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- Dr. Bal in the News...
TestimonialsDr. Bal's Patients Tell Their Stories
"I am very satisfied with the outcome of my surgery and the improved quality of life I am now enjoying..."
Shamsy Kazemi-Bardool, Iran
"I am looking forward to being able to boat and golf this summer, without having to endure the pain and limitations of prior years..."
Greg Voreis, Mo.
"Just 9 ½ weeks following my surgery knee replacements, I traveled to Hawaii and went scuba diving..."
David Booker, Mo.
"Dr. Bal did great a job explaining the procedure through conversation and with his hip surgery book. He changed my life..."
Dennis Disselhoff, Mo.
"It is so important to have a physician who you trust, and who will listen to you. That's critical. I have never seen a doctor who cares so much for each and every patient..."
Faye Bleigh, Mo.
"I am glad to have come to Dr. Bal; his office staff was great to work with; the hospital experience was very good, and the outcome of surgery was all I had hoped for..."
Craig Jacobson, Ne.
"I feel so free now. Last weekend I rode my bike to Cooper's Landing and enjoyed a great meal as I watched the Missouri River roll by and listened to the bluegrass music..."
Marilyn McCreary, Mo.
"The staff at Capitol Region were very gracious, attentive and thorough. I would go back there anytime. They made sure I was comfortable..."
Bob Smith, Mo.
"It has been a real pleasure to meet and get to know Dr. Bal. He is caring, thorough in his explanations, and a great friend...."
Richard Wallace, Mo.
Review of possible complications
This discussion addresses a very complicated area of orthopaedic care. Much is not known about implant infections, and our knowledge continues to advance.
Infection is a risk after any surgery.You should learn and be aware of this risk. Two kinds of infection exist. One can occur early after surgery. The second kind can occur late after surgery, sometimes several years later. The good news is that the likelihood of either kind occurring after routine hip or knee replacement surgery is very rare. Both types of infections are discussed below.
The human body is home to many bacteria. Staphlycoccus and Streptococcus (abbreviated Staph and Strep, respectively) normally colonize everyone’s skin. There is no way to avoid these bacteria, since they are natural inhabitants on human skin. Different people can carry different bacteria on their skin, in varying numbers.
All orthopaedic surgeons have encountered an infection in their career, and you should never believe otherwise. If a surgeon claims to have never encountered an infection, then either the volume of surgery performed is too low, or the surgeon does not know how to diagnose a subtle infection in a prosthetic joint. Our experience with the infected total joints that are referred from other institutions shows that some surgeons are reluctant or unwilling to prepare their patients for the possibility of infection, and when faced with an infection, are unable to properly diagnose it.
Early InfectionsAn early infection occurs within the first three to four weeks after surgery. Usually, it is because of skin bacteria invading the surgical wound. These infections show up as redness or drainage from the surgical wound.
Modern surgery is almost free of the risk of early infection, but the risk is not zero. To minimize this risk, antibiotics are given before surgery, meticulous attention is paid to surgical technique, and surgery is done in modern operating rooms with advanced air filtration systems. The risk of infection is also lower at institutions that do a high number of these procedures, such as our Missouri Hip & Knee Center.
Late InfectionsLate infections can affect any prosthetic device in your body, such as an artificial heart valve, prosthetic knee or hip joint, etc. A person with an artificial hip or knee joint has a very small but definite risk of late infection. This risk arises from the fact that bacteria can enter the body, circulate in your blood, and in rare cases seed the artificial hip or knee. Late infections are therefore also called “blood-borne” infections.
The presentation of late infection is usually the sudden onset of pain in an artificial hip or knee joint that has been doing just fine. This can follow an infection elsewhere in the body, such as in the bladder, kidney, mouth, or colon. Immune suppression, such as that which can accompany cancer, can also result in a late infection in a well-functioning hip or knee prothesis.
PreventionA single dose of protective antibiotic given just before the surgery ensures that your tissues are saturated with this medication before the skin incision is made. If you start the antibiotic earlier, the risks are increased rather than lessened. We use an antibiotic called Ancef for this purpose, and other drugs are used if the patient is allergic to this one. Antibiotics are continued intravenously for only 24 hours after surgery. A longer course of antibiotics is not necessary, and can in fact be harmful. The single dose of antibiotic just before surgery is the best known protection against early infection after surgery.
Your role in minimizing the long-term risk of infection includes keeping proper personal hygiene, avoiding obesity, avoiding skin sores, and reasonable attention to skin care. Infected or decayed teeth, neglected skin lesions, infected toenails, uncontrolled diabetes, obesity, and smoking will all increase the risk of a late infection in a prosthetic joint.
Our surgical team is experienced at handling difficult hip and knee cases referred to us from outside hospitals, and our practice is devoted to hip and knee surgery only. Every professional in our team has had many years of experience with hip and knee replacement surgery. Your surgical procedure is performed efficiently and smoothly, thereby minimizing wasted effort, surgical time, blood loss, and trauma. These factors are beneficial in reducing the risk of infection.
