Wednesday, November 01, 2006

orthopaedic surgical complications

Don’t worry Mr. Y, this procedure is safe.

What anybody, about to undergo an orthopaedic procedure, must know about surgical complications.

I have been suffering for months. The pain is becoming unbearable. Every possible option of treatment is exhausted. My doctor offers me surgery.
I finally see a ray of hope. Freedom from this misery, is it possible?
‘this procedure has a very high success rate Mr. Y’ …….I am convinced and why shouldn’t I be ? Modern orthopaedic surgery has become a boon for many. That is a fact. If surgery is indicated (meaning there is enough scientific proof that the surgery will benefit the particular condition), I would strongly recommend it. Today surgery to a great extent is safe.
‘This procedure has a low complication rate’ though this statement is true, I think everybody has a right to know what could wrong in a surgery. But why should I bother, I trust my doctor. Besides the benefit from the surgery far outweighs the risk, right?
Right. But what I need to realize is that
  • Surgery may not be the best option
  • Unindicated surgeries usually fail
  • Doctors with more experience (those who do the particular surgery in large numbers) have a lower complication rate.
  • Factors other than the operating surgeon can affect complication rates.
  • Anaesthesia complications are very rare but can occur.

    So why should I be more aware? …because I can make a more informed decision regarding surgery. If I know what is likely to go wrong, I can take steps to minimize those complications. I can ask the right type of questions. If malpractice is involved, it will be obvious to me.

    The purpose of this article is not to discourage someone from undergoing surgery, but to extract maximum benefit with least risk by the process of awareness.

    In this article I will discuss only general complications which are common to most orthopaedic procedures. My list is not comprehensive. My emphasis will be on those complications that are readily preventable and more common. I will attempt to put the information in understandable English (rather than use medical mumbo jumbo) This is my first attempt. I will appreciate any constructive criticism.

    The first complication on my list is the most frightening. It is infection. Most common misconceptions are

If I contract infection its probably bad luck.
Even though infection is common in certain people (like those suffering from diabetes), it is difficult to say who will get an infection. Therefore medical men discuss infection in the form of a rate, for eg. ‘The infection rate for this procedure is around 1%, Mr. Faltoo’ meaning 1 in every 100 patients will get infected. The unfortunate thing is, that 1 could be me. So I want to know whether an infection rate be reduced? The good news is yes. There are many ways like

1. The operation theatre. Patients seldom realize that the quality of the operation theatre has a major impact on infection rates. Firstly a good operation theatre is hidden behind many layers of isolation. In simple words this means that to reach inside a good theatre I will have to pass through many doors. Behind every door I will see fewer people and the ones inside will be in a surgical uniform. If I reach my operation theatre by passing through one or two doors then the alarm bells should start ringing. Secondly there are two kinds of surgical patients. The first are the clean cases. These guys have no pre existing infection. And the second are the infected cases with pre existing infection. For eg. A patient posted for an abscess drainage is an infected case. Usually the theatre for the infected guys should be very, very far away from the ‘clean theatre’. If both the types of surgeries are being done in the same complex, I want to run away.
Also some surgeries disrupt natural bacterial habitats For eg. Surgery on the colon or the genital tract. These surgeries have more bacterial contamination than most orthopaedic procedures. So if the theatre for my orthopaedic surgery is also being used for general surgical or gynaecological procedures, I again want to run. The third point is of newer advances. This is especially true for joint replacement surgery. These advances are laminar air flow & body exhaust suits. Laminar air flow is a system which reduces the no. of bacteria in the OT air by rapid air exchanges. It has made a huge impact on reducing infection rates. The operating team is a big source of bacteria. Body exhaust suits aim to reduce contamination from this source. I will always ask my surgeon about the OT quality. If his response is specific and he gives me a detailed account of the effort that has gone into constructing the OT & the list of anti infection measures taken, then I am satisfied. If his response is vague then I want to run. Last but not the least is the operating team discipline towards asepsis in the OT. A strong commitment to maintain OT sterility goes a long way in preventing infection. And in the case of infection prevention truly is the best treatment.

2. Antibiotic prophylaxis this means using an antibiotic as a preventive measure. Most surgeons will give 2 to 3 antibiotic shots perioperatively ie before the surgery and for a period of time after surgery. The protocol differs. Every surgeon uses one that he is comfortable with and that works in his set up. The important thing to remember is point no 1 is far more important than point no. 2. A antibiotic cannot be used to compensate for sub optimal OT conditions. If my surgeon says ‘ don’t worry about the OT Mr. Y, we’ll give you a powerful antibiotic’ I’ll be gone.

3. Have a bath this is such an important advice, but most surgeons will forget to tell the patient. My own skin is the most common source of bacteria which cause infection. Therefore if I have a good clean bath and especially clean the site of proposed surgery, my infection rate is going to drop.

4. Do I already harbor an infection ? if I am already suffering from an infection like a urinary tract infection, then my chances of infection after surgery rise. So I need tell my doctor about any pre existing infection. I’ll expect him to delay surgery till my infection is under control.

Infection is cured by dressing and antibiotics.
Though dressing an antibiotics are successful in curing a percentage of post operative infections, most need a second sometimes multiple surgical procedures. This amounts to a longer hospital stay & a lot of more expenses. Add to that pain and anxiety and I realize that I am very afraid of infection. I definitely want to stay far, far away from it.

I am healthy so I’ll not get infection
From the above discussion it is obvious that this statement holds no water.

I got infection because I ate rice
This is a very popular belief in Indian patients. Infection has got nothing to do with what you eat

To summarize I would like to once again stress that surgical infection is best prevented and OT quality and discipline go a long way in doing just that.

…to be continued. I will be happy to answer any queries.

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