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Interviewer: As technology and practices have improved, more people than ever are receiving joint implants. In fact, "The Journal of Rheumatology" projects as many as 600,000 joint replacements in the U.S. by the year 2030.

With more folks receiving an implant, how do you take care of it and ensure that it lasts as long as possible? To answer those questions, today, we are joined by Dr. Mike Archibeck. He is an associate professor with the Division of Adult Reconstruction at University of Utah Health.

Now, Dr. Archibeck, for someone who has just barely received a replacement joint, whether it be a knee or a hip or something like that, what do they need to know about taking care of it for, say, the first year after surgery?

Dr. Archibeck: Yeah. So I think I'm primarily going to talk about total knees and total hip replacements. That's kind of the purview of the Adult Reconstruction Division in the Department of Orthopedics. So we do total knees and total hips as well as revision total knees and total hips.

And so there are a few things that are generic in regards to how to maximize your recovery early after surgery. Most would consider the first year as kind of the recovery period. It's been shown that both hips and knees generally do improve over that year, even though the vast majority of the improvement is in the first few months.

And during that first year, there are a few things you can do to kind of maximize the outcome and protect it from the dangers. Early after surgery, one of the most common complications is a blood clot in the leg or something that we call a deep venous thrombosis. So, usually, patients are prescribed some form of blood thinner. It could be aspirin. It could be something stronger. So being sure to do bed exercise during the day, get up about every hour or so, and go for a short walk.

You also want to be sure that the wound heals. So one of the concerns early after surgery is infection. Try not to overdo it such that the knee or hip area becomes too swollen, that can slow or compromise wound healing, and being sure to avoid any other types of infections that you might get early after surgery, like a urinary tract infection or a skin infection.

So if any of those things develop, or dental issues, you want to touch base with your surgeon and be sure those are treated so they don't potentially get into the bloodstream and make it to the hip or knee replacement.

And then recovery-wise, some patients participate in formal physical therapy. And more commonly now, more and more patients are doing kind of directed physical therapy, but working on whatever the tasks might be that the therapists direct you to do.

So with a knee, early after surgery, one of the high priorities is working on range of motion. A hip, less of a concern range of motion, but with both, starting to work on gait training initially with a walker, and then subsequently, weaning to a cane, and gradually off. Usually, that process is coached by the therapist or the surgeon and his team.

And trying to avoid overdoing it. Like I mentioned, you can really set yourself back if you do too much too soon. You can get swollen, wound healing can be slower, and it can just be more painful and kind of slow the recovery process.

So, again, the main things to be careful about are watch for the signs of blood clot, which would be significant swelling in that leg that does not respond to elevation, protecting the wound from infection, and just being an active participant in your recovery and physical therapy.

Interviewer: For someone who has received a joint replacement or is about to have joint replacement surgery, the recovery takes anywhere from 10 months to a year. So when will they see the most improvement? I mean, when will they start walking again?

Dr. Archibeck: Yeah. So, with both, you'll really be walking the day of surgery, obviously to a limited degree, and you'll be using a walker typically. But with both, you're generally able to place as much weight on that implant or that extremity as you want.

But like you mentioned, the first few months, the improvement is very rapid. So week to week, you see a significant improvement.

The improvement after those first few months is a little more subtle. So you may not notice dramatic changes like you do early after surgery, but it will continue to improve, and you gain more confidence in it, and you think about it less as time goes by.

But most people kind of describe the first six weeks as the majority of the recovery, so that's really the time frame when the focus is on avoidance of complications. So blood clot, infection, things like that.

Interviewer: Wow. So after the first year, the body is healed up, we've made sure that the wounds are not getting infected, we're not getting clots, etc., but now we have a piece of hardware in our body. What do we have to do to make sure that we're taking care of the implant and make sure that we get as long of a use out of that implant as possible?

Dr. Archibeck: There are several things that are important to know. So one is how do these things fail? And there's a little bit of a difference with knee replacement and hip replacement, but in general, they can still fail by infection. So, obviously, that's a life-altering event if it occurs.

And generally, it's felt that that is caused by a remote infection that then enters the bloodstream and finds its way to the joint replacement. So, unfortunately, a chunk of metal like a hip and knee replacement is always more susceptible to infection than a native healthy joint.