DiagnosisAn early infection typically shows up as poor wound condition, with drainage, pain, and redness.
Late infections in total joints may not have many symptoms, except continued pain after surgery. A tell-tale sign of subtle, late deep infection in a hip or knee replacement is continued pain after surgery. Your surgeon may insist that all looks good on the x-rays. In such cases, it is wise to seek another opinion. If an artificial hip or knee joint has a low-grade pain that never seems to leave, it is necessary to aggressively pursue the possibility of infection.
Each laboratory test and x-ray study can give us false positive as well as false negative results. By combining several tests with a careful history obtained from the patient, by examining the patient, and by using clinical judgment and experience, we can design a treatment plan that is best for each individual. The diagnosis of infection can be very difficult since the findings may be inconsistent, and results of testing may be equivocal. Prompt diagnosis requires vigilance on part of the surgeon, and a desire to pursue the diagnosis aggressively. The diagnostic plan can vary from patient to another.
Risk Factors for InfectionSome patient factors will increase the risk of infection. Advanced age, inflammatory arthritis such as rheumatoid arthritis or psoriasis, steroid use, obesity, poor hygiene, skin sores, diabetes, fluid retention in the legs, cancers, and immune deficiencies are some conditions that will increase the risk of infection after joint replacement surgery. Even if none of these conditions apply, it is important to know that infections can occur in the hands of the world’s best surgeons, operating on the world’s most optimal patients, and at the world’s best hospitals. If an infection does occur, prompt recognition and early aggressive treatment can save the situation.
Treatment of InfectionsIf there is any drainage or redness in the surgical wound after the operation, antibiotics are started quickly. Most infections will disappear with this treatment. If redness and drainage persist, the joint may need to be re-opened and washed out with a medicated irrigation solution. In many cases, this will address the infection.
If the infection is serious, or occurs later than four to six weeks after surgery, the situation can be more serious. In such cases, the metal implant can become seeded with bacteria. Bacteria secrete a film-like substance that lets them stick to metal, and antibiotics cannot address implants contaminated in this manner. In these cases, the entire prosthesis must be removed surgically, and the joint cleaned thoroughly. The patient receives approximately six weeks of antibiotics intravenously. This can be done at home, with a visiting home health nurse. The patient is able to walk because a temporary prosthesis is placed in the joint. This prosthesis is loaded with a large dose of antibiotics that release slowly into the bone, thereby treating the infection.
At a minimum of three months (sometimes longer) after removal of the infected implant, the permanent implant is replaced in the knee, using a fresh prosthesis. This entire operation consisting of two procedures is called a two-stage reimplantation, and it is considered the standard method of dealing with late infections in total hip and knee joints in the United States. The exact duration of antibiotic treatment may vary, depending on your medical condition and the nature of the bacteria causing the infection.
We can monitor the successful treatment of infections by laboratory data, and by special x-ray scans. Sometimes, it is necessary to place a needle in the suspicious joint and draw fluid from it to check for infection. Infections in prosthetic hip and knee joints are very hard to diagnose, and often the surgeon must rely on multiple tests and clinical judgment. During surgery itself, tissue biopsies can also help make the diagnosis of infection.
Our infection ratesOur own infection rates are well within nationally published rates of less than 1 percent for first-time hip or knee replacements. Many of these infections, if they ever occur, are minor and require a short course of oral antibiotics to resolve completely.
We also deal with some very complex revision surgery on previously performed hip and knee replacements that have gone bad. These are referred to us from all across Missouri. Some patients have had multiple operations done by other surgeons. In these selected and difficult cases, the risk of infection is higher than first-time surgery. National data show infection rates of 2 percent to 3 percent in such complex cases, and an overall complication rates that can be much higher than simple, first-time hip or knee replacement surgery.
The most difficult hip or knee reconstructive surgery can require bone grafting from deceased human donors. Massive bone transplants can require many hours of difficult surgery, and no two cases are alike. Each such patient can present unique challenges, and the complication and infection rates go up with the increasing complexity of the surgery. If you are a patient in this category, we will advise you of the special considerations that apply to your situation, and you must understand how they affect you before you deciding to have surgery. We perform a very high volume of complicated and difficult reconstructions involving implants in the hip or knee joint, since such patients come to us regularly from outside hospitals.
SummaryInfections, whether early or late, can occur following a hip or knee replacement, but the incidence is very rare. Some patient factors can predispose to infection. First-time hip or knee replacements have a less than 1 percent chance of infection. Avoid any surgeon who claims otherwise, since even the top institutions encounter a small incidence of infections. More complicated surgery increases the risk of complications and infections accordingly, although modern surgery and antibiotics still make this risk very small. Finally, maintaining good body weight, hygiene, and overall good health is how you can minimize your lifetime risk of an infection developing in an artificial hip or knee joint.
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