Martin Anderson, MD
Transcription
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 page 2 3 3 5 5 7 7 7 7 8 10 10 11 15 17 21 26 29 30 32 33 2 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 5 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 6 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. 7 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. 10 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. 11 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. 35