| Pulmonary embolism |
| Pulmonary embolism or (PE) is a very serious condition. In brief, it is a clot of blood (thrombis) that breaks loose for where it began, migrates through the venous system to the heart, and is pumped out of the heart along with the blood to the lung. In the lung the blood is replenished with oxygen. The clot or embolism obstructs the vessels in the lung and stops the lung from doing its job. If the embolism is small, its impact may be unnoticed. If it is large, it may result in sudden death. Most pulmonary emboli cause significant symptoms. |
| Symptoms of a PE include chest pain, difficulty breathing or a feeling of shortness of breath. You may feel as if you are having a heart attack although there may be nothing wrong with your heart. Some emboli are large enough to cause a segment of the lung to actually die (pulmonary infarct). When this occurs, there is often pain felt when filling your lungs by taking a deep breath. |
| Symptoms may come on suddenly or be of gradual onset. You may feel confused or have difficulty thinking clearly because of lack of oxygen to your brain. There may or may not be associated chest pain. You may or may not have difficulty breathing. Indeed, the symptoms may be vague and difficult to describe. |
| Who is at risk? Everyone is at risk. Pulmonary emboli can occur in anyone. Blood clots can occur anytime circulation is impaired whether due to an injury such as a bad sprain or fracture, surgery on an extremity, or merely being under general anesthesia for a procedure of any type. Fatal pulmonary emboli have occurred from merely sitting for a long time in a car or on a plane. |
| For a P.E. to occur a clot must form somewhere. The clot can be in a vein in the calf, the thigh or deep in the pelvis. Often times the clot is silent and you are not even aware that it has occurred. Its presence may only be manifest by the serious complications it produces. |
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DVT
Deep Vein Thrombosis |
| DVT describes the condition when blood clots within a vein thus obstructing the vein. When the clotted or thrombosed vein is inflamed and painful, one may use the term Thrombophlebitis. A DVT is a potentially dangerous condition. If the clot breaks loose from where it formed, it may move to the lungs and cause a Pulmonary Embolism. |
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| Prevention of DVT and Pulmonary Embolism |
| Prevention of these potentially life threatening conditions is part of almost every condition we treat in Orthopedic Surgery. DVT and subsequent Pulmonary embolism may follow minor injury or surgery, may follow a sprain or a fracture, or may occur with no apparent reason or cause. |
Principles of prevention include:
Mechanical means of improving venous circulation (A Reducing the likelihood of a Blood Clot) |
- Active leg exercises and early return to function. Nothing works better than active muscle contractions in encouraging good circulation.
- Compression of veins in the legs to minimize pooling or stagnant blood that may lead to clot formation
- Use of elastic stockings to compress leg veins
- Use of elastic wraps to compress leg veins
- Use of mechanical devices that compress veins in the foot and increase circulation
These are often used during surgery of all types to aide blood circulation in your legs even though you may be asleep under a general anesthetic.
- Elevation of legs to facilitate blood return to the heart.
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| Medical means of reducing the incidence or effect of a blood clot |
- Use of blood thinning medication
- Coumadin
- Heparin
- Aspirin
- Other medications
- Use of an "Umbrella" inserted in the major vein below the heart to filter clots and prevent them from getting to your lungs and causing a pulmonary embolism.
