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Patients with artificial joints can be at risk…
Date Recorded
February 28, 2017 Health Topics (The Scope Radio)
Bone Health Transcription
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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When it comes to your health, you should always…
Date Recorded
September 27, 2016 Health Topics (The Scope Radio)
Family Health and Wellness Transcription
Dr. Miller: Two approaches to have your hip replaced, which one's best for you? 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's a professor of orthopedics here at the University of Utah in the department of orthopedics. What's the best way to have your hip replaced, from the back or from the front?
Dr. Gililand: The honest to goodness truth is you should have your hip replaced by a surgeon who knows what they're doing from what approach they're using.
Dr. Miller: That's pretty good basic advice. Know your approach and know it well.
Dr. Gililand: Exactly.
Dr. Miller: So talk to me about the differences because patients do assume that maybe one approach is better for them, maybe it's less invasive, requires less time in the O.R. I just don't know.
Dr. Gililand: Sure. So I think there are two major approaches in hip replacement today and that is either the direct anterior approach or the posterior approach. Both have been around for a long time. The anterior approach is not a new approach. It's been around since the 1950s, It's just taken a hold, I would say, in the last decade as a . . .
Dr. Miller: Mainstream procedure.
Dr. Gililand: Mainstream procedure. Exactly.
Dr. Miller: Why would one do an anterior approach or why did the posterior approach become ascendant?
Dr. Gililand: So the posterior approach has always been a very nice approach with very good visualization, good access to the pelvis and to the femur and it's quite extensile. Meaning if there's any troubles during surgery, you can get access to everything you need and fix any troubles there. However, with the posterior approach, we've had issues with dislocation and dislocation is a big problem for patients if you have a dislocation.
Dr. Miller: So once the hip's replaced then the patient post-operatively has a higher risk of dislocation than in a patient who's had an anterior approach.
Dr. Gililand: Well, we like to think that. We like to think that the anterior approach has mitigated some of the dislocation risks. So that's really where the surge and popularity of the anterior approach came in as well as it being a little bit less invasive, smaller incisions and patients like to think that's it's muscle sparing as compared to the posterior approach. So that's really what's driven a lot of the popularity of this approach.
Dr. Miller: Now, you do the anterior approach in your practice?
Dr. Gililand: Correct, I do.
Dr. Miller: Do you do primarily an anterior approach?
Dr. Gililand: I would say it's about 90 to 95% of my patients that I do hip replacement on get anterior approach and a small percentage will get posterior approach based on certain factors.
Dr. Miller: But other surgeons in your practice will utilize primarily the posterior approach.
Dr. Gililand: Absolutely.
Dr. Miller: So how does a patient choose?
Dr. Gililand: There's a lot of stuff on hype on the Internet, a lot of information that I would be careful of reading. I think that patients need to talk with their surgeon. They need to feel comfortable with their surgeon and they need to really listen to what their surgeon has to say in terms of their expertise and their feelings of the surgery.
I think for approach one versus the other, there are benefits potentially the anterior approach. Patients sometimes feel like in the first six weeks they're up on it quicker. It's a little easier and less painful for recovery. There's definitely less concerns for positions of the hip in terms of dislocation.
With the posterior approach we give you certain precautions or positions to avoid for dislocation. With the anterior approach there's less of those precautions. However nowadays with a well done posterior approach or a well done anterior approach, dislocation risk is very, very low and patients can do well with both.
Dr. Miller: So it comes back to what you were saying earlier which revolves around the surgeon's expertise in that particular approach, their ability to perform that particular procedure over and over again and do it really well. So I think for the patient who's looking to have a particular approach, they should listen to what the surgeon does mostly or what the surgeon recommends and not try to push him in a direction that the surgeon is not comfortable with or less comfortable with.
Dr. Gililand: Absolutely. One of the problems we've see with the anterior approach is that it has become a marketing tool for surgeons. So surgeons will use that to bring patients into their practice and start saying, "I do the anterior approach, please come and get your hip done with me."
The problem being is they may have a very low number of hips in their experience there. It's got a significant learning curve, probably around 100 hip replacements before you really are competent with the approach, and so patients may not know that their surgeon has had very little experience on the approach yet says that they do the approach and the surgeon may say that they prefer that. So I think it's wise for patients to always ask their surgeon what's your experience with this approach, why are you saying that I need this approach and be educated on that.
Dr. Miller: What's nice in your practice or your group practice is that you have surgeons doing both. Have you had a patient request a posterior approach that you've then referred to your colleague or vice versa?
Dr. Gililand: Absolutely. I think that . . . and I'll have patients come to me that request an anterior approach and I'll tell them I don't think they're a good candidate for it for x, y or z reasons. If they are not comfortable with it, they can find somebody else who may be comfortable to do that approach but we offer all approaches here at our practice. I think we all have very very good success with our hip patients regardless of approach. Again I think it boils down to surgeon's comfort and patient's comfort with their surgeon.
Dr. Miller: On the redo prosthetics of patients will come back and they'll need a new hip after a number of years. Either approach or one in particular?
Dr. Gililand: I think the posterior approach is generally the workhorse for us when it comes to going for revision surgery. They are certain cases when I will do revision surgery through an anterior approach but that really is somewhat select. Most of the time we're using the posterior approach, again, because of the nature of it being a more extensile approach that gives us better visualization of both the pelvis and the femur.
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