
the medicine and seek immediate medical care. We will assist you in obtaining appropriate
care to find out what the underlying problem that caused the bleeding is.
Sports should be deferred for 12 weeks. Court and field sports and all contact sports are not
advised. You should be able to hike, golf, play doubles tennis, bicycle, and ski if you already
were able to. Don’t be afraid to be active after your knee replacement – that’s what it’s
designed for. After a knee replacement you should not try to learn to ski or ride motorcycles
18
due to the risk of fractures. Fractures around the knee joint may be more difficult to fix
than they would otherwise have been before your knee replacement.
Good and excellent results (with no or minimal pain, good motion and restoration of
function) comprise 95% of most reported series on knee replacements. 94% of knee
replacements last over 10 years. (Ranawat, Boachie-Adjei, CORR 226: 6-13, 1988). New
developments recently introduced such as the surface ceramic knee may extend the life of
the surgery significantly. As in any new technology, there is a small chance that our new
implants will fail to meet the standards of traditionally designed knee implants and, for that
reason, older individuals may be better served not to take this small risk. The wear that
leads to reoperation the ceramic knee is reduced 85% compared to the previously available
implants, when studied in the laboratory. It has not yet been shown if this new surface will
make knee replacements more durable. Only the passage of time will tell.
Risks of Knee Replacement
•
Loosening and wear: if you live long enough, your knee components will wear and
become loose. Your knee will have to be revised (redone).
• Continued pain: about 5% of all patients have sufficient pain after knee replacement
to warrant taking medicines. Rarely is pain more severe than the arthritis pain.
• Infection: about 0.3% of my patients and 1% of all patients in the country will have
a deep infection (more
Infected TKA with
common in revisions). This
spacer – new TKA
will require additional surgery
was done in 6 wks.
– usually removal of the
This occurs 0.3% of
components followed by
the time.
revision. The surgery is usually
done in space suits and
Rarely, an
antibiotics are given around
incurable
infected knee
the time of surgery to help
will require
prevent this. Infections may
fusion.
occur late – months or years
Amputation
from the surgery and I
for infection
recommend antibiotics for
is very rare.
dental work for two years after
knee replacement. Incurable
infections require fusion and if
infection is associated with gangrene, amputation may be required if all else fails.
• Loss of motion: the surgeon and you share responsibility for this. It is the surgeon’s
job to obtain the motion in the operating room and your job to maintain the motion
in therapy after surgery.
• Unsightly scars: usually when prior scars must be utilized.
The usual scar is 7 inches long, straight and not accompanied
by any discoloration long-term. Severe problems with
healing are rare and we will ask for consultation with a plastic
surgeon when there is any reasonable likelihood of these
problems. Redness of the incision line is customary for the
first 1-2 years and can be minimized by applying sun screen
Previous incisions may
before sun exposure. Many of my patients use aloe vera or
require unusual approaches to
Vitamin E with the belief that the scar will mature faster,
knee replacement and can
although the benefits are unproven. These lotions and oils
place the skin at risk
19
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
should not be applied until the scar is fully healed (1-2 weeks after staple removal).
Blood clots often form from total joint surgery but, with the use of blood thinners,
problems can be minimized. Deep venous thrombosis which can lead to chronic
swelling and pulmonary emboli (which can be fatal).
Bleeding is often sufficient to make transfusion advisable although requests not to
transfuse are honored as in the case of our patients who are Jehovah’s Witnesses.
Hemarthrosis & drainage: especially if your blood is thinned from blood thinners,
bleeding into the knee and drainage may occur. This will rarely require additional
surgery but may slow down therapy.
Fracture or tendon rupture around the knee are rare but would require additional
surgery in many instances. Tendon rupture around the kneecap (patellar ligament)
can be crippling.
There is always a mild patch of numbness on the outside of the incision due to the
way the knee is innervated. Neuromas can form and be painful but most patients
have only a patch of painless numbness.
There is often a click or subtle different feel of the artificial knee. Painful “clunks”
in the knee (where the kneecap seems to jump may rarely require surgery.
Swelling may persist for months after knee replacement.
It is possible to pull apart the deep stitches and require additional surgery to repair
this and to allow the kneecap to track normally but this is uncommon.
The knee will rarely feel unstable or dislocate. This is very rare for first time knee
replacement and is uncommon for revision (redo) knee replacement.
Malposition of the component: the surgeon may fail to align the knee correctly,
leaving a deformity or preventing the kneecap from tracking normally. This is
uncommon in the hands of experienced surgeons.
Metal allergy: usually nickel, rarely may cause swelling with a rash. If you get blisters
under your jewelry, please inform me of this before surgery.
Complications from medicines used around the time of surgery will rarely cause
grave problems that are life threatening.
Death from heart problems, stroke, infection, organ failure and blood clots
(pulmonary emboli) is now rare (0.3%).
Injury to major nerves usually consists of a foot drop and occurs 1% of the time and
is most common in rheumatoid arthritis or when you have a severe valgus (knockknee) deformity. A foot drop may occur when the knee is made straight due to
stretch of the nerve (common peroneal nerve). This usually resolves within 16 weeks
but rarely will persist permanently and require the use of an ankle brace.
Component failure: failure of the materials or design of the implants is very rare
although an unforeseen recall can occur with any medical device. Recalls do not
usually require removal of the implant from your body.
Complications of transfusions include AIDS (1/500,000), death from transfusion
reaction (1/500,000) and hepatitis C (1/103,000). I no longer require that you
donate blood for yourself before surgery.
