The Breakdown of Joint Replacement
What Happens When A Joint Replacement Goes Wrong
Two years after she had both hips replaced, Judy Comunale got some bad news from her doctor's office: The all-metal artificial hip used in her operations had been recalled.
"The metal ball and metal socket were rubbing together, and slivers of metal that were rubbing off were going into my bloodstream," she remembers being told at the time. Comunale, now 68, would need a blood test every 3 months to determine the level of metal accumulating in her body. Two years after the recall, that level was deemed high enough to warrant a second surgery, or a revision, but her original surgeon wouldn't perform it himself. She was sent from her home in Hackettstown, NJ, where she runs her own part-time cleaning service, to Philadelphia, where a specialist performed her left revision in 2012 and her right in 2013.
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The second time around, it was "much harder to recover," she says. The surgeries had been more invasive, more extensive this time. She was in more pain; she had to rely on a walker for longer. She had lost some of the bone in her hips, and tumors had grown in its place.
Blood tests after the revision surgeries showed the metal in her blood was retreating, but in 2015, about 5 years after the recall, she's still not completely back to normal, she says. Still, she's glad she opted for the initial replacements. "I wish I had a different implant that didn't cause all these problems, but without surgery I wouldn't have been able to walk," she says.
Hip and knee replacements can certainly help people like Comunale maintain their ability to walk and perform other day-to-day activities that might otherwise become intolerably painful. In a recent randomized controlled trial of 100 patients eligible for knee replacements, surgery provided a 32-point improvement on a scale of pain, symptoms, quality of life, and daily activities. A nonsurgical treatment program that included exercise and shoe insoles—and in some cases pain medication, dietary advice, or weight loss—led to a 16-point improvement on the same scale.
Despite the benefits of surgery, only 26% of patients who didn't have surgery in the study went on to have a replacement later. Surgery of any kind carries risk and benefits; in the experiment, the surgical group experienced a higher number of serious negative consequences than the nonsurgical group.
Luckily, worrisome complications occur in less than 2% of hip and knee replacement patients. Many of the most common complications could result from any surgery, says Geoffrey Westrich, MD, a professor of clinical orthopedic surgery and director of research in adult reconstruction and joint replacement service at the Hospital for Special Surgery in New York. Simply undergoing anesthesia makes us all temporarily somewhat more at risk for things like heart attacks, stroke, digestion issues, and kidney problems—even death. The site of any surgery can become infected, and nerves in the area can be damaged. Hips can dislocate, and knees can stiffen—but that occurs in less than 1% of cases, Westrich says.
Shirley Green, 64, of Wheat Ridge, CO, is all too familiar with the type of nerve damage that can take place. Her mother, Mae, who passed away in 2001 at the age of 81, had been "nicked" by her doctor in the sciatic nerve during her 1991 hip replacement. The family didn't find out about the complication until Mae'sthirdrevision. Convinced the joint was coming loose, in 1992 she returned to her surgeon, who used a different type of glue to keep her hip in place. But her hip still felt loose to her, Green says. In 1995, Mae saw a different orthopedist who told the family about the damaged sciatic nerve. "Apparently, it was in her records from the first surgery, but the first surgeon never mentioned it," Green says. Eventually, the pain caused by her damaged sciatic nerve became so great Mae had a pain pump surgically installed to drip morphine directly into her spine. (Find solutions for sciatic nerve pain here.)
Westrich says complications like these are best avoided by doing your research to find a hospital with a good reputation in orthopedic procedures. "Sometimes people have the misconception that staying at their local hospital will be more convenient," he says. "But once they have a complication, even if they travel to another hospital, it doesn't mean they'll necessarily be the way they would have been if they didn't have a complication." In other words, you definitely want the best treatment you can get the first time around.
He specializes in these second (and third) surgeries, which are more complex, often seeing patients from across the country. "There are only so many times you can operate on a joint," Westrich says. "Every time you do, you create more bone loss, greater risk of infection, greater fracture risk, and more scar tissue." Hips and knees can become even more stiff and painful after multiple surgeries, he says.
Randa Manning-Johnson, 41, sought out a knee replacement to get rid of joint stiffness. But after the procedure, the joint quickly became infected. "A month or so after surgery, they went back in and tried to clean out the infection, but the infection didn't go anywhere," she says. She needed an antibiotic spacer, a device that maintains the stability of the joint while releasing medicine to fight off infection, and additional antibiotics delivered through an IV by a nurse at her home. Five months later, her doctor performed a second knee replacement, which again became infected, and again resulted in an antibiotic spacer, this time for 3 months. Her knee was replaced a third time in May 2015. "The infection is gone," she says. "However, it ate through most of my flesh and some bone." Her doctors transplanted some of her calf muscle to the front of her leg to fill in the eaten-away area between the joint and her skin.
Manning-Johnson knows she's a "worst-case scenario," she says, and that plenty of other patients, young and old, breeze through replacement surgery. But the busy publicist in Murrieta, CA, says "it's been horrible." She's been sleeping in her living room to avoid climbing the stairs to her master bedroom. Her affected leg is now 2.5 to 3 inches shorter than her healthy leg, and her heel doesn't touch the ground. She's only just now relearning how to walk after the first surgery in 2013. "I'm kind of on my tippy toes, and the calf muscle that would need to be stretched to fix that is now on the front of my leg," she says. "It's a mess."
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Doctors have told Green she needs surgery of her own; her left knee and right hip should be replaced, she says. But hearing of her mother's and others' trying experiences is enough to convince her otherwise. "I walk with a cane now, and sometimes a walker depending on how swollen my knee is," she says. "I'm scared because I've never known anybody who has done hip or knee replacement surgery who hasn't had problems." She climbs stairs sideways and drives a van because she can't bend down low enough to get into a sedan.
Video: Knee Replacement Second Time Around
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