Little-known risk behind joint-, valve-replacements

September 10, 1998|By Jonathan Lerner

MY FATHER HAS always had enormous energy. If he ever felt ill, you didn't know it. Twenty-five years after ending his career as a foreign service officer, he was enjoying vigorous retirement, a pillar of the Florida community where he lives.

Then a bad infection -- one he might have avoided if he'd received an adequate warning from his doctor -- dramatically changed all that.

It's a problem that affects scores of people annually -- those who, like my father, have had a joint or heart-valve replacement.

For years, Dad has led a volunteer organization, marshaling neighbors to help with small crises, such as the rat terrorizing a lonely shut-in, and with continuing needs, such as driving patients to the hospital 45 minutes away. With a map and pins, he devised a plan for evacuating the housebound in case of a hurricane. Last time he bought a new car, he chose a station wagon -- easier to haul other people's wheelchairs and walkers.

Danger in the bushes

Two years ago, at 85, Dad had knee-replacement surgery and made a quick recovery. A few months later, working in his garden, he gashed his leg on a branch. He treated the wound topically and thought little about it, even when he began to have flu-like symptoms. Uncharacteristically, he took to his bed. A day later, he was wracked with chills. At the local clinic, his blood pressure was very low: 65/30. A helicopter was dispatched to take him to the hospital. He was in septic shock -- a condition which is fatal in two out of three cases.

Prosthetic joints and heart valves are marvelous things -- a boon especially to older people. But the metal and plastic devices can never become part of the body's vascular and lymph systems. So they make perfect places for infections to hide out and grow. What began as a small inflamed puncture on my father's leg had become a life-threatening systemic infection.

After nearly dying, he spent eight weeks in the hospital. Massive doses of antibiotics saved his life, but with unfortunate side effects: They damaged his kidneys and destroyed the balance mechanism of his inner ears. Now, whenever he's upright, he's dizzy. Even after all the treatment, the infection is not and will never be eliminated from his body. For the rest of his life, he must follow a strict regimen of medications and close monitoring.

About 400,000 knee, hip and heart-valve replacements are performed annually in this country. Numerous medical journal articles suggest that "late" infections (those not resulting from the replacement surgery itself) are eventually experienced by between 1 percent and 3 percent of patients. That's at least 4,000 potentially devastating infections a year. Many of them could be prevented by a clear, complete and timely warning.

Patients routinely sign releases regarding the risks of surgery. But evidently no standard exists among physicians about how to warn joint-and valve-replacement patients of their permanent risk of possibly fatal infection.

Some doctors surely make the full danger clear. But many, apparently like my dad's, only mention risks to the functioning of the prosthesis. Even a brochure on joint replacements distributed by the American Academy of Orthopedic Surgeons lacks any mention of infection risks.

A week or two before surgery, Dad was given a pamphlet typical of those that joint-replacement surgeons provide. On its last page, under the heading "Lifelong Prevention of Infection," the booklet advises that for any wound or cut that looks inflamed, a person with a prosthetic joint should immediately see a doctor. "Bacteria from a variety of sources can enter your bloodstream and invade your new joint," the text explains. "This can eventually cause it to become loose and painful."

Lack of warning

The booklet does not mention other possible consequences, like the need to remove the prosthetic joint, or severe infection, or death.

Ever the fair-minded diplomat, on a photocopy of this page Dad has written, "Can't fault them on this very explicit warning." But a notice buried in a booklet one is handed before surgery -- when patients are concerned with their operation and recovery -- amounts to fine print. At no time before or after his operation did my father's surgeon, or any medical worker, point out or reiterate the warning about infection, or explain that such an infection could cost him his life.

Would this have been too much to expect? It would have needed only a word -- or better still, a separate advisory handout at the time of his post-surgery discharge. Ironically, Dad's quick initial recovery coupled with this incomplete warning led him not to link the symptoms he experienced after he cut his leg to his knee replacement. If he had clearly registered the risk of infection with his new knee, he would have seen a doctor right away, been prescribed a course of oral antibiotics and continued to enjoy uninterrupted mobility. Now, because of his constant dizziness, he must rely on a walker.

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