In orthopedics, surgical site infection (SSI) after implant surgery is a disaster both for the surgeon as well as the patient. This results in increased antibiotic use, repeated debridement, prolonged hospital stays, prolonged rehabilitation, and morbidity as well as mortality. SSIs are important complications of orthopedic procedures that include prosthetic implants.
The number of aged and trauma patients needing joint replacement or internal fixation devices is progressively increasing. Open reduction and internal fixation (ORIF) of fractures with orthopaedic implants and prosthesis became the predominant modality of fracture treatment in most trauma centers. This is not only due to the better understanding of the biomechanics of implantable materials but also more importantly due to the better functional consequence in these patients.
Incidentally, this is related to post-operative wound infection (POWI) reported being in the series of 0.8–13% for both superficial and deep infections with increasing cost and morbidity. This category of patients is mainly vulnerable because ORIF interferes with the supply of blood to the bones and implants are foreign bodies, which offer surfaces for bacterial adherence. Despite significant progress in the prevention and treatment of implant-related infection, the absolute number of patients with such infections is rising because of the lifelong risk for bacterial seeding on the implant. The SSI prolongs hospital stay on average for two weeks, doubles re-hospitalization rates, and costs may increase by over 300%. Moreover, patients can have physical limitations and noteworthy reduction in the quality of life. The pathogenesis of infection in fracture fixation devices is associated with microorganisms, which grow in biofilm, and thus its eradication is hard.
In prosthetic joint infections, early infection is well-defined as a manifestation of infection at the ortho implant site during the first three months after surgery. Delayed infection is well-defined as the manifestation of infection 3 to 24 months after surgery. Late infection is well-defined as the manifestation of infection more than two years after surgery.
Implant removal belongs to the foremost common elective orthopedic procedures in industrial countries. In an often-cited Finnish study, implant removal contributed to almost 30 percent of all planned orthopedic operations, and 15 percent of all operations of the department.
Controversy exists as to the necessity for routine orthopedic implant removal. In children, it can be essential to remove implants early to avoid disturbances to the growing skeleton, to avoid their bony confinement making later removal technically hard or impossible, and to enable for planned reconstructive surgery after skeletal maturation (for example, in case of hip dysplasia).
In adults, pain, the resumption of strenuous activities or contact sports after fracture healing, soft tissue irritation, as well as the demand of patient are typical indications for removal of the implant in clinical practice. Numerous surgeons will remember patients whose intractable, barely explainable local symptoms and complaints resolved rapidly after the procedure. Though, ortho implant removal needs a second surgical procedure in scarred tissue and poses a risk for re-fractures and nerve damage.
Pain can even get worse after implant removal. In a series of 109 femoral nail removals, a rise in pain and discomfort was noted in 4/58 (7 percent) of all patients with, and 10/51 (20 percent) of all patients without pre-operative signs. Similar observations were made in subjects who had experienced open reduction and internal fixation of ankle fractures.
Corrosion, systemic release of nickel, cobalt, and chromium, and it’s presumed allergic, toxic, and even carcinogenic potential have been related to stainless steel implants. Yet, none of these adverse effects had influentially been confirmed in the clinical setting. Orthopedic fixation devices made from titanium alloy are considered less vulnerable to degradation and safe to be retained in situ, but aluminum and titanium had been traced in serum and hair of 16 out of 46 patients after spinal instrumentation as well.
It is best to surmise that decision to remove an Orthopedic implant should be taken in consultation with the Surgeon who can help evaluate the need, effectiveness, and risks of this common procedure in different clinical settings.
- You’ll feel a little off for 1 day or 2 after the anesthetic. During that time, you shouldn’t drink alcoholic beverages, make any significant decisions or engage in any potentially hazardous activities. It’s very common to be slightly nauseated and you should initiate with a light, low-fat diet until your appetite comes back. Do not drink cold water, as it may upset your stomach.
