Contemporary Advances in Hip, Knee and Shoulder Arthroplasty April 11, 2015

Transcription

1 Complications in Total Hip and Knee Replacement Regina Barden, RN, BSN, ONC Department of Orthopedic Surgery Rush University Medical Center Chicago, IL Disclosures I receive no funding from any company Department of Orthopedic Surgery at Rush Total Joint Arthroplasty Miracle of modern surgery! No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 1

2 TJR Replacement Surgery Approx 1,000,000 performed per year in US (AAOS, 2011) Expanding use to younger, more active patients Long term outcomes not well established for new technologies Changing TJR Population No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 2

3 Changing Surgical Options Minimally invasive surgery Navigation Alternative bearing surfaces Surface arthroplasty Fast track recovery protocols Anterior approach No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 3

4 Complications are NOT eliminated based on new technologies, approaches or protocols! IN SOME CASES THEY MAY BE INCREASED Pre-op Planning Focus on optimizing pre-op health & recognizing increased risk Multi-disciplinary approach Multiple medical co-morbidities Chronic narcotic use Identify discharge/rehab plan early Early Complications Wound healing problems Infection DVT / PE Neurovascular injury Instability Leg length discrepancy Stiffness Pain No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 4

5 Late Complications Hematogenous Infection Component loosening Component failure / wear squeaking, late instability osteolysis, metallosis, corrosion, pseudotumor Focus on the Post-op Period Enhance therapist s skills Early diagnosis of problems Prompt intervention Optimizing patient outcome First Basic Question Is there anything in the clinical picture that arouses suspicion? Change in wound / limb circumference Decreased gait/muscle strength Progressive loss of function Altered tone of voice - nature of complaint No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 5

6 Second Basic Question Does change from normal warrant action? Increased observation Change in treatment plan Urgent evaluation by surgeon When Time Matters Early intervention more critical in some situations Infection Loss of blood supply Dislocation DVT Notify surgeon if anything is out of the ordinary Everybody is Different Range of acceptable varies with any given surgeon or any given patient Safest to err on the side of caution No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 6

7 Early Complications Wound Healing Problems Prolonged or increased drainage Erythema Scabbing Limited superficial dehiscence Tape blisters Wound Healing Interventions Elevate limb Hold ROM? Oral antibiotics I&D of wound Remember: NOT all problematic wounds are infected!! Failure to Face the Problem Consequences: Draining wound becomes infected TJR Acute infections become chronic Chronic infections not recognized No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 7

8 Deep Infection Incidence of Deep Infection <1% Prophylactic Antibiotics Laminar Flow Exhaust suits Private rooms Decreased hospital stays Pre op medical clearance Chlorhexidine Infection: Who Is At Risk? Joint history Prior surgery Osteomyelitis Septic arthritis Remote Sepsis Sinusitis UTI Severe psoriasis Cellulitis Venous stasis ulcers No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 8

9 Infection: Who Is At Risk? Chronic Immunosuppression Steroids Diabetes Transplants Renal Failure Chemotherapy ETOH, Poor Nutrition + HIV / AIDS Multiple incisions Biologics Prolonged Hospitalization What to Watch For? Systemic Symptoms Fever, Chills Local Signs Erythema Swelling Drainage Infection Classification 1) Acute Post-Operative Prolonged Drainage Fever, WBC, Pain 2) Delayed Deep Poor result Confused with mechanical Bone / Cement demarcation or loosening of cementless implant 3) Late Hematogenous Acute Pain, Sepsis, Pus No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 9

10 Clinical and Lab Findings Night, rest pain vs activity related Wound or sinus tract drainage WBC - only in fulminant sepsis ESR - Not helpful in isolation CRP with ESR greatly increases accuracy Clinical and Lab Findings Synovial Fluid Cell count: <3,000(No) >10,000 (Yes) segs Purulent aspirate doesn t mean pus Positive cultures Radiographic Changes Long Standing Infection No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 10

11 Nuclear Medicine Bone Scan Definitive Dx of Infection Bacteriologic supported by - Clinical Findings - Laboratory Studies - Imaging Studies Treatment Principles Debride and retain the well fixed acutely infected implant Remove the loose and or chronically infected implant No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 11

12 Prostalac or Articulating Spacer Antibiotic Spacer Technique Patellar Tendon Rupture Interdigitated Cement Do articulated spacers decrease the risk of recurrent infections? Most agree they make reimplantation easier. No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 12