Bowel obstruction or perforation is very rare
Due to the gravity of some potential complications, it is imperative that you have confidence
in the surgeon and the hospital that you choose for your knee replacement.
20
Cementless
hip
Total Hip Replacement
If you could choose a joint in your body to wear out, you would choose
the hip. The success of total hip replacement is very high, the operation
and rehabilitation is much less painful than in knee replacement and hips
are extremely durable, with good potential to last for more than twenty
years.
Hip replacement is usually performed with
cementless fixation, and you will be asked to avoid
anti-inflammatory medicines and excessive activity
for six weeks after the surgery. Occasionally, you
will be asked to keep some weight off of your hip at first. Older
patients and others who have a partially cemented (hybrid) or fully
Hybrid
cemented prosthesis are allowed to place full weight on the hip
hip
beginning the day after surgery. There is good
evidence that either cementless or hybrid techniques
are preferable to fully cemented hips because most surgeons report
inferior results with the cemented cups.
There have been recent developments in hip replacement that may greatly
extend the life span of the replaced hip. Metal and highly cross linked
polyethylene (the bearing surface in the artificial hip) is so resistant to
Cemented
wear that we believe that we can use larger heads on the artificial hip
hip
without significantly increasing wear. This means that the replaced hip
can be made more stable.
Metal on Metal Hips
There are long term reports on small numbers of all
metal hips. They may last longer and be more stable.
There have been no reports of problems with the
long term use of these implants in the small numbers
done years ago. I don’t routinely recommend the all
metal hip (one of which was recently recalled) due to
my concerns about detectable metal levels in the
blood and urine. We are not yet sure that smaller
amounts of metal particles will be better than
polyethylene particles in extending the life of these
artificial hips. I don’t believe that we have enough
knowledge about the long term biologic effects of
these metal levels. We do not want to underestimate
the long term biologic effects of a material like we did with silicone breast implants.
Ceramic on Ceramic Hips
The use of ceramics looks very appealing. Historically, ceramics have been extremely wear
resistant, but would break on rare occasions (4/10,000). There is one report of migration of
ceramic on ceramic hips possibly because of the more rapid loading of a hard on hard
surface (Böhler, et al, “Comparison of Migration in Modular Sockets with Ceramic and
Polyethylene Inlays.” Orthopedics 23(12), Dec, 2000). Because of this, these bearing
surfaces may be best for patients with very good bone and used with caution in
osteoporosis.
21
The decision to use an alternative bearing surface is one that we must make together, based
on your level of comfort with the uncertainties inherent in the use of new technologies and
needs for extreme durability.
The surgery is accomplished through a 4-7 inch incision in most instances (as short as 3
inches for some slender patients, and longer than 7 inches in obese patients). The operation
takes about 75 minutes and will sometimes result in enough blood loss to warrant a
transfusion. I no longer require donation of blood before surgery but occasionally use blood
boosters when preoperative blood tests show a mild anemia. Medicare does not pay for
designated donor blood. I always respect the wishes of our Jehovah’s Witnesses not to be
transfused and have had good results from bloodless surgery in this setting. Less than 1% of
hips require a single low dose radiation treatment to prevent calcification of the soft tissues
around the hip, as occasionally these calcifications can lead to pain or loss of motion.
The hospital stay is one or two days long in the majority of instances. If you are not
independent enough to return home after one day, it is better to transfer to a rehabilitation
hospital for a few more days so that you aren’t around other patients with contagious
diseases and resistant bacteria. It is estimated that 90,000 people die in the United
States each year from hospital acquired infections.
http://www.jcaho.org/news+room/news+release+archives/ic_standards.htm
The rehab hospitals would be happy to arrange tours or their facilities before your surgery.
These facilities are in Carson City and Reno, Nevada. There is no way to predict which one
will have bed availability and best serve your needs until after the surgery when your case
manager precertifies the transfer with your insurance company. Transportation to the rehab
hospital is supplied. You need only get yourself to the hospital and home from rehab.
For one month after surgery you will be on the blood thinner, coumadin, to prevent blood
clot propagation and development of pulmonary embolism. Each Monday you should go to
the laboratory and have a test (protime with INR) drawn. The lab will fax this to my office
at 775-884-5463 and we will call you with any adjustments to keep your blood from
becoming too thin or too thick on each Wednesday. We adjust the lab (INR) to keep it
around 2.0. Coumadin will be adjusted around each of the medicines that you usually take.
Because it has interactions with most other medications, you should call our office or call
your primary care physician to discuss the use of coumadin with other medications that you
wish to start after leaving the hospital. This includes over the counter and herbal
medications. Occasionally, ulcers and growths in the colon or bladder may lead to blood in
the stool, black stools or blood in the urine. Should this occur while you are taking
coumadin, stop the medicine and go to the emergency room. We will assist you in finding
appropriate care to find out what the underlying problem that caused the bleeding is.
For 6 weeks after surgery, you will need to adhere to certain limitations to prevent
dislocation of the artificial hip. You should not flex the hip more than 90° or rotate the knee
inward. This will allow the hip capsule that is repaired at surgery to heal in a tight position
and prevent future dislocations. It is better to sleep on your back for the first 6 weeks. At
any point after hip replacement you should not bend over your hip sideways to pick up
objects on the side of your chair while seated and you should not work on the outside of
your foot. These activities flex the hip while rotating it inward and are highly associated with
dislocations.