So you just want to take generally good care of yourself. Keep your dental work up to date. That can be a potential source of infection.

Interviewer: Really? Dental work?

Dr. Archibeck: Yeah. In the past, they used to recommend antibiotics prior to any dental work, and that still is a bit of a controversial topic, but that's not felt to be absolutely necessary unless you're high risk or have multiple joint replacements. But again, that's a topic you'll get different opinions about.

Any other bacterial infections, so common ones would include urinary tract infection, skin infections on that leg or other areas, obviously sinusitis, pneumonia. As you typically would if those things develop, you just want to be diligent about getting them looked at and treated, and more so if you have prosthetic joints.

I mean, obviously, we're talking about hip and knee, but there are elbow replacements, ankle replacements, and others. So any bacterial infection can potentially go to those areas. So just kind of taking good care of yourself like you generally would.

Implants can wear out. So, luckily, hip and knee replacements, the materials that we use have significantly improved over time over the last couple of decades. And so, even at 20 years, most are still functioning well, but they do wear and tear.

So a few things you can do in that regard. It's generally recommended that you avoid repetitive, high-impact activities, such as running, for exercise or aggressive cutting and pivoting sports. Things like walking, hiking, biking, swimming, golfing, dancing, most people feel like skiing is fine, are all activities that are absolutely fine to do and don't need to be limited at all. You can do as much as you want.

Then there are those in-betweeners, like tennis, pickleball, skiing, where some of those the risk is more the risk of a fall. But generally speaking, those activities are felt to be okay too, just avoiding the really high-intensity cutting and pivoting type things.

The other thing that can help add to the longevity of an implant is maintaining a good body weight. So it's been shown that the risk of wear and tear . . . and by that, I mean the plastic can wear or parts can loosen. The risk of those issues arising increase a bit as your BMI, or body mass index, increases. So trying to maintain a good body weight is helpful. Avoiding high-impact activities.

And then another rare cause of failure would be an injury of some type. So the implants themselves are very durable. But obviously, the bone adjacent to the implant can be susceptible to fracture or injury.

Especially as you get into your advanced years, being careful to avoid situations that might put you at risk for a fall or an injury, making sure your home is safe in regards to no obstacles on the floor or edges of rugs, and just kind of doing your best to minimize the risk of a fall. A fracture around an implant obviously is considered a failure and typically requires surgery to correct.

With that being said, though, like I mentioned, when patients ask, "How long do these things last?" we give a relatively simple answer, like, "Hopefully 15 to 20 years." But to be honest, even at those intervals of time, the vast majority are still functioning well. Yeah, they're pretty durable implants.

Interviewer: What I'm hearing is after you get your joint replacement, if you take care of your body, your health, your weight, and so on, that your implant can last as long as 15 to 20 years?

Dr. Archibeck: Yeah, I think that's fair to say. The other thing that I should mention is that even if a joint replacement is functioning well, it's wise to see your physician. And recommendations vary, but I would say probably about every five years.

So the first year, there's a regimen of post-op visits. Usually two weeks, six weeks, maybe three months, a year. After that, though, we usually let patients go for a while. And it's wise, though, to return and get an X-ray and be evaluated, I would say, anywhere from every five to ten years.

The reason being is that there are things that can occur with the hip replacement or knee replacement that aren't always painful. So if you get a little bit of plastic wear, that might be something that we would be able to see on X-ray, but may not be a painful problem.

And sometimes, if caught early enough, the solution to that issue is relatively simple. If caught late, when it's maybe resulted in loosening of an implant, it can be a much more problematic issue to correct.

So routine follow-up, even after that first year, is wise. Especially as you get to the 15- to 20-year interval of time since surgery, then it becomes even more important because that's about when our concern kind of increases a little bit in regards to the risk of some of these wear-and-tear type mechanisms of failure.

The other thing that's worth mentioning is beyond just having it last a long time, obviously all patients want it to be as comfortable and functional as possible. And it's true that a hip replacement and a knee replacement probably will never feel like a totally normal joint, but the closer we can get it to that, the better.

And typically, hip replacements, for whatever reason, seem to approximate a normal hip more closely than a knee replacement. In other words, it's much more common to have some residual symptoms with a knee replacement.