13 Reconstruction Options Re-implantation Resection Arthroplasty Arthrodesis ( Fusion ) Amputation Re-implantation: Indications Host Factors - Immune status - Nutritional status - Mobility potential Local Factors - Sterile bed - Neurovascular intact - Adequate soft tissue envelope - Adequate bone to anchor prosthesis and/or graft Ideal Re-implantation Interval? No clear data comparing various time intervals in significant & meaningful way (usually 6wks IV antibiotics) Dependent on host health Wound healing Nutritional and immune status Organism susceptibility No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 13

14 Re-implantation Best choice for restoring of normal function May not be best for patient In order to choose you must know the alternatives arthrodesis, resection, amputation Resection Arthroplasty Eradicates infection Reserved for severely disabled or most difficult infections Poor functional outcome Resection Arthroplasty No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 14

15 Resection Arthroplasty Hip Arthrodesis ( Fusion ) Rarely done Technically difficult Secondary effects on back and knee Knee Arthrodesis More functionally limiting than hip fusion + stable limb short leg gait disturbance functional disability No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 15

16 Arthrodesis External Fixation Allows for skin care Acceptable union rate Potential pin site infection Arthrodesis Intramedullary Rods Highest union rates (90-100%) Requires open canals Requires clean bed Amputation? Life-threatening infection Unsalvageable limb Intractable pain To enhance patient mobility No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 16

17 Venous Thromboembolism VTE VTE Risk Factors Age (>40) Obesity Race Malignancy Chemo tx Hypercoag Hx of DVT (x8) Hx of stroke Smoking Lower ext. surgery Prolonged surgery Tourniquet Hormonal replace. Spine fx Major trauma Pelvis fx Immobility No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 17

18 Venous Thromboembolism (VTE) Frequent complication after major orthopedic operations WITHOUT prophylaxis Highest risk early post-op period (4 wks) Extended risk period in less mobile One of the leading causes of readmission after D/C Venous Thromboembolism Incidence WITHOUT Prophylaxis* Total Hip Arthroplasty 50% DVT 20% PE (2% fatal PE) Total Knee Arthroplasty 80% DVT 7 % PE * Research in early 1980 s Signs and Symptoms: DVT Calf discomfort Edema, erythema Homan s sign Fewer than 1/3 present with classic symptoms All are poorly correlated No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 18

19 Pulmonary Embolism (PE) Classic Signs and Symptoms Tachypnea (most common sign 85%) Tachycardia Fever Rales Decreased O2 sats Symptoms may be very vague Cough Diaphoresis Palpitations Altered mental status Apprehension Thromboembolism - Prophylaxis Modern prophylaxis lowers incidence to 2-12% for TJA Prophylaxis is the cornerstone for preventing morbidity and mortality Thromboembolism Prophylaxis Chemical inhibition of coagulation Warfarin Low Molecular Weight Heparin Xarelto, Arixtra Anti-platelet aggregation: Aspirin Nonpharmacologic methods Pumps SCD s Early ambulation No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 19

20 AAOS Guideline on Preventing Venous Thromboembolic Disease in Patient Undergoing Elective Hip and Knee Arthroplasty ( ) DVT / PE Given the limited accuracy of clinically diagnosing DVT / PE, even vague symptoms or signs should be investigated Ultrasound / CT scan Pulmonary Embolism Best prognosis with early detection and treatment Spiral CT Treat suspected PE as an emergency No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 20

21 DVT / PE Treatment Location of clot Heparin vs LMWH Coumadin Therapy (3-6mos) Further hematologic work up prior to future surgeries Nerve Injury Sciatic Peroneal Branch Femoral Lateral Femoral Cutaneous Nerve Injury Etiology usually unclear Leg lengthening ( stretch injury ) Direct injury Retractor Reamer Scapel Suture No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 21

22 Sciatic/Peroneal Nerve Palsy - THR Incidence 1% Primary 3% Revision Recovery Rate 50% complete Peroneal Nerve Palsy - TKR Incidence < 0.5 % Mechanism Direct compression Stretch Increased Pre Op Risk Flexion contracture Valgus deformity High recovery rate Nerve Palsy - Treatment Brace - AFO Physical therapy - ROM - E stim Pain Management No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 22

23 Nerve Injury - Good Prognosis Less severe initial injury Isolated sensory loss Early nerve recovery Femoral nerve Peroneal division vs. total sciatic Direct trauma vs. lengthening What is Instability? Sensation that the components of the joint are not moving synchronously Sensation that limb won t support patient Radiographic or visual demonstration of abnormal component position or motion Subluxation vs dislocation No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 23

24 Safe Range Of Motion Affected by Multiple Factors Instability -Local Factors Limb alignment Surgical approach Component selection Component alignment Muscular forces about the joint Bony impingement Neighboring joint pathology Incidence Primary % Dislocation: THR Multiple Revisions 8.2% - 27% No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 24