22
At 3 weeks you can drive if you are not taking pain pills and you feel that your reaction time
has returned to normal. You can return to sit-down work at 3 weeks. At 6 weeks you need
only avoid extremes of positions and you can sleep on either side. You will usually be
allowed to place full weight on the hip at 6 weeks, sometimes immediately. You can return
to full work duties by 3-6 weeks.
Sports should be deferred for 12 weeks. Court and field sports and all contact sports are not
advised. You will be able to hike, golf, play doubles tennis, bicycle, and ski if you already
were able to. After a hip replacement you should not try to learn to ski or ride motorcycles
due to the risk of fractures. Fractures around the hip joint may be more difficult to fix than
they would otherwise have been and dislocations of the artificial hip are more common than
in a normal hip. Bo Jackson in now on his third hip replacement. This tells us that
extraordinary fitness, motivation, and coordination are not substitutes for prudent activity
modification after hip replacement.
For two years after joint replacement I recommend antibiotics for dental and urologic
procedures. Every one to two years we will take X-rays to ensure that the joint is stable, not
wearing excessively and not causing bone to thin (osteolysis) around the implant.
Risks of Hip Replacement
•
Loosening and wear: if you live long enough, your knee components will
wear and become loose. Your knee will have to be revised (redone). The durability
of the result depends on the technology of the implant, the quality of the surgery,
your size, and your activity level. New technology, such as ceramic hips, all-metal
hips, and highly cross-linked polyethylene may greatly extend the durability of the
hip replacement. Only time will tell.
•
Leg lengths may change; especially in revision (redo) surgery. Most
commonly, the operated hip is made longer to increase stability of the joint. A shoe
lift is occasionally required. Surgery to correct the problem is rarely recommended.
•
The limp may not resolve. Limping can occur if there is continued pain, if
the surgeon fails to reestablish the offset of the hip (which balances the muscle
forces) or if the muscles around the hip detach after surgeries that move the muscles.
•
Dislocation: the artificial hip may dislocate, especially if
it is flexed too far or rotated with the knee pointing in. A
dislocation usually results in a trip to the emergency
department for anesthesia to relax the muscles so that it can be
reduced. A brace may be recommended for 6 weeks.
Additional surgery may be required. There is great variability in
the risks of this from surgeon to surgeon depending on the
A dislocated
surgical technique used, whether the hip capsule is balanced
total hip
and repaired, and the positions of the components that the
prosthesis
surgeon places. Patients with dementia, alcoholism and
neurological problems are at greater risk because of falls and
loss of protective reflexes. Risk is 2%.
•
Continued pain: about 2% of all patients have sufficient pain after hip
replacement to warrant taking medicines. Rarely is pain more severe than the
arthritis pain that made you seek knee replacement. 98% have no pain or minimal
pain.
23
•
Infection: less than 1/4% of my patients will develop a deep infection (more
common in most series in revisions). This will require additional surgery – usually
removal of the components followed by revision. The surgery is usually done in
space suits and antibiotics are given around the time of surgery to help prevent this.
Infections may occur late – months or years from the surgery and I recommend
antibiotics for dental work for two years after hip replacement.
•
Fracture: the surgeon may create a fracture while pressfitting an ingrowth prosthesis. This will usually require placement
of a cable but is not expected to compromise the result in most
instances. In rare instances a fracture can require additional
surgery and special equipment to repair. Risk to my patients is 1%
in primary hip replacement and 3% in revision hips.
•
Loss of motion: the inflammation from surgery may result
in the formation of calcium deposits in the soft tissues around the
hip (heterotopic ossification), which can cause the artificial joint to
Fracture
lose motion. If certain risk factors are present (previous HO with
fixed
with
hip surgery, ankylosing spondylitis, DISH, and hypertophic OA),
cable
low dose radiation therapy may be recommended to you to prevent this
complication. It occurs frequently, but it is rare to have motion limited or to have
the result compromised by this process. Low dose (700 cGy) is required, compared
to high dose (5000 cGy) used for tumors.
•
Unsightly scars: the scar will slowly become the color of the surrounding
skin over two years and is rarely a source of complaint for patients.
•
Blood clots: deep venous thrombosis which can lead to chronic swelling and
pulmonary emboli (which can fatal). Blood thinners (coumadin and fractionated
heparin) will be used to help prevent this. Pumps are placed on the legs after surgery
to prevent this as well. Risks include: previous blood clots, smoking, the use of
estrogen and evista™ (used to treat osteoporosis), old age, obesity, air travel and
being sedentary. I recommend that you quit smoking, stop medicines associated
with clots one week before surgery (you may restart them 4 weeks after surgery), and
that your therapy be started the day after surgery. I usually use coumadin for one
calendar month after surgery. This will require a blood test (done each Monday) to
ensure that the level of blood thinner is correct. Blood clots have been found in
Doppler testing when we had a suspicion of deep vein thrombosis in 2% of my
patients.
•
Bleeding & drainage: especially if your blood is thinned from blood thinners,
bleeding into the incision, bruising and drainage may occur. This will rarely require
additional surgery.
•
Periods of confusion or cognitive dysfunction may occur after anesthesia and
surgery (possibly from circulating fat elements) and with the use of narcotics and
sleeping pills. This is more commonly identified in people who already have
problems such as Alzheimer’s disease. This can result in excessive sleepiness,
confusion and agitation, which may be seen for several days after surgery.
•
Death from heart problems, infection, organ failure and blood clots
(pulmonary emboli) is now rare (0.3%). All medical problems that create a high-risk
situation should be evaluated by the appropriate specialist before hip replacement.
