Metal Detectors and Implant Cards

All patients who have undergone total joint replacement receive a metallic implant card. The purpose of this card is to identify the patient as having an implant and also to provide information regarding the need for taking antibiotics after total joint surgery.

While most patients have no trouble passing through metal detectors after total joint surgery, several patients have reported triggering the alarm. By carrying the implant card this assists you in being identified as having a total joint replacement.

Antibiotics For Protections After Total Joint Surgery

All patients who have had total joint surgery should receive prompt treatment for any bacterial infection. This is done to prevent the infection from spreading to the total joint site through the bloodstream. Although such spread is rare, it can happen.

In addition, patients who have had total joint surgery are advised to take antibiotics prior to any procedures they may have done. These procedures include dental work, sigmoidoscopy, cystoscopy, etc. In general, any procedure in which there is the chance of introducing bacteria into the bloodstream calls for the patient to receive antibiotics. This is done to prevent any bacteria from possibly traveling through the bloodstream and settling at the total joint site. The standard antibiotic used for this regimen is Amoxicillin 2.0 g taken by mouth one hour prior to the procedure. If you are allergic to amoxicillin, clindamycin, cephalexin, or azithromycin may be taken.

The length of time post-operatively necessary for patients to take these prophylactic antibiotics depends on the patients overall health. Patients with normal immune systems will need only to take antibiotics prior to procedures for the first two years after total joint surgery. However, patients who have a chronic disease which affects the immune system (such as lupus or severe R.A.) will need to continue taking these prophylactic antibiotics any time they have one of these procedures done.

In cases of major surgery, it is routine for patients to receive antibiotics during surgery and therefore be protected.

The most important thing for any patient to remember regarding antibiotics and their total joint surgery is to communicate to each of their physicians that they have had total joint replacement. In addition, each patient who has undergone total joint surgery receives a metallic implant card which has information regarding the need for prophylactic antibiotics before procedures.

Infection After Total Joint Surgery

General Information

Infection after total joint surgery can be a serious occurrence. In our experience, and across the country, the risk of infection after total joint surgery is approximately 1/2% or less. This is equivalent to 1 case in 200 having an infection occur after surgery. In most cases, these infections can be cured. They may require the patient to be hospitalized longer, treated with antibiotics for a longer period, or perhaps even to undergo a second operative procedure.

Signs of a Possible Infection

The signs of a possible infection are:

a temperature elevation (especially if prolonged)
localized swelling, redness, or tenderness
purulent (pus) drainage from the incision
any change in color or odor of drainage from the incision

Prevention of Infection

When a patient is hospitalized for a total joint replacement, the prevention of infection begins in the operating room. Surgery itself is performed in a sterile environment in the operating room, with special air filters to help provide clean air that is free of most bacteria. In addition, patients receive antibiotics throughout their surgery via the IV line which is started upon admission to the surgical area.

During the hospitalization period, patients continue on their IV antibiotics for 24-48 hours as a preventive measure. In addition, careful examination of the incision, observation of any drainage, and monitoring of the patient’s temperature are all preventive measure taken throughout hospitalization by the nurses and physicians caring for the patient.

At the time of discharge patients are given a list of discharge instructions which contains the signs of infection and whom to call if these signs become apparent.

Long range post-operative prevention of infection is maintained by total joint patients taking oral antibiotics prior to procedures which could possibly introduce bacteria into the bloodstream. Once a patient has undergone total joint surgery, he/she should always inform other physicians that they have a joint replacement.

Treatment of Infection

If a patient does develop an infection after total joint replacement surgery, it is either a superficial (localized) infection or a deep infection. Treatment for the infection will be based on several criteria. These criteria are:

the type of organism causing the infection
the organism’s sensitivity to antibiotics
the length of time of the infection
the condition of the patient’s bone

Once the diagnosis of the type of infection is made, treatment is done in one of the following ways (click a heading below to learn more):

Antibiotic Therapy

Treatment for a superficial or localized infection consists of antibiotics given either by mouth or by IV. Treatment may be anywhere from 3 days to 1-2 weeks.

Incision and Drainage

For more serious localized infections an I & D (incision and drainage), or “cleaning out” of the surgical area may be performed. This is a limited surgical procedure in which the wound is washed out and the patient is treated with antibiotics IV. In this procedure all of the original prosthetic components are retained.

Direct Exchange

For a deep infection which has not advanced to the bone, the recommended treatment is to perform a “direct exchange.” In this surgical procedure the total joint components are removed, the surgical area is cleaned, and new total joint components are inserted. These procedures are performed at the same time, and the patient is treated with IV antibiotics before, during, and after the surgery.

Delayed Exchange

This treatment is performed for deep infections in which the bone is involved. In the first surgery, all total joint components are removed. The surgeon may then insert a temporary prosthesis which is a “spacer” made of cement and treated with antibiotics. This temporary prosthesis is left in place for a period of time (usually 6-8 weeks), during which the patient is also maintained on IV antibiotics. A second surgical procedure is then done in which the surgeon inserts new total joint components. This 2 stage treatment of infection will necessitate separate hospital admission for each surgical procedure.

Fusion/Girdlestone

If a total joint replacement patient’s infection cannot be eliminated or if the condition of the bone is too severe to allow for the exchange treatments discussed above, the patient and surgeon may decide that the preferred option is to remove all of the total joint components permanently.

In the case of a total knee patient, the procedure to be performed is called a fusion, and in the case of a total hip replacement the surgery would be a girdlestone procedure.

The goal in both procedures is to provide a stable, solid, infection-free lower extremity which will allow the patient to perform activities of daily living. However, neither procedure allows normal joint function. Comfort and reasonable activities are still possible.