25 Hip Instability - Surgical Factors Surgical Approach - Posterior 5.8% - Anterior 2.3% - Lateral 3.1% Component Malpositioning % of cases with instability Sudden onset Pain Decreased ROM Shortened limb Rotated leg Can t bear weight The Classic Picture Hip Instability Patient Factors Cerebral or cognitive dysfunction 4.3 fold increase Woolson & Rahimtoola J. Arthroplasty 14:1999 Neurologic dysfunction Alcohol Intake Delirium Movement disorder Non-compliance Spasticity Charcot arthropathy No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 25

26 No Flexion greater than wks Hip Precautions No adduction past neutral Conservative Care Evaluation under anesthesia Closed Reduction Sedation/OR Abduction Brace Limit flexion Limit adduction Limit rotation 2/3 successful Total Knee Instability Not well understood or measured Usually more subtle than seen with THR May present as pain, fatigue or limitation in activity rather than instability Wider variety of presentation and severity Tibia on Femur vs Patellofemoral No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 26

27 Intra-articular impingement Synovium Retained meniscus Snapping tendon Popliteus IT Band Patellar clunk Recurrent synovitis Masquerading Knee Instability Risk Factors Inadequate Surgical Exposure difficulty of balancing / protecting ligaments Obesity Higher incidence of medial collateral rupture Alignment and balancing more difficult Ligament abnormalities Intrinsic laxity, prior damage or repair Brittle or calcified soft tissue structures Risk Factors Bone Loss Bone defect mimics instability findings despite actual ligament competence Stiffness from one extreme to the other Degree of release needed de-functions ligaments Intrinsic neurologic/muscular problems Recurvatum No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 27

28 Posterior Stabilized - Posterior Dislocation Actual dislocation may occur with post locking behind the cam Usually dramatic and painful with locking Emergency! Component Factors Patellofemoral Problems Crepitation to Clunk Subluxation to Dislocation Barely Noticeable to Disabling Treatment VMO strengthening Bracing or Taping Arthroscopic debridement Soft tissue release and reef Tuberosity transfer Patellar Tracking Problems Mechanical symptoms Retropatellar pain Clinical mal-tracking Stiffness Radiographic evidence of maltracking No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 28

29 Avoided By Attention to Component Position-Rotation & Alignment At The Time of Surgery Minimal resection Increases JRF Excessive resection Risk Fx Asymmetric resection Fx / Instability PF Resurfacing Errors Resection No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 29

30 Leg Length Discrepancy Restoration of hip biomechanics including leg lengths is a desired goal of THA Leg Length Discrepancy Williamson & Reckling (1978) Mean 1.6 cm LLD 27% required lift Love & Wright (1983) 18% LDD >1.5 cm Woolson, % <1cm (n=440) Preoperative planning Intra-operative assessment Leg Length Discrepancy Implications Patient dissatisfaction Low back pain Pelvic obliquity Shoe lift Nerve injury Litigation No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 30

31 The Effect of Pelvic Obliquity BE CAREFUL ABOUT DETERMINING LEG LENGTH LEVEL PELVIS FIXED CONTRACTURE Perceived LLD Leg Length: Clinical Variables Actual leg length Pelvic obliquity AB/ADductor contracture Contralateral hip pathology Increased Hip Offset - Stretches the abductors - Leg length feels off - Trochanteric symptoms - IT band syndrome No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 31

32 LLD Early Management Don t scare the patient Carefully assess Focus on soft tissue, pelvic obliquity, balance, and gait No automatic lift to shoe Confer with surgeon or staff Stiffness post TKR ThePatient at Risk Poor ROM pre-op Poor pain tolerance Low motivation History of CRPS Mechanical Factors Limiting ROM Lack of Flexion Tight PCL Lack of tibial posterior slope Patella too low or too thick Supra-patellar heterotopic ossification Quadriceps contracture Lack of Extension Posterior osteophytes Flexed femoral component Insufficient tibial cut No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 32

33 Lack Flexion + Lack Extension = ARTHROFIBROSIS Obtaining Good Motion Surgical technique is key Manipulation can be very helpful if done early The Stiff Total Knee: Prevention Good pre-op plan, including pre-op PT Aggressive post-op physical therapy Adequate pain management Proper positioning Communication with MD if lack of progress or decline No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 33