BATHING AND WOUND CARE:
- It’s not rare for some blood to show through on the dressing. If bleeding seems to be ongoing after the first twelve hours and the part is larger than 2 inches or so, please contact the doctor. You can cover your dressing with a plastic bag to take a shower but don’t get the dressing wet.
- The dressing should cover the wounds and support the leg but shouldn’t feel overly tight or uncomfortable. If it seems too tight you should go to the medical attendant.
- Don’t Remove the dressing till you have been examined by the treating doctor and advised to do so.
- A long-lasting local anesthetic is injected into the ankle after surgery and often wears off 6 to 12 hours later. As it wears off your ankle will start to hurt more.
- The interval for having pain medication, as noted on the bottle, is the least interval. You shouldn’t take the medication more often than that. You may take the medication less frequently than on the prescription if you aren’t in pain.
- You have been prescribed narcotic pain medication. This medicine should be taken to relieve pain, not to avoid it. You shouldn’t set your alarm clock to remind you to have your pain medicine, nor should you take it on a set schedule even if you aren’t hurting, as this may lead to overdosing of the medication.
- If you don’t have trouble with ulcers or stomach pain, and if you don’t have kidney problems, you can also take an anti-inflammatory medicine in addition to or instead of the narcotic medicine. These work well and don’t cause bleeding. After the first or second day, you can start an over the counter anti-inflammatory.
ELEVATION and ICE:
- The elevation is the best method to reduce your pain and swelling. It only means as elevation if your ankle is above your heart. Sitting in a chair together with your foot on the coffee table isn’t enough. Please ice and elevate your leg for at least the first 3 days after surgery. On the fourth or fifth day after surgery please start to gently move your big toe. Do this without removing the dressing. Gently hold your toe with 1 hand and stabilize your foot with the other. Then move the big toe up and down for five minutes every 2 hours.
- You can bear weight on your heel on the advice of the treating doctor, once you feel comfortable to do this. Crutches will be offered to help you during the first 2 weeks out from surgery. Surgeons use orthopedic instruments in the surgical procedure.
- Take up driving of a vehicle strictly as per the advice of your surgeon.
- You can’t drive if you are having narcotic pain medicine.
- You need to be examined by the surgeon in two weeks. Physical therapy should start shortly thereafter.
SOME REASONS TO CALL:
- Fever more than 101.5 (it’s very common to have a low-grade fever the first night or 2 after surgery)
- Redness or swelling that’s spreading from the boundaries of the incisions
- Pain that is out of control or worsening and not relieved by elevation, rest, ice as well as pain medication.
- Shortness of breath, Chest pain
What to Expect:
The local anesthetic can make your hand areas feel numb for 8 to 12 hours.
You will have a moderate amount of pain for the first 3 to 4 days; this could be adequately addressed by the oral narcotic pain medicine as prescribed when you left the day surgery suite: like Oxycodone or Vicodin.
It is normal to experience swelling after the surgery, particularly in your fingers. The surgeons use orthopedic implants in surgery of wrist such as wrist fusion plate, 2.0 MM LCP adaptation plate, condylar plate, LCP Straight plate. Measures that are helpful to relieve in selling involve elevating the hand above your heart on some pillows and draping a plastic bag full of crushed ice over your fingers, splint, and dressing. Place a dish towel or small hand towel over your arm and hand first thus the dressing does not get wet.
You can loosen your outside ace wrap if the dressing feels extremely tight.
To keep your hand from throbbing it may be useful to elevate your hand above your heart. When lying on your back if you place your hand on a pillow you may place your hand inside the pillow case in order that your hand won’t fall off the pillow.
Keep a plastic bag over your hand and forearm when showering (keep the dressing dry).
If you experience any worrisome symptoms like a fever higher than 101.5 degrees or markedly augmented pain, contact the doctor.
Leave the post-operative dressing on till you come back to the clinic for dressing removal and placing of a brace or cast, which will be around 9-14 days after your surgery. You can start a gentle range of motion exercises with your fingers only. This should consist of lightly flexing and extending your fingers. You can use your hand for light activities like eating, dressing, typing, etc.