•
Injury to major nerves, blood vessels, or internal organs is rare but in some
centers has occurred as often as 1% of the time. It is more common with revision
(redo) surgery. Most commonly this results in a foot drop and requires the use of an
ankle brace. It usually resolves by 16 weeks but if permanent could require lifetime
24
ankle brace use. Risk of temporary foot drop in my hip patients is 0.3% (none
permanent/complete).
•
Complications of transfusions include AIDS (1/500,000), death from
transfusion reaction (1/500,000) and hepatitis C (1/103,000). I no longer require
that you donate blood for yourself before hip replacement surgery.
•
Component failure: failure of the materials or design of the implants is very
rare. There have been recent recalls of one all-metal hip and of certain ceramic
materials even though the actual failure rate of well made ceramics has been low
(4/10,000, historically). An unforeseen recall may affect any medical device but
rarely results in removal of the device form your body.
•
Malposition of the components: the surgeon may fail to align the hip
correctly, resulting in dislocations. Only the vast minority of dislocations are from
such badly positioned components that reoperation is mandated after the first
dislocation.
•
Metal allergy: usually nickel, may cause swelling with a rash.
If you know that you have a severe metal allergy with bad rashes
(blistering) around jewelry or watches, you should discuss this with
me before your surgery.
•
Complications from any of the medicines used around the
time of surgery may rarely cause grave problems that are life
threatening. The blood thinner may result in bleeding into the
incision, from the bowel or kidneys (especially if an ulcer or
undetected cancer is present), or into the muscles or head (from
trauma or undetected vascular malformations). These occurrences
are rare.
•
Bowel obstruction or perforation may be more common
when using pain medications and after total joint surgery. While rare, it can be life
threatening especially if a delay in diagnosis occurs.
Poorly
placed
screw may
damage
blood
vessels
Due to the gravity of some potential complications, it is imperative that you have confidence
in the surgeon and the hospital that you choose for your hip replacement.
25
FAQ (frequently asked questions) – Joint Replacement
1. How soon before I get up after surgery?
You will get out of be the morning after surgery. Longer periods of bed rest result in fever
from atelectasis (incomplete expansion of the lungs), blood clot formation, bedsores,
elevations of serum calcium with confusion and deconditioning (weakness and lightheadedness when you do get out of bed).
“…25,000 out of every million of people we
have must die every year. That amounts to
one-fortieth of our total population. Out of
this million ten or twelve thousand are
stabbed, shot, drowned, hanged, poisoned, or
meet a similarly violent death in some other
popular way, such as perishing by kerosene
lamp and hoop-skirt conflagrations, getting
buried in coal mines, falling off housetops,
breaking through church or lecture-room
floors, taking patent medicines, or committing
suicide in other forms. The Erie railroad kills
from 23 to 46; the other 8445 railroads kill an
average of one-third man each; and the rest of
that million, amounting in the aggregate to the
appalling figure of nine hundred and eightyseven thousand six hundred and thirty-one
corpses, die naturally in their beds!
You will excuse me from taking any more chances on those beds.”
Mark Twain, “The Danger of Lying in Bed,” 1906, Harper and Brothers, New York
and London
2. How long will I be in the hospital?
Usually one or two days. I try to keep the hospital stay short to prevent complications from
contagious diseases in the hospital. Hospital-acquired infections such as pneumonias and
wound infections are not rare and often involve resistant bacteria. Shortening the hospital
stay appears to lessen the risks of these complications.
There are several options on leaving the hospital. You can return home with the assistance
of home health services (for therapy, dressing changes, lab testing and assistance with
bathing) if required. You can be admitted to our acute rehab center. There you will be
supervised by a doctor who specializes in Physical Medicine & Rehabilitation for a stay of
several days at which time you will be independent in your activities of daily living (stairs,
dressing, bathing and dressing). This is the gold standard of quality care and is appropriate
for all but the very strongest and very weakest of patients. We are often pressured by
insurance companies to have your rehabilitation performed at a nursing home or skilled
nursing facility, to reduce their costs. This is rarely appropriate as these facilities have
significant problems with contagious diseases and resistant bacteria, the very problems that
your short hospital stay is supposed to prevent. Subacute facilities are primarily for very
elderly debilitated patients and those with profound dementias (Alzheimer’s disease, etc.) and
are, therefore, not appropriate for most total joint patients.
26
3. When can I resume my normal activities?
With knee replacement you may bear full weight on the leg immediately (with rare
exceptions in revision knee replacement). Most hips are cementless and may occasionally
require limited weight bearing. In the case of 50% weight bearing, you can estimate what
this feels like by placing the operated leg on a scale and pressing down until the scale reads
half of your weight. Protected weight bearing is believed to encourage bone growth into the
prosthesis, but the surgery done now usually allows full weight to be borne on the operative
leg. It is best to listen to your body: if it hurts to bear full weight, stay on the walker or
crutches until it becomes painless.
There is a chance of dislocating an artificial hip and precautions about sleeping on your side,
sitting in low chairs without arms on them, flexing the hip more than 90 degrees, and the use
of elevated toilets seats, grabbers and the pillow between the legs should be observed for 6
weeks (12 weeks for revision hips). Do not ride in or drive cars with low seats for 6 weeks.
This allows the hip capsule to heal without stretching out and will provide better stability
with less chance of dislocation. With knee replacement you should not sleep or rest with a
pillow behind the knee for 12 weeks, as a permanent contracture of the knee may develop
and prevent full extension.