But the most common reasons we see patients back who maybe had a knee replacement or a hip replacement five years ago, 10 years ago, and just somehow, again, feel concerned that it's not as comfortable as possible, or as they were hoping it would be, include weakness.

So that early post-op time frame, like we mentioned, it's important to work on strengthening. Maintaining that strength is equally as important to allow that hip or knee to function as good as it possibly can.

Again, maintaining a good body weight. It's been shown that if your BMI kind of creeps up a little bit, sometimes the patient's satisfaction level with their replacement decreases. So even though it's not intuitive that that would be the case, maintain a good body weight, maintain good strength.

And obviously, if it really seems like something is wrong, if it's painful and it seems to be not resolving or worsening, then you definitely want to see your physician to kind of rule out any concerning findings.

But again, continuing with those strengthening exercises, maintaining a good body weight, those things can help the joint replacement function most effectively for a long period of time.

Interviewer: Now, going back to that idea of satisfaction, if a patient gets a replacement and is able to take care of it for those 15, 20, or more years, what kind of improvements in quality of life can they expect after receiving a joint replacement?

Dr. Archibeck: That's a good question. The good news is that the vast majority of patients, even though they may have some residual symptoms, feel as though they're dramatically improved when compared to their status preoperatively.

So like I mentioned, it's often the younger patients that maybe notice the limitations or the shortcomings of joint replacement because of maybe their demands of it or their expectations of it.

Because they're just by nature more active, they may notice those limitations a little more than a very elderly patient that maybe isn't as active. Those patients often feel like, "Hey, this does feel pretty normal to me," whereas, maybe the younger, more active patient feels that they're still a little limited by it.

But like I mentioned, most patients, younger or older, generally feel significantly improved after surgery.

And as I mentioned earlier, they should expect to be able to participate in those activities that I mentioned without significant pain: walking, hiking, biking, swimming, things like that. The more demanding activity is, so things like stairs, squatting, walking up or downhill, long hikes, it's not uncommon to still maybe develop a little fatigue or a little ache in the joint. And those things, unfortunately, may persist.

So, with knee replacement, it's been estimated that about 15% to 20% of patients continue to have some degree of what they describe as pain, even though most patients are still very satisfied. Hip replacements, it's a little less. So maybe 5% to 10% of patients still have occasional pain. So, yeah, unfortunately, not a totally normal joint, but definitely typically a significant improvement.

Although the things that I mentioned, like infection or injury, are extremely scary and worrisome, they are very, very rare. And most people do very well after hip or knee replacement in regards to a significant improvement in their quality of life, both in regards to the level of pain that they have as well as their level of function and the activities that they're able to participate in.

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Interviewer: Today's listener question is what should somebody look for in an orthopedic surgeon when they're having a knee or hip replacement done. We're talking with Dr. Chris Pelt. He's an orthopedic surgeon and an expert in these types of replacements at University of Utah Health Care. What do you tell somebody if they were to come up to you at a party and say, "What should I look for in a doctor when I'm considering this kind of surgery?"

Dr. Pelt: I tell them to find a surgeon that they feel personally comfortable with, someone that they connect with.

Interviewer: Even if they're really, really good at it, if you're not making that connection you say go find somebody else.

Dr. Pelt: Yeah, exactly. I think that's an important thing because this will become a lifelong relationship with a surgeon. We will follow it for the rest of your life, so you want to be able to connect with that surgeon. But the other thing is you want to find someone who's technically very, very skillful. That's often with experience. Surgeons that perform over 100 hip or knee replacements a year tend to have a better outcome than surgeons that perform fewer surgeries per year, and so often is an important question to find out how many of these types of surgeries your surgeon performs.

Interviewer: And that's something you could just ask. You can just ask, "How many do you do a year?"

Dr. Pelt: Absolutely. And if a surgeon is offended by that question, the patient may want to take pause. Most surgeons that are experienced and comfortable with their own skill set will have no problem answering a question like that.

Interviewer: Beyond the surgeon, where you go, does that make a difference, kind of like the philosophy of the surgical center you do go to?

