Complication Prevention

All surgeries come with a risk of complications; they are not common, but they can happen. The complication rate following joint replacement surgery is low. Different people react to complications differently both physically and emotionally. Being aware of your tendencies for reaction will help understand and deal with complications should they occur. Chronic illnesses (diabetes, heart or lung disease) may increase the risk so a complete evaluation of your health is required before your joint replacement to determine your fitness for surgery. By following your doctor’s orders and knowing the possible complications you can do a great deal to prevent or lessen complications.

Low Blood (Anemia)

Depending on the type of surgery you have, you may lose a significant amount of blood. Blood loss can result in a drop in your haemoglobin; this is called anemia. Haemoglobin carries oxygen throughout your body and can be measured with a blood test. If your haemoglobin level is too low, you may feel dizzy and weak, short of breath, nauseous and very tired and you may have a headache. You may require a blood transfusion.

You may prevent low blood and a blood transfusion by:
• Following Canada’s Food Guide for healthy eating.
• Having a complete blood count (CBC) at least 3 months before you come to the hospital and follow-up with the results of your test. Ideally your haemoglobin level should be in the high end of the normal range.
• Consulting with your family doctor about the need for iron, or vitamin supplement.

Blood Clots

Blood clots can develop in the deep veins during the first several weeks after surgery. These blood clots could dislodge and travel to the lungs causing serious health risks. If you already have problems with your heart or circulation, are inactive, overweight or have other health problems such as diabetes or cancer you have a greater risk of developing blood clots. Let your surgeon know before surgery if you have had a clot in the past.

You can prevent blood clots after surgery by:
• Getting up and moving frequently. Every hour, pump your feet and ankles; and tighten and release the muscles in your legs and buttocks.
• Wearing leg support stockings while you are in bed in the hospital if your doctor feels you need them.
• Taking blood thinners (anticoagulants) as prescribed by your surgeon. Blood thinners are used to prevent clots after a major operation on your legs, such as a hip or knee replacement. The number of days you require this medication depends on your risk and is decided by your surgeon. Blood thinners vary in preparation and may be in pills or by injection. Your surgeon will determine with you the best option for your particular circumstances. Oral medicines are taken as a pill or capsule. Some oral medicines require blood monitoring to ensure they are not interacting with foods and other drugs, and to ensure the correct dose; others do not. Injectable medicines are given as a small injection under the skin of the abdomen. They are administered once or twice daily, and the hospital nurses will teach you or your support person how to use these medications so you can manage at home.

Infection

Less than one percent of patients develop a wound infection after surgery. However, when infection occurs, it is a very serious complication – so prevention is key. Infections can start in your joint during surgery, in the hospital or when bacteria travel there from elsewhere in your body. You are more likely to get an infection if you are not well nourished or if your immune system is not strong (such as with diabetes or rheumatoid arthritis).

You can prevent infection by:
• Getting your body in shape by eating healthy foods before and after your surgery
• Taking the antibiotics you will receive after surgery
• Washing your hands frequently
• Following carefully instructions for wound care
• Avoiding people who have colds or infections
• Stop smoking before your surgery
• Talking with your physician if you suspect or see signs of an infection

Signs of an infection:
• Fever
• Redness or swelling of a wound
• Drainage from a wound
• Increased pain in the surgical area during activity and rest

The symptoms of an infection may also be signs of a hematoma (bleeding into the tissues around the surgery). Alert your health care provider if you experience these signs; it is very important to talk to your health care provider as it is important to differentiate between the two conditions. Be sure to notify your dentist and other doctors if you’ve had a joint replacement. Even during a routine dental examination, you might run the risk of an infection. A small infection can be a major problem, and your health care professionals know what precautions to take. It’s up to you to keep them informed.

Dislocation

Dislocation occurs when the ‘ball comes out of the socket’. This occurs in 1-2 % of cases although the risk can be dramatically higher in cases of revision. The risk of dislocation is greatest just after surgery as the tissues (muscles, ligaments) around the new joint are not fully healed. However a small risk is always present after this type of operation. The signs of dislocation are sudden, sharp, severe pain and a shortened leg. If dislocation occurs, a hospital visit is required to relocate it. This can usually be done without opening the joint surgically. After this you may require a brace for a few months.

You can help to prevent dislocation by:
• Consistently and carefully follow the activity guidelines and precautions provided to you by your health care team. (avoid, twisting the hip, crossing the legs and bending the hip past 90 degrees towards your chest)
• Obtain and use the assistive equipment (long-handled reachers, shoe horns, raised toilet seats) prescribed for you by the physiotherapist and occupational therapists.