Schedule a post-operative appointment for 9 to14 days after the surgery. At this visit, your post-operative dressing are removed. Your sutures also will be removed at this time. A cast can be applied at this visit, or if the internal fixation enables for early motion, a removable splint can be applied.
Orthopaedic implants provide orthopedic surgeons with a way of precise bone fixation. They also play a usually supportive part in treatment, fracture healing, and reconstructive surgery (osteosynthesis and improvement in degenerative diseases). However, implants aren’t appropriate to replace normal body structures or bear the weight of the body (see product-specific instructions).
Choosing an Implant/Indications
While treating traumatic and/or degenerative skeletal changes, consider the following points:
Choosing the implant. It is of supreme importance to choose the appropriate implant. The possibility for success is improved by selecting the orthopedic implant of right size and shape. The features of human bone and soft tissue pose limits to the size and strength of ortho implants. No partial weight-bearing or non-weight-bearing product may be predictable to withstand the full and unsupported weight of the body. If a strong bone union is to be attained, the patient requires acceptable external assistance. Similarly, the patient must limit physical activities that would give stress upon the implant or allow movement at the site of fracture and therefore delay healing.
Factors related to a patient. A number of patient-related aspects have a strong effect on the success of surgery:
a) An obese or overweight patient may place a lot of stress on the product such that it may fail, even perhaps reversing the results of surgery.
b) Occupation or activity. Professional occupations cause a risk when external forces subject the body to considerable physical loads. This may cause the product failure and even undo the successes of surgery.
c) Mental illness, senility, or alcoholism. These situations can cause the patient to ignore certain essential limitations and precautions, resulting in product failure or other complications.
d) Certain degenerative diseases & smoking. In some instances, degenerative disease can be so advanced while implantation that it can considerably reduce the expected useful life of the ortho implant. In such cases, the products serve only to delay or momentarily relieve the disease.
e) Sensitivity to foreign bodies. When hypersensitivity to the material is assumed, suitable tests should be undertaken before choosing or implanting the material.
Accurate handling of the implant is extremely essential. If the implant shape must be altered, the device shouldn’t be bent sharply, bent backward, notched, or scratched. Such manipulations, in addition to all other inappropriate handling or misuse, may cause surface defects and/or concentrate stress within the core of the orthopedic implant. This, in turn, can ultimately cause the product to fail.
Post-operative care is necessary.
Physicians should update their patients about the load restrictions of implants and provide a plan for postoperative behavior as well as increasing physical loads. Failure to do this may generate malalignment, failure of the implant, delayed bone healing, thrombophlebitis, infections, and/or wound hematomas.
Removal of the osteosynthetic product.
While the physician makes the concluding decision on when to remove the implant, it’s wise – if possible and suitable for the individual patient – to remove fixation products after the process of healing is complete. This holds true mainly for young and active patients.
The product-specific instructions for usage must be followed. It’s not advisable to mix products of one manufacturer with those of different manufacturers since designs, mechanics, materials, and construction are not harmonized. Manufacturers assume no liability for any complications arising from mixing components or from utilizing foreign instruments. If not otherwise mentioned, it’s not recommended to mix different orthopedic implant metals. Mixing of metals can lead to galvanic corrosion and a release of ions. This can cause an inflammatory response, metal sensitivity reactions, and/or detrimental systemic effects for the long term. Moreover, the corrosion process may reduce the implant’s mechanical strength.
Information & qualification. Surgeons should be completely aware of the intended usage of the products and the applicable surgical techniques, and they should be qualified by suitable training (for instance, by the Association for the Study of Internal Fixation, AO).
Potential Risks: –Failure of the implant from choosing the wrong implant and/or overloading the osteosynthesis – Allergic reactions from the incompatibility of material– Delayed healing from vascular disturbances – Pain triggered by the orthopedic implant.
MRI – Magnetic Resonance Imaging When a device has been evaluated for usage in the MR environment, MRI information are found in the instructions for use.