You should not drive for three weeks. Even then,
you should not drive if you are taking narcotics,
having periods of confusion or forgetfulness, feel
that the leg is weak, or not be able to flex the knee
at least 90 degrees. If you are doubt, ask your
therapist or me.
Most patients will not be able to return to work
more than 4 hours a day at 3 weeks, full-time at 6
weeks. You should not resume limited walking for
exercise, gentle water aerobics, heated pools or hot
tubs for three weeks and then only if the incision is
fully healed.
4. How do I take my blood thinner
(coumadin)?
This is taken each evening (no more than once a day), as directed by me. Everyone’s dose if
different and you need to have a blood test done each Monday for two weeks after returning
home to ensure that your blood is not too thick or too thin. The lab will fax the results to
me at 775-884-5463 and you should hear from us by Wednesday with your report. If you do
not hear from my office by Wednesday afternoon, call us at 775-884-5470. You should not
start any new medicines while taking coumadin without discussing it with your primary care
doctor or me. Coumadin interacts with most medicines including herbal medicines and
vitamins and this can result in blood clots (if the blood is too thick) and in life-threatening
bleeding (if blood is too thin). Because of bleeding risks you should avoid falls and injury
while on this medicine and seek medical attention should an injury occur. You will be on
Coumadin™ for one calendar month in most instances.
5. Will I set off metal detectors?
Yes, now that detector sensitivity has been increased following the need for increased airport
security. Should it happen to you, they will ask you to empty your pockets and manually
scan the area of your replaced joint. They will not honor cards that show you have had a
joint replacement, as cards would be nearly as available to a terrorist as they would be to you.
27
6. Do I need to take antibiotics for dental work?
This is controversial. Some orthopedic surgeons recommend amoxicillin one gram before
the dental visit and one gram 60 minutes later
(except in penicillin allergic patients). I recommend
no prophylaxis if it has been over two years from
the joint replacement otherwise Keflex™ one gram
before the dental visit (erythromycin in the same
doses in pcn-allergic patients). In multiply allergic
patients I recommend against prophylaxis as the
risks of an allergic reaction may outweigh the
benefits. The risks of getting an infected total joint
after a dental procedure are about 1/10,000. The
dentist may provide this prescription, or ask you to call our office for it.
7. Might I be having an allergic reaction to the metals in my joint replacement?
In over 1000 joint replacements, I have seen only one case that is suspicious for this. If you
are severely metal allergic (bad rashes under watchbands and jewelry) you should alert your
surgeon before surgery. If you have a rash and swelling over the replaced joint patch testing
may be recommended in consultation with a dermatologist. We can avoid nickel but not
titanium in total joint surgery. There is now a program for blood testing (lymphocyte
proliferation testing) through Rush medical Center in Chicago (Ms Zheng Song 313-5764511, CPT code 86353) to evaluate metal allergies further.
8. Do you use any implants that have been recalled?
Once a recall is made these implants are physically removed from our hospitals. Most
recalled implants actually do not have problems that require any additional surgery. This is
the case with the recent voluntary recall of certain ceramic hips in the US following an
increase in the fracture rate of these devices in Europe. The recalled ceramic heads have not
been demonstrated to fracture more frequently then the non-recalled lots in the United
States to date. It has long been known that surgical technique may lead to broken ceramic
hip components. The historical risk of fracture has been 4/10,000. I have returned to the
use of ceramic implants now that safety issues have been resolved as there is evidence that
wear is reduced and we would expect this to result in better longevity of the joint. Cemented
surface ceramic knee replacements are not affected by any recalls and continue to look very
promising. The cementless versions of surface ceramic implants failed to ingrow 2% of the
time and were voluntarily recalled by their manufacturer. As I generally do not use
cementless total knee implants this recall did not affect my patients.
About 2% of the Sultzer™ all-metal hips have had to be revised due to failure of ingrowth
into the acetabular shells as a small amount of oil was left on them in the manufacturing
process. I have not used this device because of the detectable metal level in the serum and
urine of the patients who received them. I believe that long-term follow up in larger groups
of patients will be required to know that this is safe.
Any device may be recalled if a safety issue is identified. I am conservative in the application
of any new technology. My partner, Eddie Tapper, MD, who trained at the Mayo Clinic,
advises us to “stay two trends behind” to prevent disasters when new technology becomes
available. I only use implants that have a favorable American experience.
28
9. My total joint still has pain. Has something gone wrong?
There is pain in about 5% of total knees and in 2% of total hips in most series. It is very
rare to have pain that is as bad as the preoperative pain and, in this setting, testing for
infection is undertaken. A careful exam and X-rays are obtained. A blood test is ordered. If
the C-reactive protein and erythrocyte sedimentation rates are normal, infection is unlikely
(97% sensitive). If there is fluid on the joint or these results are abnormal, a sample of joint
fluid is sent to the lab. This will be done in the office for knees, and by the radiologist in the
hospital for hips. Occasionally bones scans may be ordered to look for loosening or failure
of ingrowth but in a normal total joint the bone scan can be hot for up to two years. An
infection would require removal of the components followed by 6 weeks of intravenous
antibiotics. Once the infection is resolved the total joint is then revised to a new one unless
severe antibiotic resistance prohibits it.
80% of patients with pain in their artificial joints do not have infections. Other causes
include tendonitis, inflammation of the lining of the knee, bleeding into the joint capsule,
loosening of the implant, and instability of the implant. Most hip pain is actually from
sciatica related to the back and in this instance further spine evaluation is recommended.
