Patient Outcome Optimization: How to Best Manage Joint Replacement Risks and Get Back on Your Feet
One of the most common questions I get asked in the outpatient clinic is "How old is too old for joint replacement?" Patients are often surprised by the answer. In truth, there is no absolute age limit on who can safely undergo joint replacement. When it comes to making that decision, it's a matter of balancing the benefits of surgery vs. the risks. In some patients, even into their 90s, the benefits may outweigh the risks. What surprises most patients is that, several times per visit, I tell young patients they aren't appropriate candidates for surgery -- often due to factors that are mostly under the patient's control. Many of these factors predispose the patient to prosthetic joint infection, or PJI, a devastating complication of total joint arthroplasty.
Prosthetic joint infection occurs in 0.5 to 2.5 percent of joint replacements in the United States, depending on the hospital system. The cost to treat PJI in the U.S. is approximately $600 million annually, with costs expected to reach $1.6 billion by 2020. Not only is it a tremendous economic burden to the US hospital system, but PJI often represents a long, painful journey for the patient that compromises overall function and pain relief that a patient may otherwise have realized.
The cheapest way to cure PJI is to prevent these infections in the first place. Prevention is controlled both by surgeon and patient factors. If you're considering joint replacement, ask your surgeon if they screen patients to determine if they are carriers of staphylococcus (a bacteria that commonly causes joint infections). Not all hospital systems perform this simple test. Those patients who are carriers are given an antibiotic ointment to apply to their nose and special medicated wipes to use before surgery. This can decolonize the patient and lessen their risk of infection. At the Cleveland Clinic, all patients are given the wipes to use, and those who are carriers are given the antibiotic nasal ointment.
Factors that the patient can control to minimize their risk of PJI include smoking, diabetes and obesity. Patients who use nicotine in any form are at a greater risk of having wound healing problems. Wound healing issues can lead to PJI, and those patients who quit using nicotine prior to surgery can decrease their infection risk. Another important factor in minimizing infection risk is adequate control of blood sugar for those patients who are diabetic. Diabetic control is often checked with a blood test called Hemoglobin A1c, or HbA1c. Those patients whose HbA1c is above 7 are at greater risk of PJI, and surgery should be delayed until better diabetes control can be obtained. Finally, and probably most importantly, maintaining a healthy weight can dramatically reduce the risk of PJI. Ideally, a body mass index less than 35 to 40 kg/m2 can be achieved prior to surgery. If a patient's BMI is over 40, their risk of complications may be up to seven times higher.
Over the past two years, Cleveland Clinic's Department of Orthopaedic Surgery has developed Care Paths -- process-based tools designed for the electronic medical record to guide clinical work flow and assist physicians and caregivers in making specific guidelines operational. The aim is to standardize care around best practices during all stages of patient care, especially for total hip and total knee arthroplasty, where all of the phases of care (pre-, peri- and postoperative ) are all highly critical to patient outcome.
In today's health care environment, patients need to take ownership of their health. In order to prepare yourself for surgery and minimize your risks, consider losing weight, aggressively managing any medical issues -- especially diabetes, stop smoking and ask your surgeon what steps the hospital takes to manage infection risk.
Dr. Robert Molloy is the Director of the Center for Adult Reconstruction at Cleveland Clinic Orthopaedics in Cleveland, Ohio. An orthopedic surgeon, he received his medical degree from Wayne State University School of Medicine and has been in practice for 15 years.