Dr. Pelt: Just like the surgeon, the facilities are very important both in their quality and cleanliness, their infection rates. A surgical center that does more of the same types of procedures will be better at what they do, so high volume centers that perform high numbers of hip and knee replacements annually will have better outcomes than places that do it more uncommonly.

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Tom: You have osteoarthritis? What can you do about that before you require a total joint replacement? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Tom: I'm here with Dr. David Petron. He's a professor of sports medicine. He's a non-operative physician and he works in the Department of Orthopedics here at the university.

David, what options does one have, prior to a joint replacement, in order to treat that pain and dysfunction?

David: Well, ultimately, you want to try to stay away from a joint replacement obviously. And the thing that leads to that is osteoarthritis of the joint, most commonly weight-bearing joints like hip or knee. And a lot of people don't even know what osteoarthritis is, but it's generally the wearing out of articular cartilage, which is that smooth shiny cartilage at the end of bone. So it's more of a wear-and-tear process, and ultimately the joint narrows and you start to get bone spurs, and aching, and stiffness, and swelling. And then really what drives the patient to the doctor is pain.

Tom: Does everyone anticipate that type of wear and tear over their lives, or are just some people prone to that?

David: Some people are prone to it. So there is a genetic predisposition to it. But if you're overweight or you've had prior trauma, that also can predispose you to arthritis. But it's really insidious, so most people are surprised when I tell them they have arthritis because they didn't have an injury, and they said their knee just started hurting and swelling . . .

Tom: Slowly comes on, over time, and it's nagging. And after a while, they just can't take it anymore.

David: And finally they figure out, "Well, I can't run, anymore. I can't do the things I want to do, anymore, so I'm going to go see the doctor."

Tom: So, by that time, I'm assuming they've maybe tried some home therapies. They've taken over-the-counter pain relievers like ibuprofen, or Naprosyn, or even aspirin, and, at some point, maybe those aren't really cutting it and they're not able to do the things that they used to do. What do you offer them?

David: Well, there's really three things they can do that they can control themselves. One is to get the muscles around the joint as strong as possible. So if it's a knee, quadricep strengthening, and usually doing lower-impact activity.

Tom: So that improves function. Does it help with pain?

David: It does help with pain. So if they can increase strength, that helps the pain, really the muscles surrounding the joint are the shock absorber for the joint. So the stronger, the more balanced, the more strength you have, the less likely you are to have pain in that joint.

Tom: So first tip is physical therapy. That's the way to start. And don't go with the old adage, don't use the joint. You know, don't slack off. Don't rest the joint.

David: Well, exactly. That's when people get in a vicious cycle. It hurts, so they quit doing anything, so the joint stiffens. And because they're not doing anything, they gain weight, which makes the joint hurt more, and on and on it goes.

So really there are three things they can control: one, keeping the strength up, two, avoiding high-impact exercise, and the third thing is keeping your weight right.

Tom: Now, by high-impact exercise, I assume you're talking about running, jumping rope, skydiving?

David: Right. Lower-impact things are okay, so usually walking, which can . . . you know, there's some impact with that, but that's usually not too bad. But biking can be a really good exercise for it, or even weight-lifting. So it's usually the high energy things. So, like, if you jump even off the height off the stair step, that could hurt the knee. But if you slowly low that up by, like, getting out of a chair, that doesn't hurt the knee, and you build strength with it.

Tom: So how about running on a treadmill? So for people who like to run, and there are a lot of them, plenty of people don't bike and they love to run, I guess they could switch to swimming, but what about walking or running on a treadmill versus being outside?

David: Absolutely, that can be easier on it. And we actually have a running clinic at the Orthopedic Center, and we, a lot of times, evaluate runners and find that they can be putting too much stress on their quadriceps and not running enough out of their hamstring and their gluts. So they tend to over-stride, which makes them load up the quadricep, which puts more stress on the knee. So sometimes it's something as simple as learning how to run a little bit differently, a lot of time, shortening the stride, and having more of the energy through the gluts and through the hamstring.

Tom: So let's say that they do these things and they're very diligent about the physical therapy, and they lose weight, but they still have pain. What else can be done?

David: There's different injections that can be done. One of the things that can be done that's usually a short-term answer to the problem is a corticosteroid injection. But a lot of times, that can kind of reset the pain. So it can settle down inflammation and settle down the pain so that we can institute some of these other things that we're talking about.