34 Stiff Total Knee: Treatment Aggressive physical therapy Pain management CPM, flexionator or extensionator splints Manipulation under anesthesia Arthroscopic fibrolysis -Tunneled epidural / pain management The Stiff Total Hip: Heterotopic Ossification Heterotopic Ossification (HO) More common in total hips High risk patients - hypertrophic arthritis - prior history of HO - multiple re-ops or trauma No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 34

35 Heterotopic Ossification (HO) Prophylaxis - Radiation therapy within 72 hr of surgery - NSAIDS Treatment - Surgical resection of HO - Aggressive ROM Chronic Pain surgical pain vs multiple variables Chronic Pain: Patient at Risk Chronic Regional Pain Syndrome Fibromyalgia, fibrositis Depression + sleep disorders Ankylosed joint Expectation / Result mismatch Compensationitis No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 35

36 Chronic pain: Peri-Articular sources Peripheral Neuroma IT Band Syndrome Bursitis / Tendonitis Stress fracture Neurovascular problems - radicular - vascular - claudication Chronic Pain: Multi-Modal Approach ROM and strengthening Modalities Adjuvant medications Pain clinic referral Chronic Pain - Assessment Careful, systematic assessment Don t get distracted by personality issues Consider other sources of pain (infection, instability, loosening, wear, metallosis, etc) No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 36

37 Possible Late Complications Hematogenous Infection Component loosening Periprosthetic fracture Component failure / wear Wear related concerns - osteolysis, late instability, metallosis, Adverse Local Tissue Reaction, corrosion, squeaking Loosening of Components Cement debonding Loss of fixation related to lysis May be associated with peri-prosthetic fracture, component fracture or infection Aseptic Loosening: Cemented THA 6 weeks 46 months No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 37

38 Aseptic Loosening: Cementless THA 6 weeks 16 years Aseptic Loosening: Diagnosis Patient history ESR/CRP to rule out infection Serial xrays Additional testing: Bone scan, CT, MRI Periprosthetic Fracture Fracture associated with joint replacement May be related to trauma May be associated with stress shielding of bone (local bone weakness due to stress transfers through prosthesis) No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 38

39 Periprosthetic Fracture Component Failure Metal component fracture Ceramic head/liner fracture Polyethylene wear through or cracking Fracture of Metallic Components Sudden pain Instability Inability to bear weight Mechanical crunch or grind Possibly minor symptoms No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 39

40 Ceramic Head or Liner Fracture Sudden pain Instability Inability to bear weight Mechanical crunch or grind Poly Wear-Through or Cracking Gradual change Increasing groin pain related to particulate synovitis Mechanical crunch or grind Instability of hip Osteolysis Consequence of particulate debris plastic, ceramic or metal Leads to local bone resorption May lead to late instability of joint May limit longevity of hip implants May lead to failure of component fixation / peri-prosthetic fracture No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 40

41 Poly Wear with Osteolysis 6 weeks 36 months 176 months Extensive Lysis 2 0 To Poly Wear Metallosis What is it? Metal debris in soft tissue related to an implant May be related to articular wear ( joint wear ) May be related to other reasons for metal on metal contact (fx of components, impingement, corrosion) No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 41

42 Metallosis Unwanted Metal Release Metallosis Now < 3% No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 42

43 Other metal issues No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 43

44 What is different about metal debris? Wear particles much smaller than that of polyethylene (nanometer size), but more abundant Metal ions levels 2-4x those with poly liner Delayed hypersensitivity to metal debris reaction possible Granulomatous masses reported ( psuedotumors ) Metal ions found in placental blood of mothers with MOM hips Fears of Systemic Toxicity Cobalt Carcinogenesis Polycythemia Hypothyroidism Cardiomyopathy Neurologic (HA, tinnitus,vertigo, deafness, blindness) Chromium Carcinogenesis Renal prox tubular necrosis Hepatocellular necrosis Hypersensitivity Ceramic Issues No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 44

45 The Squeaking Hip Results from a forced vibration Possible causes: malpositioning of cup, edge-loading, and/or mismatch between shell and liner (causing liner to tilt in the cup with hip motion) in younger, heavier, taller patients In Conclusion Complications Medical co-morbidities and surgical techniques impact risk Knowledge of post-op complications is critical Late complications exist No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 45

46 Conclusion Primary TJR 95% successful but numerous possible complications Listen carefully to patients complaints Look for changes that aren t normal Intervene appropriately and promptly Patient Expectation The quality of the end result is often a function of the patient s expectations Patient expectation is a function of the attitude of the health care professional Education is Key Be careful of what you say to the patient about clicks, leg lengths, etc. Communicate when you suspect a problem No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 46

47 Thank You!! No part of this document may be reproduced without the written permission of the author(s) or Rehab Connections 47