Leg Length Difference

It is common to have up to a 1cm leg length difference after hip replacement. This difference is to ensure there is enough tension in the muscles around the hip to prevent the hip from dislocating. At first you may feel you have a longer leg and find yourself limping, but with walking and exercise, the sense of imbalance will often pass. A small number of patients may require a shoe lift placed either within or to the sole of their shoe, depending on the size of the lift required.

Persistent Limp

A small number of patients can have a persistent and sometimes permanent limp after joint replacement surgery. There are many causes of ongoing limp including pain, arthritis elsewhere in the body, persistent muscle weakness around the hip, leg length discrepancy, and nerve injury. If the leg length difference or limp is bothersome to your recovery, speak to your therapist or doctor about it. In some cases, additional therapy or surgery could be required to address the underlying cause of the limp.

Swelling

You may experience significant swelling in the affected limb for the first few weeks after surgery. To help reduce the swelling, elevate the affected limb, ideally 8 to 12 inches above the level of the heart, whenever possible. If the affected limb is your leg or foot, avoid sitting for long periods and pump your feet and ankles to keep your circulation going. Swelling is often on of the last symptoms to resolve after surgery and may be present for up to 12-18 months following surgery.

Respiratory or Lung Complications

Lung complications such as fluid in the lungs or pneumonia may occur due to the anaesthetic and prolonged bed rest.

To prevent them:
• Do not eat or drink after midnight on the night before your surgery.
• Get up and move, change your position in bed frequently.
• Take 10 big deep breaths and cough every hour on the days after your surgery.
• Quit smoking at least two weeks prior to surgery.
• If there are any problems with breathing or shortness of breath, see your health professional as soon as possible.

Cardiovascular

The two most common postoperative heart complications are heart attack and heart failure. The stress of surgery can cause a heart attack in people with coronary artery disease, which may or may not have caused symptoms before the surgery. In and extremely small number of patients, this can result in death. Be sure to inform your surgeon and anaesthetist about your cardiovascular health and follow their instructions.

Delirium after surgery

Sometimes older people go through a period of confusion or delirium after surgery. They may act or talk in ways that are not normal for them. For example, they may become forgetful, mixed up, and or see, hear and believe things that do not make sense. Delirium usually goes away in a few days but sometimes lingers for a few weeks. Delirium is usually due to more than one cause. Some common causes of delirium are: side effects of anaesthetics and medications, lack of sleep, pain, infection, alcohol withdrawal, constipation and low oxygen levels. The health care team looks for and corrects the cause of the delirium whenever possible.

Urinary Retention

The inability to urinate (go to the bathroom) is a very common problem following any type of surgery. The problem is relieved by passing a catheter (tube) into the bladder and draining the urine. The catheter may be left in place for several days or removed immediately after the bladder has been emptied.

Nausea

The most common postoperative complication is nausea. Intravenous hydration (fluid through the IV tube) is often all that is required. If nausea and vomiting continue, medication may be given. You are given clear fluids after surgery to make sure you are not nauseated; once your stomach is working, you will be moved on to your normal diet.

Constipation

Lack of activity following surgery and the use of narcotics, which control pain but also reduce bowel function, is usually the cause of constipation. If needed, stool softeners and laxatives may be prescribed.

Antibiotic Diarrhea

Antibiotics given to the patient around the time of surgery for prevention of infection in the surgical wound, may result in diarrhea. This occurs when the natural bacteria in the bowel or intestine are killed off by the antibiotic and other bacteria become more plentiful. The patient may require replacement of fluids by intravenous for a few days if the patient becomes dehydrated.

Allergic Reactions

There may be allergic reactions as a result of the medications you have been prescribed. The most common is a reaction to penicillin or sulpha drugs. Reactions can vary from a mild rash to an intense life-threatening reaction. Be sure to tell your doctor about any previous allergic reactions. If you suspect you are having an allergic reaction, inform the nurse immediately.

Skin Complications

Bed sores may result from pressure on the skin over bony parts of the body in patients who are in bed for long periods or in a poor state of nutrition. This condition can be prevented using good skin care techniques, a sheepskin cover on the bed, or devices to raise the affected area off the bed.

Nerve Injury

Depending on the surgical area, nerve injury may result due to the proximity of the nerves and blood vessels. Usually the result is temporary especially if the nerves have been stretched by retractors holding them out of the way. Permanent injury is rare.

