This article is more than 5 years old. Information may no longer be current.
Just say ‘no’ to operating on patients at high risk for periprosthetic joint infection
Click Here to Manage Email Alerts
Treatment of nosocomial infection is the single most expensive item of U.S. health care with more than $5.7 billion of the health care budget being consumed by this potentially preventable complication. In fact, the Center for Medicare & Medicaid Services believes in the philosophy of infections being preventable so much that it will not reimburse in-hospital infections developing following sternotomy.
In my opinion and those of many others is that periprosthetic joint infection (PJI), with its immense social and economic cost can be considered a preventable problem. I am not advocating that PJI should be considered a never-event – quite the opposite. I believe that despite all our efforts we will never be able to attain a zero infection status after total joint arthroplasty (TJA). However, the increasing prevalence of PJI and the cost associated with treating this dreaded problem, which is estimated to be around $350 million, is not acceptable and further efforts to minimize PJI are required.
One of the most effective strategies, in my opinion, is to limit this elective surgery to those who “qualify.” Allow me to expand on this by illustrating a case of patient on whom I performed TJA.
|
|
Patient encounters
My encounter with Mr. Jones, a pleasant and intelligent 56 year old man, began 3.5 years ago. He was referred to our specialist center for consideration of joint replacement. He weighed 340 pounds with a body mass index of 42. He was complaining of pain in his hips and knees. He had diabetes, hypertension, arrhythmia, obstructive sleep apnea and his legs were wrapped to treat underlying severe lymphedema. His radiographs showed end-stage arthritis and he was truly in pain with motion of his joints.
During the first encounter, I was able to convince the patient that TJA was not an option on many accounts, most importantly because of his active and severe lymphedema. I proposed that we considered weight loss and possibly bariatric surgery, exercise in a pool that would help control his diabetes, and other modalities. As almost always is the case with such patients, he returned three more times during the following 2 years and each time there was a compelling reason not to offer him elective arthroplasty.
During our last encounter, the patient became emotional in the presence of his family and claimed that he had lost his dignity and self-worth due to chronic pain and was unable to continue with his life. He “demanded” surgery. To his credit, he had complied with our instructions to some extent leading to 20 pounds of weight loss and moderate control of his diabetes and lymphedema. I conceded and accepted to perform a single joint arthroplasty, with both of us aware that some serious complications could arise.
The surgical procedure, due to his extreme obesity, was extremely challenging. His postoperative course from a medical standpoint was far from smooth. He required admission to step-down unit to monitor his arrhythmia and obstructive sleep apnea. He did well from orthopedic standpoint. I saw the patient on frequent basis following his discharge from hospital. In our early encounter, it became clear that he had a deterioration of his lymphedema and was beginning to develop leg ulcers. He developed PJI, and as a result, he has undergone three additional surgery with the latest being resection arthroplasty. It is hard to know when, if ever, he will become candidate for reimplantation.
Although further studies to delineate the exact risk factors of PJI are needed, the majority of patients who are at risk of developing PJI can be predicted. In fact, we are in final throws of completing the design of software that will help surgeons predict who is at the highest risk for PJI. In the meantime, no one will disagree that patients with active lymphedema, in addition to diabetes and arrhythmia requiring anticoagulation are at high risk of developing PJI and should not be subjected to elective arthroplasty. Operating on Mr. Jones may be considered a misjudgment on my part that has lead to more severe problems than his original arthritis.
The immense success of TJA in alleviating pain and restoring function makes it difficult to withhold this procedure from patients who are afflicted with end-stage arthritis. The patients, aware of the success of TJA, also actively seek this procedure. However, the patients may not be aware of the complexity of the decision-making process and selection for TJA. Further, they need to be made aware of the risks — with PJI being one of the most important — and the devastating path that the complications may take.
Having been in practice for more than a decade, I can attest that I have not properly exercised my judgment in every case and have been influenced by the emotions of situations and performed elective arthroplasty in patients in whom risks may have outweighed the benefits. I can also attest that I was not alone in facing such situations and selecting the “wrong” option for the patients.
Health care reforms
One may argue that despite well-intentioned nature of such decisions, the ultimate outcome of the elective surgery did not benefit the patient. Moving forward and with the implementation of health care reforms, selection of “appropriate” patients for elective TJA will gain center stage. With readmission and reoperation certainly being some future “quality” metrics, there will be a disincentive to operate on patients who are at higher risk of failure. With possible introduction of bundling, namely accountable care organizations, hospitals and surgeons may resort to “cherry-picking” practice to avert financial loss by operating on patients who are at high risk of failure. Finally, as implemented to a large extent in many states, the availability of public data on the “quality” of care provided by a specific surgeon and hospital will most certainly fuel this practice.
I do not believe we should be concerned with none of the latter issues as much as ensuring that patients receive the best care they deserve. Not offering patients an elective joint arthroplasty can be as much as of a good choice as alleviating their pain by surgery. The balance in the decision-making process is affected by many factors for a given individual patient. Understanding the importance of factors that influence outcome of surgical procedures in general and TJA in particular is an important mission facing the medical community. In the meantime, we need to uphold the Hippocratic Oath of “Primum non nocere.”
References
- Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis. 1998;275:1247-1254.
- Parvizi J, Pawasarat IM, Azzam KA, et al. Periprosthetic joint infection: the economic impact of methicillin-resistant infections. J Arthroplasty. 2010 Sep;25(6 Suppl):103-107.
- Pulido L, Ghanem E, Joshi A, et al J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-5. Epub 2008 Apr 18.
- www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.
- Stone PW, Larson E, Kawar LN. A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000. Am J Infect Control. 2002; 30:145-152
- Javad Parvizi, MD, FRCS, editor of Infection Watch, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; 267-339-3617; email: parvj@aol.com.
- Disclosure: Parvizi is a consultant to Stryker.