Sciatica causes buttock pain. Hip pain is felt in the groin and front of the thigh. Revision
surgery is usually only recommended for infection, loosening, component failure, severe or
progressive osteolysis (dissolving bone around the implant), and significant instability. Your
surgeon should evaluate even a painless joint replacement one year after the surgery and then
every 2 years.
10. What activities are not allowed after joint replacement?
Contact, court and field sports are not recommended. Bo Jackson is on his third hip
replacement. This should tell you that motivation, athletic ability, and conditioning do not
make you an exception to this rule. Running is not recommended. Substitute hiking,
biking, and swimming. If you are an excellent skier, you may return to skiing at a lesser level.
You must avoid falls to prevent fractures and dislocations around the total joint. Sexual
relations are permissible as soon after surgery as participation is comfortable. The only
precaution is against flexing the replaced hip into extreme positions (knees on shoulders) as
this may result in dislocation. Kneeling may not ever become comfortable after knee
replacement. About one-fourth of total knee patients cannot kneel comfortably and must
use stools to garden or kneepads for activities that require kneeling. Don’t work on the
outside of your foot after hip replacement (avoid activities that flex the hip while rotating the
hip inward).
11. When can I have the other knee/hip replaced?
When you are physically and psychologically prepared, usually in about 6 weeks but it can be
put off indefinitely. If the first surgery resulted in a significant anemia, the second operation
should be postponed until the blood is built back up.
Martin Anderson, MD
Chip Nuttall, PA-C
29
Schedule for Joint Replacement
1. Consultation with Surgeon: my policy is to see patients who need joint replacement
surgery without delay. If you experience any delay in getting an appointment with
me, please call my staff directly.
2. Medical Clearance: we will coordinate with your primary care physician, cardiologist,
or other specialist to make arrangements for any special evaluations needed when
other medical problems require such an evaluation. It is advisable to have dental
work done before, not after, this surgery.
3. Insurance Preauthorization: we will perform this as soon as possible once the
decision for surgery is made. Medicare does not require precertification.
4. Blood Donation or Blood Booster Therapy: the blood bank will call you for this
appointment. Blood should be donated about two weeks before surgery. Blood can
only be stored for 42 days. Blood booster therapy will be scheduled thru an
ambulatory infusion center or your local hospital or primary care physician. This
requires three visits weekly for an injection and will be started about one month
before surgery. I do not require and usually do not recommend donation before
surgery. Medicare will not pay for designated donor blood nor, in most instances,
will it pay for blood booster therapy.
5. Laboratory Testing: the EKG and blood testing should be done about 30 days
before surgery. Blood tests are done on two occasions. The bulk of testing is done
one week before surgery to allow us to correct any problems that might otherwise
interfere with safe surgery. The blood cross-match must be drawn within 72 hours
of surgery and can be done on the day of surgery for patients who travel from any
significant distance. The other blood tests and EKG can be done at your local lab
with results faxed to me.
6. Changes in Medications: aspirin, blood thinners (warfarin and Plavix™), premarin,
evista, and herbal medications are stopped one week before surgery to decrease
bleeding risks and risks of blood clots. You will be told which medications to take
on the day of surgery. Beta-blockers are the only medications to be taken on this
day.
7. Admission to the Hospital: you will preadmit as soon as possible after your surgery
is scheduled, typically when you have your blood tests and EKG done. Your actual
admission is on the day of surgery, two hours before the surgery is scheduled.
8. Day of Surgery: you will be given this date from my office. You will meet with your
anesthesiologist on the day of surgery. You should request spinal or epidural
anesthesia as it lowers your risks of blood clots and your need for narcotics
which may cause confusion, respiratory depression, nausea, vomiting, and GI
problems (ileus). You can still be asleep for the surgery. If it is unsafe for regional
anesthesia, you will be informed of the reason. Previous spinal surgery does not
mean that they cannot attempt spinal anesthesia. When Duramorph™ spinal is
uses, I prefer a low dose to avoid vomiting. After you leave the preoperative area
just outside of the operating room, it takes about 45 minutes of preparation for
surgery, positioning, and draping before surgery begins. Most surgeries take 60-90
minutes. You will then be transferred to the recovery room for a period of about 90
minutes. Your family will be able to visit you when you are transferred to the
hospital ward, about 3 hours after they have last seen you in the preoperative area.
The surgical waiting room is just outside of the operating room and I will meet with
your family and friends after surgery to let them know that you are doing well. SCD
(sequential compression devises will be applied to your legs to improve circulation
and to prevent blood clots.
30
9. Postop Day 1: You will meet with your physical therapist and get out of bed. The
catheter in your bladder will be removed in men (this is done on the second day for
women). A blood test will be performed to check for the level of the blood thinner
and hemoglobin. You will discontinue the PCA device (patient-controlled analgesia)
which gives you a dose of morphine for pain through your IV line and begin using
pain pills. On the evening of this day you will be transported to rehab in most cases.
10. After release from rehab, each Monday for 2 weeks after Surgery you will go to your
lab to have the level of your blood thinner checked and faxed to my office at 775884-5463. We will call you on each Wednesday to adjust your medication
(Coumadin™). If you do not hear from us by Wednesday afternoon, please call my
staff.
11. Postop Day 10-14: You will be given an appointment to have your skin clips
removed. Please call us if you were not given this appointment.