Vascular Injury

There is a small risk of injuring a major blood vessel to the leg. This can result in major blood loss and well as loss of blood flow to the portion of the leg below the injury. This could require additional surgery to be performed by a vascular surgeon and, in vary rare circumstances, can result in the loss of the leg.

Fractures

Sometimes when inserting the prosthesis into the bone, the bone may break. This is a more common complication of revision joint replacement or in those with thinning of the bones (osteoporosis). If this does occur it is often recognized during the surgery and is treated immediately. If you have a fracture there may be a period of time when you will not be allowed to put all your weight on your operated leg.

Hematoma

Bleeding (hematoma) may occur in the muscles around the hip joint following the operation. If a hematoma occurs, a bruise may be visible or the area may be red, hot and swollen. In some cases, the hematoma may need to be drained, otherwise the body will absorb the blood naturally. Exercise and therapy usually help remove excess blood.

Misalignment or loosening of the prosthesis

One or both parts of your new joint may loosen with time or can sometimes fit imperfectly during surgery. It is important to follow the activity guidelines and attend all follow-up appointments with your surgeon so that the alignment and fit of the new parts can be monitored by the surgeon.

Stiffness

A knee joint may stiffen after surgery. Patients who have stiff knees before surgery are more likely to have this problem. It is important to maintain your flexibility while awaiting surgery to reduce the risk of stiffness following the operation. This can be done through exercises provided by a physiotherapist. Manipulation (stretching of the joint) may be required to correct stiffness after surgery.

Pain, Swelling and Fluid in the Knee

It is common for knees to have some swelling, be red and warm after surgery. This may last several months. This is different from infection which causes a sudden increase in pain, swelling and stiffness as well as fever and chills.

There are a variety of non-surgical treatment options that should be considered before proceeding with a joint replacement.

Weight Loss

For both the hip and the knee, the forces acting across the joint are a combination of body weight pressing down on the joint and the muscles pulling up to stabilize the joint. As these values combine, the hip and knee experience 3-4 times the body weight in pressure with each step. Loosing excess weight reduces the pressure on damaged joints and can relieve pain.

Physical Therapy

By stretching, strengthening and re-balancing the muscle- forces across the joint, the movement and control of the joint can be improve. Pain can also be improved with therapy in addition to the mobility of the joint.

Acetaminophen

Acetaminophen (Tylenol) containing products can be very useful analgesics in arthritis. Given its low cost and good side effect profile, it is a good first-line drug for treating arthritis. It should be avoided in some patients with a history of liver disease and care should be taken not to exceed the total daily dose of 4gm per day. This is especially true when a patient takes multiple different medications that contain acetaminophen.

NSAIDs

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications that block the COX receptors on cells and reduce inflammation which can play a significant role in both osteoarthritis as well as other inflammatory arthridities such and rheumatoid arthritis and lupus. Different versions of this type of drug have different side-effect profiles, but, in general, NSAIDS, when taken for extended periods, can play a role in stomach irritation, ulcers, and bleeding and kidney problems with elevated blood pressure. While these can be very helpful medications, their prolonged use should be done under the guidance of a physician.

Steroid Injections

Steroid injection (often referred to as a “cortisone shot”) is generally performed with a depot version of a corticosteroid that remains within the joint. Once in the joint, the steroid blunts the inflammation within the joint and can reduce the pain of the arthritis. This effect can last from a few days to 6 months. There is a small risk of infection with an injection which can be very debilitating and destructive if it were to happen. The risk of infection is less than 1%. There is no agreed upon number as to how many times an injection can be repeated if the most recent injection had benefit for multiple months. Most agree that multiple injections can be offered, the whether a limit should exist or how high the limit may be is unknown.

Unloader Bracing

As arthritis progresses in the knee and joint space is lost, the leg becomes more bow-legged or knock-kneed. As this collapse occurs, increased load is applied to the already diseased and damaged section of the joint. By applying and unloader brace, the leg can be straightened and the load shifted back onto the more healthy area of cartilage remaining. This can reduce pain and suffering during activities such as walking, shopping and yard-work.

Viscosupplement Injection

Viscosupplement injections inject a purified, viscous fluid into the joint. The injection frequently includes components of normal healthy joint fluid known to be reduced in arthritis. While the exact mechanism of benefit is not known, many patients, especially with early arthritis, can benefit from these injections for a variable period of time.

Walking Aid

Many patients find the use of a cane, walking stick or walker to reduce their pain. By transferring weight to the walking aid, the effected joint can be off-loaded reducing the pain experienced and improving the distance that a patient can walk.