Many complications can occur with surgery. The following are the some of the most common in orthopedic surgery.

Infection

With the advent of improved surgical techniques, as well as modern antibiotics, the number of infections as a result of surgery has decreased over the past several decades. Although this risk is small and every precaution is taken, it is still possible to develop a post-operative infection after orthopedic surgery.

The most common type of infection is a superficial wound infection, or cellulitis, caused by the staph aureus bacteria. This presents as increasing pain and redness about the surgical site, often with red lines (lymphangitis) leading to the trunk of the body. There may or may not be a fever and the patient may feel ill, as if they have a cold or the flu. The wound drainage may increase and the drainage changes from clear to dirty red or grey. The extremity will become more painful and the patient's motion of the joint will decrease significantly.

Note that it is not uncommon for patients in the immediate post-operative period to run a low-grade fever, particularly at night. Temperatures to 101.5 degrees are common, but as long as the patient feels well and has no increase in pain they can be safely watched for several days. If higher temperatures continue for more than 48 hours straight, it should be reported to the doctor and medical office.

The major symptom of infection is pain that develops several days after surgery. The most common presentation is a patient who has been progressing routinely for seven to ten days and suddenly develops unremitting pain that is not handled by pain medication. If this occurs, the patient should be taken immediately to the doctor or to the nearest emergency facility. Other signs of infection (such as redness, wound drainage, and low-grade temperature in the absence of severe pain) can usually be handled on an urgent basis by calling the office for discussion and routine appointment.

The typical post-operative infection caused by staph aureus bacteria can be readily treated by surgical removal of the infected tissue and either oral or intravenous antibiotics. Although this complication may cause a delay in recovery, the overall results of the surgery are not usually affected. Infections with special staph that are resistant to most antibiotics (for example, MRSA Staph Aureus) or other types of bacteria (Streptococcus, Clostridium, Tuberculosis) can be much more serious and involved. These, however, are very rare. For infections, the earlier treatment is instituted the better the overall results. Therefore, any signs or concerns that the patient may have should be brought to the attention of the doctor.

Thrombophlebitis (Blood Clots)

Thrombophlebitis is the term used when a blood clot forms in a vein. Unfortunately, this is a condition that can occur after orthopedic surgery, particularly in major hip or knee surgery (such as a joint replacement). It is also associated with periods of prolonged rest or sitting for a long period in a car or airplane. Risk factors for this condition include increased age, smoking, birth control pills or a family history of blood clots. Obviously, a person who has had one episode of blood clots will be at risk in the future and should inform their physician before surgery. Blood clots typically start in the calf of the lower extremity and are rare in surgery of upper extremities (like the shoulder or elbow).

The typical signs and symptoms of phlebitis (vein inflammation) are pain and tenderness in the calf with swelling of the ankle. Remember that swelling of the ankle after surgery is common, but if that swelling does not subside with elevation it may be the result of thrombophlebitis and should be evaluated.

Thrombophlebitis of the leg is divided into two types: Superficial and Deep Vein Thrombophlebitis (DVT). These both have the same clinical appearance but can only be diagnosed by testing, usually a venous ultrasound. Superficial phlebitis involves the veins near the skin and has little chance of traveling to the lungs or other organs. It is usually treated symptomatically with warmth and aspirin.

Deep Vein Thrombophlebitis (DVT) involves the deep veins of the leg. These blood clots can break loose and travel to the lung causing a Pulmonary Embolism (PE). When this occurs, the lung function can be decreased, resulting in shortness of breath, coughing with blood, chest pain and even death. As a result, DVT's are a medical emergency and require active treatment with blood thinners or surgery.

It is important to report pain and swelling of the leg to your physician. Any signs of a pulmonary embolism should be evaluated immediately in a hospital emergency department.

Compartment Syndrome

In the arm and leg, there are “compartments” that contain a group of muscles surrounded by a tough layer of tissue called the “fascia”. Within the compartments are veins and arteries which provide blood to the compartment and to the remainder of the extremity. In some cases, such as after injury or surgery, the muscles within the compartment can swell, causing increased pressure in the compartment. If the pressure increase is high enough, the blood supply to the muscles decreases, which results in a lack of oxygenation. This lack of oxygen causes the muscles to swell, increasing the compartment pressure. This further decreases the blood supply and a vicious cycle results. This cycle is called a “compartment syndrome” and is considered to be a surgical emergency. If untreated, compartment syndrome can result in loss of function and sometimes, loss of limb.

The most important sign of compartment syndrome is pain. This pain develops progressively over several hours and is severe, unrelenting pain that is unchanged by position or use of narcotic medication. While movement of the muscles around a fracture or injury is generally painful, it is tolerable. If pain is significantly magnified by movement of the muscles around an injury, this may indicate the development of a compartment syndrome.

If these symptoms should occur, the first step is to remove any constriction on the leg or arm. This means that the surgical dressing should be removed completely. If this relieves the pain, elevate the leg and call your doctor immediately. When the pain is not relieved by narcotics, elevation or removal of the dressing, proceed directly to an emergency room for evaluation.

Reflex Sympathetic Dystrophy (RSD)

Reflex Sympathetic Dystrophy is an unusual condition that can occur after surgery, trauma or, in some cases, without any inciting event. It is most common in the hand or foot but can also occur in the knee, shoulder or hip. It is characterized by significant burning pain, which is out of proportion to the causal agent. The pain is constantly present and worsened by light touch or even wind moving across the area.

RSD is often accompanied by skin changes such as redness, swelling and a shiny appearance (caused by increased sweating). The cause of RSD is not fully understood but is believed to be a hyper-reaction of the sympathetic nerves. These nerves control body functions such as breathing, heart rate and blood pressure and are not under conscious control.

Diagnosis of RSD is difficult to make and is usually done by excluding other causes of pain. X-rays and bone scans can help show weakness of the bone secondary to loss of calcium.

Treatment of RSD is also very difficult and often requires a pain specialist. Narcotics are of temporary benefit but can not be used on a long term basis. The most important factor in treatment is to continue to use the extremity, despite the pain. If the extremity is kept immobile the stiffness will worsen, causing more pain and resulting in a vicious cycle.

The recovery from RSD can be prolonged and can take years. There are those who say once a patient has RSD it is never truly over and that it can return if there is a recurrent injury or surgery. Luckily, RSD is extremely rare and if caught early can be prevented from fully developing.