12. Postop Day 21: you will be allowed to resume driving so long as you are no longer
taking narcotics for pain and you are not feeling confused or lacking good motion in
your legs.
13. 4 weeks after surgery: stop your Coumadin™ unless otherwise instructed. It is now
safe to resume the use of Premarin™, Evista™, herbal medications and other blood
thinners. You should no longer be using narcotics as further use could lead to
addiction. Occasional use of narcotics is no safer than smoking an occasional
cigarette form the standpoint or addiction.
14. 6 weeks after Surgery: this is our last routine appointment for x-rays in the year after
surgery.
15. One Year after Surgery: your first long term checkup and X-rays.
16. Within Two Years of Surgery: antibiotics are used to prevent infections in the
artificial joint with dental and urological procedures in most instances. If your
dentist prefers, we will prescribe the medication. Just call the office.
17. Every Two Years Thereafter: make an appointment for a checkup with me.
31
RISKS OF BANKED BLOOD IN JOINT REPLACEMENT
Total joint replacement surgery may require a transfusion of blood. I encourage the
donation of your own blood (autologous blood). This requires a trip to the blood bank and
will minimize, but not eliminate you risks of requiring banked (homologous) blood. The
table in blue below is the most recent estimate of your risks should you require blood from
the general pool of donors (not directed or autologous blood). Because designated donor
blood is statistically no safer than banked blood, the use of designated donors is discouraged
and may not be paid for by your insurance company. The risks of using banked blood are
not prohibitive. In fact, many activities of daily living are equally dangerous, as shown in the
tan table below. I always honor requests for bloodless surgery in my patients who are
Jehovah’s Witnesses and we have had uniform success in these patients.
Depending on your level of hemoglobin (the oxygen-carrying molecule in red blood cells),
donating blood for yourself may not decrease your risk of requiring blood for your total joint
replacement surgery. If your hemoglobin is less than 11, additional testing is usually
recommended to discover the cause of your anemia. If your hemoglobin is between 11-13,
the use of erythropoietin (epo™ or procrit™ 600U/kg, blood boosters that build up
hemoglobin and has been used in blood doping by athletes) is usually preferential to
donating your own blood. The substantial costs of epo™ are not currently covered by
Medicare, however. When the hemoglobin is above 13, most but not all, will be allowed by
the blood bank to donate blood for themselves.
Risks of One
Pint of Blood
Complication
Minor Allergic Reaction
Bacterial Infection
Viral Hepatitis
Lung Injury
Hemolytic Reaction
(Red cells break up)
Hepatitis B
Risk per Unit (pint)
1:100
1:2500
1:5000
1:5000
Hepatitis C
1:103,000
HIV/AIDS
1:500,000
Anaphylaxis (Major
Allergic Reaction)
1:500,000
Fatal hemolytic Reaction
1:600,000
HTLV I/II infection
(Risk for bone marrow cancers)
CVHD
Immunomodulation (lowering
resistance to infection)
1:6000
1:63,000
1:641,000
Rare
Unknown
Compared to other
life time risks of death
Death from smoking one
pack per day
Death from influenza
Death from an auto
accident
Death from a plane
accident (frequent flyer)
Death from leukemia
Death from birth control
pills
Death from tornadoes in
the Midwest
Death from a flood
Death from an
earthquake in California
1:200
1:5000
1:6000
1:20,000
1:50,000
1:50,000
1:445,000
1:445,000
1:558,000
Data from John J. Callaghan, MD, “Blood Management in THR,” Current Concepts in Joint Replacement
Spring, 2000, Las Vegas, NV
32
Total Joint Infection Surgery
Infection rates vary from surgeon to surgeon and hospital to hospital. National total hip
infection rates are 0.2-1% and total knee infection rates are 1-2%. Risks of infection are greatly
increased when there was a previous infection in the joint, when re-do (revision) surgery is
carried out, when surgery takes over four hours, and when your immune system is abnormal.
Common causes of abnormal immune systems are rheumatoid arthritis, the use of
immunosuppressive medications to treat rheumatoid arthritis, kidney failure, liver failure,
diabetes, malnutrition, AIDS, cancer and obesity. Obesity is associated with poorly functioning
white blood cells.
Most infections occur from airborne bacteria from the operating room, often the staph
bacteria that are harbored in the noses of the surgeon, operating team, or the patient themselves.
While the use of ointments can decrease the risk of transmitting these bacteria, we have seen the
emergence of resistant bacteria in these circumstances and cannot safely recommend their use.
The length of your surgery may thus affect the chances of infection as may the operating room
discipline, the use of clean air procedures (space suits, laminar flow, and the maintenance of
appropriate air flows and pressures in the OR). Shorter operating time is possibly the reason
that surgeons and hospitals that do a lot of joint replacements have lower infection rates. Unless
you have prohibitive allergies to multiple antibiotics, you should receive an antibiotic
intravenously within one hour of your surgery. This will reduce your chance of infection by
about 50%. Supplemental oxygen has been shown to decrease infection rates in abdominal
surgery. It is not known if this will hold true in total joint surgery.
Rare causes of infection are contaminated implants, instruments, or bone cement. In
January of 2003 one manufacturer recalled their bone cement due to concerns about the
packaging of their product although the actual contents of the packaging (the cement) were
sterile. In the 1980’s a popular agent for skin preparation was recalled because a bacteria
(pseudomonas) was growing in the solution used to prep the skin of the patients. Late
infections can occur from bacteria traveling through the bloodstream of patients. The risk of a
dental procedure causing a total joint infection is 1/10,000 from spread through the blood
stream, for instance. The vast majority of infections are not related to incompetence or your
surgeon, hospital, or equipment manufacturer. Most infections are simply a matter of the small
odds catching up with the occasional patient, in spite of very high quality surgical care.