Tom: Now, there are other things besides corticosteroid injections that you have used in the past, I think.

David: Right, there's something called viscosupplements which are more of a lubricant for the joints, so it's like . . .

Tom: Those 50 weight [inaudible 00:04:41].

David: Yeah, that's it. It has a thickness to it, and that's either in a series of one to three injections, and it kind of resets the environment of the joint so that the arthritis doesn't progress as quickly. So there's some evidence to suggest that it may slow down some of the progression of arthritis, but it certainly can help with the symptoms.

Tom: And how long can that effect last if it works?

David: That tends to last . . .

Tom: I guess the question might be: How many patients will respond to those viscous injections?

David: I would say, in general, the less advanced the arthritis is, the more likely it is to respond. So if somebody gets down to bone-on-bone, a lot of times I don't even try it, and that's when you start looking at surgical options. But if there's still some joint space left, then those patients can respond well to these injections.

Tom: That's the importance of getting in early and making correct diagnosis.

David: Right.

Tom: So with the corticosteroid injection, as well as the viscous injections, they last for a few months, and maybe longer in certain people. When can you repeat those, and how often can you repeat those injections if they work well?

David: Oh, that's a great question. With corticosteroids, kind of a general rule is I wouldn't do it more than about three times a year. With viscosupplements, insurance companies will cover that about every six months. So most people with viscosupplements, it lasts a little bit longer. And typically with a viscosupplement, it's usually a series of three injections. And with the first injection, we put a corticosteroid in with the viscosupplement. So you get kind of a quick onset of the corticosteroid and the longer lasting on set with the viscosupplement itself.

There's a couple other injections, too . . .

Tom: Yeah, let's talk about those.

David: . . . that can be done. One is called PRP, or platelet-rich plasma. And platelets have certain growth properties, healing properties, so we draw the patient's blood, spin it down, separate the platelets and inject that into the joint. And then I think a lot of people have probably heard about stem cells, and there's been a lot of publication about that. And I think if you think about it more as pain-relieving and maybe slowing down the progression of arthritis, rather than that it really heals or reconstitutes the joint, then stem cells can also be a good treatment for the joints.

Tom: Let's talk about the stem cell therapy for just a little bit. Now, is that obtained from the patient's own blood? And then, how do you do that?

David: There's different ways to obtain it. One is through bone marrow, so we do a bone marrow aspirate, usually out of the pelvis, which is a relatively pain-free procedure. Another way is derived from peripheral fat, so we can take fat cells and obtain the stem cells. And the third way, and this a little bit more controversial, but there's more and more amniotic stem cells that are out there. But there are some question about how many stem cells there really are, depending on how they're stored. A lot of times those are stored freeze-dried, and it's a little bit questionable on whether there's significant stem cells in that, or not. But there's no question that some of these amniotic stem cell treatments have helped patients, myself included, with arthritic pain.

Tom: That's great. You've listed a whole list of procedures and treatments that can perhaps delay and improve patients' function and decrease pain prior to considering a total joint replacement. I think the first thing you said is, one, be healthy, lose weight, and then keep fit, use a physical therapist to strengthen the ligaments and tendons, muscles around the joint. And then moving on from there, to seek a diagnosis early on so that certain therapies can be applied before things get to be too advanced, and then, you know, eventually you just have to move into a joint replacement.

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Dr. Miller: Artificial joints and infection, we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He is a Professor of Orthopedic Surgery here at the University of Utah in the Department of Orthopedics. For patients and people who have prosthetic joints or artificial joints, are they at higher risk of having an infection in that joint?

Dr. Gililland: Well, the joint itself we put in is a metal and plastic joint. It inherently doesn't have its own immune system like our own joints do. So if you get an infection, even an innocuous infection in the blood stream that would have normally been cleared, there is a chance that could get to the joint and take over and so you are at more risk of that joint becoming infected.

Dr. Miller: So how does one become infected? I mean, is that due to a cut or some other site in the skin that could be infected or is it some other way that you are infected? How does that happen?