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| How Blood thinners work: |
| A variety of medications exist which have an impact of the way your blood clots. The use of these medications is often difficult and fraught with potential complications. It is important that your blood clot normally after surgery so that normal healing may begin. On the other hand, it is useful to slow down the clotting mechanism and thus reduce the risk of forming a potentially dangerous blood clot. |
| Coumadin (Warfarin) is one of the more common blood thinning medications that I use on my patients after joint replacement. Interestingly this drug is also a common constituent of rat poison. The rat eats the drug and then quietly bleeds to death internally. Of course, the medical application of this chemical , if done properly, is to slightly slow down the clotting mechanism just enough to reduce the risk of forming a blood clot yet not so severe that it causes you to follow the fate of the rat. |
| Unfortunately not everyone responds the same to these medications. Some individuals are very sensitive to these blood thinning drugs and even a small dose will cause severe bleeding while in others a large dose is required to have a desired effect. When prescribing these medications I may do follow-up blood tests to determine how you are responding to the medication. |
| There are other drugs, besides Coumadin, which I use for the purpose of thinning your blood after surgery. They include inject able medications such as heparin and lovenox. The use or choice of one medication over another for this purpose includes considering many factors including the ease of administration, the ease of monitoring the medication, the cost of the medication and your personal history and risk factors as they relate to your risk of developing a blood clot following surgery |
| Aspirin has an effect on blood clotting as well and may be used as well to reduce the likelihood of a blood clot forming. |
| Unfortunately none of these methods, either mechanical or medical, are effective in eliminating all of the risk. Sometimes bad things happen no matter how hard you try to reduce the risk. |
| When considering any surgical procedure or treatment, you must always ask yourself if the potential benefits of the treatment warrant taking the risks that go along with that treatment |
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| Infection |
| Infection following surgery is a serious complication. If not treated early, aggressively and effectively, it may lead to failure of the procedure performed as well as chronic disease and even death. An infection occurs when bacteria take up residence either at the site of surgery or some other site and begin to grow and cause damage. |
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| Prevention of Infection: |
| I worry constantly about infection and its prevention. An infection can create disaster out of what may have been a perfectly executed surgical procedure. I use a number of procedures and processes to try to minimize your risk of developing an infection after surgery. Unfortunately, though infections are relatively rare, they sometimes occur even though all appropriate procedures have been strictly followed. |
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| I do the following to minimize your risk of getting an infection: |
- Perform surgeries in facilities where care and attention is taken to assure that the surgical instruments and facilities and clean and sterile.
- Make all possible efforts to assure that the surgical site is properly prepared with antiseptic solution prior to beginning the surgery.
- When appropriate, apply intravenous antibiotics to you (the patient) just prior to the beginning of surgery and, in major joint replacements, continue to administer intravenous antibiotics for 24 hours following surgery.
- Try to be a delicate as possible in handling your tissues such that your bodies healing mechanisms are not adversely inhibited.
- Encourage good nutrition and good general medical care to assure your body is in the best shape possible to ward off potential infection.
- If you appear to have a potential source of infection on your body prior to planned elective surgery, delay the surgery until after the source of infection has been resolved. In some cases this may include taking care of dental or other problems prior to proceeding with elective orthopedic surgery.
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| Some people are at greater risk of getting an infection than others. These "higher" risk patients include those with diabetes, peripheral vascular disease and those with cancer or other diseases which may suppress your normal immune mechanisms. Some are on medications to treat a particular disease and a side effect of that medication may be to reduce you ability to ward off infections. There are many factors which effect one's ability to successfully undergo surgery without the complicating factor of an infection. |
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| Implant failure |
| When performing either a partial or total knee replacement one must always consider the possibility that the implant will eventually fail. Implants can fail for a number of reasons. |
- Poor materials
Concern: The technology behind implants has improved dramatically over the years but from time to time assumed "reputable" companies have produced implants which shortly there after have had to be "recalled" because of design or materials problems. My Response: I use implants for partial and total knee replacement that are manufactured by J&J/DePuy. This company is an industry leader with and excellent track record in producing quality materials. The long term outcome studies in patients with these products are some of the best in the entire joint replacement industry.
- Poor fixation
Concern: If the implant is poorly fixed to the bone, it will fail.
My Response: I use state of the art systems in bonding your implant to your bone. This may include bone cement or bone "ingrowth" systems to bond the componet to your bone.
- Poor Alignment of Componets
Concern: It has been well established that failure rates correspond to the accuracy of alignment of the components relative to the mechanical axis of your leg. Just like the tires on your car, if the alignment is good, the tires last longer.
My Response: I employ a the finest Computer Assisted Orthopedic Surgical system in the world to help me put your components in as accurate alignment as is possible. This system has proven to be far more accurate than the mechanical alignment systems that have been in use. This new technology has only been available since mid 2004. This technology has dramatically changed knee replacement surgery and I expect will change many of the other things we do in Orthopedic surgery.
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| Equipment problems - Coming Soon |
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| Failure of procedure - Coming Soon |
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| Failure of rehabilitation - Coming Soon |
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| Other medical problems - Coming Soon |