Bacteria form biofilms (slimes) around the implants. We all know about slimes. They are
the substances that make the inside of a hot tub or swimming pool slippery. It is not possible at
this time to remove these slimes from joint replacement implants in the body. Bacteria cannot
be eradicated from slimes with systemic or
local antibiotics.
The standard of care for infected total joints
in the US is to remove the artificial joint,
possibly substituting a temporary one
(PROSTELAC-prosthesis of antibiotic loaded
cement), and to then redo (revise) the joint in
about six weeks. During these six weeks, you
will be on intravenous antibiotics. You may
be asked to keep some or most of your weight
off of the extremity to prevent fractures
around the joint.
In Europe and occasionally in the
United States (for infections less than 3 days
old and occasionally in other circumstances) a
debridement or one stage reimplantation may
33
be considered by your surgeon. Although the success rates are not as high, it may be worth
an attempt to eradicate the infection without multiple surgeries, spacers, or temporary
implants. This decision is complex and must be made by your surgeon based on operative
findings and general considerations about your overall health and well-being. Patients who
have very recent onset of infection or have multiple other medical problems may be
considered for a debridement with retention of the components that are solidly fixed due to
the risks posed by the more extensive surgery required to remove the prosthesis or to
equivocal findings of infection. The use of postoperative antibiotics that I recommend to
these patients is the same as the use of postoperative antibiotics as for those patients
undergoing two staged revisions except in the situations described below.
This is an example of an infected total knee
after the components have been removed and
an antibiotic spacer has been placed. It is not
possible to move this knee until it has been
converted to aback to a total knee arthroplasty
with removal of the spacer and revision
surgery. If this knee is flexed, bone damage
may occur. While this knee is at this
intermediate stage, a brace should be worn and
only touch toe weight bearing should be
allowed to prevent fractures and additional
bone loss.
The bone cement antibiotic spacers can
also develop slimes around them. This
is especially true if too low of a dose of
antibiotics is used in the cement. In
this case, the emergence of bacterial
resistance is common. Complicating
our efforts, Eli-Lilly has ceased
production of their product, Nebcin,
which has very favorable characteristics
when mixed into bone cement at
higher doses (3.6-4.8 grams / unit of
cement). The spacers are not
necessarily sterile when they are
removed and I often replace them once
before revising the joint, especially if
the patient was referred from another
surgeon who placed the spacer.
SEMs of bacteria on PMMA beads Used to Treat an Infection
Courtesy of Danielle Neut
University of Groningen
Groningen, Netherlands
There are two blood tests that are beneficial to your surgeon and infectious disease
specialist as they judge the activity of your infection while you are under treatment for a total
joint infection. The C-reactive protein (CRP) is the first to return to normal, followed by the
34
erythrocyte (red blood cell) sedimentation rate (ESR) and your infection is eradicated. Either
of these tests may be abnormal for other reasons, so it is important to inform your treating
physician if you have other symptoms (sinus infection, bladder infection, diarrhea, etc) while
you are receiving antibiotics. Occasionally, super infections which can be serious emerge
and require additional care. If, by 6 weeks, the CRP is not substantially improved another
debridement (clean out surgery) may be recommended prior to the definitive surgery to
revise your total joint.
When the new joint is placed, you will remain on an IV antibiotic until the CRP is
normal and then an oral antibiotic until the ESR is normal in most instances. This will
eradicate the infection about 80% of the time. I do not recommend the use of life long
antibiotics except when someone is too fragile to survive surgery or when multiple attempts
to cure an infection fail and a patient will not accept a Girdlestone procedure (permanent
removal of a hip joint), or an amputation (in the case of the knee joint). A successful
surgical treatment, by definition, does not result in life-long antibiotic therapy. The
antibiotics should be discontinued when the markers of infection in the blood serum
(sedimentation rate and C-reactive protein) have normalized. At that point the labs are
followed periodically and if they again increase a decision about more surgery or life-long
suppressive antibiotics should be made by the surgeon, the infectious disease specialist and
the patient.
We can salvage most of the infected joints with these procedures. The options left if
infection recurs include the following:
1 – Attempt another staged revision. This is preferable except in
patients who have so-called “host factors” that preclude likelihood of
successful additional surgery such as kidney failure, the use of dialysis,
poor soft tissue coverage, abnormal immune systems, vascular disease,
severe diabetes and in patients who cannot quit smoking.
2 – In the case of the hip, remove the joint and let fibrous tissue
comprise the only joint. This is called a Girdlestone procedure and
may result in acceptable level of pain control but usually requires a built
up shoe and results in a limp and the need for a walker or crutches.
3 – In the case of the knee, fusion or above knee amputation may be
considered. Fusions are not well accepted due to limp and problems
sitting with a knee that doesn’t bend. Function with a prosthetic leg
after amputation may be preferable.
4 – Suppressive antibiotics can be used for patients who are too
debilitated even for an amputation or Girdlestone hip arthroplasty but
we would fully expect resistant bacteria to emerge over time in many
instances. Permanent use of antibiotics is not recommended for
patients who have undergone either one-stage or two stage
debridement which have not failed with recurrent infection. Very
resistant bacteria (vancomycin resistant enterococcus) have emerged in
total knee patients who have been left on prolonged antibiotics.
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