Dr. Gililland: The answer is, probably most of the time we don't know how it happens. It comes about as an infection that we probably wouldn't have picked up otherwise or have been aware of otherwise. Sometimes we are aware, they had a bad urinary tract infection or they do get an infection in the skin and that then gets to the joint, but most of the time we don't know and these come on seemingly out of the blue.

Dr. Miller: How often does it happen? I mean, it's not common, right?

Dr. Gililland: It's not common. We would say that in most big registries, infection in any given practice should be about 1% to 2%. There is difference in infection that happens right around the time of surgery which would be a surgical site infection which can come from either the wound itself.

Dr. Miller: The wound itself, healing, the incision.

Dr. Gililland: Exactly and that's different than infection that ensues say two or three years down the road in an otherwise well-functioning joint.

Dr. Miller: So you see infection more commonly after surgery or two or three years down the road?

Dr. Gililland: Generally what we see here is our infection rate here at the university is very low. It's less than 1% of our own infections and in cases that happen here in terms of patients getting surgical site infections, but we definitely see infections coming in from outside or infections in patients that have had well-functioning joints and that's probably a bigger problem in terms of dealing with those long-term.

Dr. Miller: So dealing with an infection in a prosthetic joint is a different kind of beast than having an infection in a joint . . . in a normal joint.

Dr. Gililland: Correct. Dealing with an infection in a prosthetic joint is rather difficult because now you have a piece of metal in there that's infected and we are starting to learn more about infections and the way that they form and bacteria is just a single bacteria creating infection. They create a big environment of what we call a biofilm that's almost . . .

Dr. Miller: Sticky.

Dr. Gililland: Right.

Dr. Miller: They stick to the plastic and the metal and . . .

Dr. Gililland: Exactly. They almost create their own colony and their own surface that sticks to the metal and it's almost impossible to get rid of with just antibiotics.

Dr. Miller: So I think most people would believe that you might just take an antibiotic for a few weeks and then the infection would go away, but that's not really true in this situation.

Dr. Gililland: Yes, it's very, very unlikely that that's going to be successful and often we get patients that have come in and have been on antibiotics for a long period of time and that's been rather unsuccessful for them and it makes our job somewhat harder because now these bacteria can be somewhat resistant to some of these antibiotics.

Dr. Miller: Well, let's talk about the patient who might have an infection. What signs would they look for, what symptoms would they have that would alert them to the fact that they might have an infection in that new prosthetic joint?

Dr. Gililland: Yeah, the biggest thing is pain. Most of these patients are patients that were functioning well, doing well with their arthroplasty, their joint replacement, and then they started to develop pain down the road. And whenever that happens, the patients need to go and be seen and be evaluated to make sure the parts aren't loose and there is no fracture, and most importantly, they don't have an infection.

Dr. Miller: But there could be other reasons for pain aside from the infection.

Dr. Gililland: Absolutely. Pain in and of itself does not mean infection, but it's certainly something that we ought to be looking for. Any painful joint that comes in that was otherwise well functioning always gets an infection workup in my clinic.

Dr. Miller: Would there be other things going along with the pain? So would the joint be swollen or red or will the patient have fever or chills? What kinds of things are you typically seeing in these infections that occur two to three years out?

Dr. Gililland: Yes. So certainly there you can have swelling about the joint, redness. You can get drainage from the wound or start to develop draining sinus tracts or sites of drainage.

Dr. Miller: That would be bad.

Dr. Gililland: Yeah, that's obviously, obvious signs of infection. Patients can have fevers or systemic symptoms where they start to feel sick, nauseated, lightheaded, those kinds of things. That could be a sign that they are becoming septic from this. Those are the things that are . . .

Dr. Miller: What is septic?

Dr. Gililland: Sepsis is when the body system actually becomes infected, it gets into the bloodstream and you start to have multi-organ involvement from the infection.

Dr. Miller: Fever, chills, sweats, dizziness . . .

Dr. Gililland: Blood pressure issues . . .

Dr. Miller: . . . nausea. That's actually a very severe infection and of course should be treated quickly.

Dr. Gililland: Absolutely.

Dr. Miller: So what do you do if antibiotics alone are not going to fix this problem? You as an orthopedic surgeon intervene and what are the things that you do to cure that infection?