Surgical fusion of a knee or girdlestone procedure of the hip is performed in less than 10% of all infection cases after total joint surgery or 1 in 2,000 cases.

Summary

The occurrence of an infection after total joint surgery can be a serious event. Infection may occur immediately after total joint surgery, after the patient goes home, or even years later. For this reason if an infection develops in any part of a total joint replacement patient’s body, this should be addressed.

All total joint replacement patients are advised to consult their physician if they experience any signs of an infection. In addition, these patients are advised to make any physicians they may see aware that they have a total joint replacement. Careful follow-up of total joint patients and appropriate communication between the patient and their physicians are always the best measures in the prevention of infection.

Risks and Possible Complications

It is important to understand that there are risks and possible complications associated with any major surgical procedure and total joint replacement is no exception. In all cases, discussion between the patient and the treating physician is imperative to put possible complications into proper perspective for a specific patient.

Risks

The risk of death is present in any major procedure requiring anesthesia and blood transfusion. The risk of death in a patient undergoing a total joint replacement is 1 in 750 – 1,000 cases. The specific risk for each individual is dependent on their general medical condition, their age, and the difficulty of the surgical procedure performed.

Possible Complications

Although the occurrence of these complications is low in number, each patient needs to be informed of these possible risks prior to surgery. Click on a heading to learn more about each one.

Medical

Medical risks after total joint surgery are of course varied, and range from minor to more serious complications. These may include complications involving the cardiovascular respiratory, gastrointestinal, or genitourinary systems or any system in the body. Each occurrence of a medical complication is addressed as it occurs and will vary for the individual patient.

While total joint surgery or any type of orthopedic surgery does involve certain risks, it is safe to say that most of these risks are encountered in any major surgical procedure. Careful pre-surgical screening, superior surgical technique, and conscientious post-operative management are the cornerstones to minimizing not only the occurrence of any complications, but certainly the outcome of these risks as well. It is our policy to adhere to these criteria whenever a patient undergoes any operative procedure, and in doing so, keeping these risks to a minimum.

Dislocation

In total hip replacement surgery, there is about a 1% chance that the hip will (Hip) dislocate in the immediate post-op period. This may occur because of an inadvertent movement in which the ball part of the prosthesis becomes dislodged from the socket. In the vast majority of these cases, this can be treated by manipulation and does not require another surgical procedure, though use of a small anesthetic may be necessary. If unsuccessful in relocating the prosthesis, a second open surgical procedure may be necessary to correct the situation.

Loss of Motion

In the case of total knee surgery, a decrease in motion after total joint (Knee) replacement may require a manipulation to help break the adhesions formed in the postoperative period. If this were to occur, the patient is given a small amount of general anesthesia and while asleep, the knee is passively bent for them. In most cases, this is performed on an outpatient basis, with the patient starting physical therapy within 48 hours from the time of the procedure.

Thrombosis

The occurrence of a blood clot or thrombosis after total joint replacement is another potential risk. Because patients are mobile very early in the postoperative period, this is a complication that is seen much less frequently now than in the past.

In addition to early mobility, patients are treated with pulsatile stockings, (to prevent the stasis of blood in the lower extremities) and low doses of aspirin or other anticoagulation medications to reduce the risk of forming a thrombosis.

If a patient is diagnosed with a blood clot, treatment with intravenous heparin and oral coumadin is initiated. As a result, patients may need to be hospitalized slightly longer, but recuperation remains normal overall.

While these complications may occur after any total joint surgery, both hip and knee joint replacement have unique problems which may occur.

Loosening

Loosening of a prosthesis is another potential risk in total joint surgery. Loosening may occur in any one individual component or occur in all the components. The occurrence of loosening in a total joint replacement is approximately 1% per year in our experience. Loosening of a prosthesis is not usually a sudden occurrence, but a gradual process, characterized by increasing discomfort. In most instances, if a prosthesis becomes loosened, it can be corrected by another surgical procedure.

Infection

A major potential risk with total joint replacement is the risk of infection. When a patient undergoes total joint replacement, they are started on intravenous antibiotic therapy to reduce the chance of infection.

In our experience, and across the country, the risk of infection is approximately 2% or less. This means that 1 case in 200 has the potential for infection.

Infection in the post-operative course in most patients is treatable. It may simply require longer hospitalization, treatment with antibiotics for a longer period than normal, opening the joint and draining it, or in some instances removing the artificial components in order to cure the infection before implanting another artificial joint.

In extreme cases where infection cannot be treated successfully, a patient may need to have the artificial joint removed permanently and have the joint fused.

General Do’s and Don’ts After Total Joint Surgery (The First 12 Weeks)

You will be told how much weight bearing you can do prior to your discharge. Do not advance this until you have seen your physician or been instructed to increase your weight bearing.

Do continue using the devices (crutches or walker) you have been instructed to use. Do not change this assistive device without checking with your physician.

Do continue to wear your elastic stockings until your 6 week check-up. You may remove these at night when in bed or for short periods during the day but in general these need to be worn.

Do continue taking your pain medicine as needed. Call the office if you need a refill, but remember to call in advance, not when you only have one pain pill left. This is especially important if you are taking a narcotic pain medicine because in most instances these prescriptions CANNOT be telephoned to your pharmacist. Prescriptions for a narcotic medicine generally need to be picked up by a family member or mailed to the patient, so keep this in mind.

Do maintain any and all position restrictions given to you by your therapist or doctor.

Do call your surgeon’s office if you have questions regarding your progress or activities.

Do not drive a car or return to work unless you have first checked with your physician.

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