Dr. Gililland: Generally, this chronic situation where the patient has been well functioning but now has an infection, the likelihood is it's usually an infection that's probably been there for longer than we think. We treat those infections, it's a rather invasive process. Meaning, we need to go in, we need to take out all the metal because again the metal has the slime layer that's created by the bacteria that we can't just get rid of. We think we can scrub it, but reality is our data which show that we're not very good at that. So we go in, we take all the parts out.

Dr. Miller: So this is a real big deal and somebody who has had a hip replacement, now their prosthetic is removed and they're going to need a new one at some point.

Dr. Gililland: Absolutely. In our minds most of the time it involves the two-stage process. Meaning, we take out all the parts, we put in a temporary joint replacement usually made out of cement with antibiotics impregnated in that cement that gives antibiotics to the bone, to the tissue. And after a period of IV antibiotics and a period of time off the antibiotics, if everything looks like it's been eradicated successfully, then we go back and try to rebuild the joint.

Dr. Miller: You talk about a period of time, how long is that actually?

Dr. Gililland: Usually three months minimum.

Dr. Miller: The other thing that comes to mind is now that the prosthetic joint is out, how does the patient get around? What do they do?

Dr. Gililland: That all depends on what we put back in. Usually we can put back in something that functions. Meaning, they have structured limb and they can still use the limb, but most of the time we don't let them put much weight on the limb, so they're using a walker or crutches to get around and trying to keep the weight off of it because again we are putting in a temporary part that's really not designed to be structurally sound for a long period of time.

Dr. Miller: So they're also on long-term antibiotics during this time, is that correct? Once you take the hardware out.

Dr. Gililland: Absolutely. They're usually on a period of six weeks of antibiotics IV and then after that if everything looks like it's getting better and their labs are normalizing, then we'll stop that, we'll give them what we call an antibiotic holiday to see if their labs remain low and make sure the infection does not recur once they're off of their antibiotics.

Dr. Miller: Once you complete this treatment and get to the point where you're going to put a new joint in, how successful are you in terms of really knocking out that infection, making sure it doesn't come back?

Dr. Gililland: That's a tough question to answer. I think everybody thinks we're better at than we really are. If you look at the literature, it's probably somewhere in the realm of about 75% success with that type of a two-stage process. But I think it really has to do with the patient and the patient's medical comorbidities and it has to do with the bug and how receptive that bug is to the antibiotics, what kind of bug it is, how virulent it is and then how many times they have attempts at prior surgeries.

We sometimes have patients that come in that have had four or five other attempts at surgery and at that period of time, he got an infection that's been really dwelling in there for many upwards of several years and it's very, very difficult for us in those cases to get rid of it. And I would say sometimes during the realm of about 50-50.

Dr. Miller: Obviously, this is a very big deal for somebody who has had a prosthetic joint put in. What tips would you give to patients or what advice would you give patients to prevent infection if that's possible?

Dr. Gililland: Absolutely. I think that's the ultimate crux to this is how do we prevent the problem from happening in the beginning. There are several things that we know put patients at risk for infection. Uncontrolled diabetes is a big risk. Being a smoker is a big risk. Morbid obesity with body mass index is probably somewhere above 40 puts you at risk. Other risk factors for infection such as rheumatoid arthritis or being on immunosuppressive drugs can put you at risk.

All these things need to be evaluated by your surgeon preoperatively before you have the initial joint replacement and that's something that we do very vigilantly here at the university. We make sure that we try to mitigate any risk factors that we can preoperatively to avoid infection in the beginning.

Dr. Miller: What about little cuts and nicks on the skin? Does that bother you?

Dr. Gililland: No, I don't think. I mean, if you have a little cut and nick on the skin, as long as it's healing well and it doesn't show any evidence of infection, I don't think you have to be extra vigilant about everything in life. I mean, I think most people have a well-functioning joint and get along very, very well and we're talking about a small percentage of people here. But I think it just takes a reasonable approach.

Dr. Miller: So bottom line is if you have a hip or a knee that's been replaced, and you have pain, you should have that checked out by your orthopedic surgeon or another competent provider that can actually look to make sure that you don't have an infection as a cause of that pain. And if you have infection, that needs to be treated aggressively.

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