I am writing on behalf of my 71-year-old father who has been living with rheumatoid arthritis for the past 40 years. He is considered a complex case by his consultant, as he has multiple issues stemming from RA.
I am seeking advice regarding surgery complications, specifically related to the reluctance of doctors and specialists to operate due to the risk of infection associated with a compromised immune system. My father urgently needs a hip operation because his hip joint is deteriorating to the extent he cannot walk and is in constant pain. However, both NHS and private surgeons have expressed that the risk is too significant given his condition, and they refuse to proceed with the surgery.
If anyone has suggestions on alternative options or can recommend other groups or specialists to consult, your input would be greatly appreciated.
Please note: He attends a pain clinic where he receives morphine patches, which provide some relief. Nevertheless, he ultimately desires to regain his mobility, as he believes his current quality of life is unsustainable in the long term.
Thanks in advance for any advice received,
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Springhill132
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So I can understand their reluctance, both as a previous orthopaedic ward sister, and as a immunosuppressed patient. Usually you will stop your immunosuppressants at least 2 weeks prior to surgery, although it can be longer. It depends on the half life of the drug.
I had foot surgery at the start of the year, and despite stopping my meds, I ended up with a wound infection and delayed healing. It took 12 weeks to heal, and I had to stay off my immunosuppressants all that one, which wasn’t fun.
You are unlikely to find a private hospital, that will take on a complex case, as they are not equipped with ITUs, some have high dependency units, but not on par with its nhs equivalent. If infection gets into the hip, it is a much bigger problem, than my foot surgery. Often it results in the metalwork being removed, to get on top of the hip bfection. Some are lucky, and havd the metalwork put in at a later date, however, many end up having what is known as hip arthrodesis, or girdlestone, where soft tissue fills the gap. If he has other health issues such as kidney disease, that makes recovery much harder. Has he tried steroid injections into the joint, that can often settle things for a while. When I’ve had them in my knee, it’s resolved pain gor nearly a year. They may consider doing a simpler procedure like an arthroscopy, and smoothing the rough cartilage down, as that doesn’t have the added problem that comes with metalwork. The problem is your body sees metalwork as a foreign body, but when your immune system is suppressed, it can’t fight it as well. Sorry I’m unable to offer more suggestions.
Brilliant reply. Nothing to add except perhaps that I am in a similar position. I am given two weeks IV antibiotics before surgery to make sure my lungs (Bronchiectasis) are clear of infection before surgery.
I had Girdlestones procedure in 2009. I think they nicked my bowel removing my old hip. It took months of IV antibiotics and long stay in hospital. The pain of having no hip was off the scale and Oxycodone did not touch the sides! I don't recommend it.
I’m sorry to hear this. It is certainly a life changing operation, and makes everyday tasks extremely difficult. I don’t think many realise that an infection in an infected joint replacement, is far worse and potentially life changing results, compared to your regular post-op would infection. Hope your doing ok 🤗
Yes! I couldn't do anything, had to use a frame, had carers and have a shoe made to counterbalance the shortened leg etc., traction at night but still they had to cut a tendon leaving no external rotation on that side. Not the result I wanted and it is the accelerator and brake leg. Had it been the left hip, driving would have been easier and more comfortable.
Also the hospital on-site microbiologists said to me, contrary to popular belief, there is NOT an antibiotic to treat every bacteria. Luckily they were able to test the infection on site and found 3 that did work for me, but I was also told I was lucky not to have got sepsis. I agree, most people think it was MRSA, a skin/wound infection, but far from it.
Yes, sadly partly due to gps over prescribing antibiotics, when not needed, we have a lot of bacteria’s that have morphed into resistant forms. I understand, they feel pressured, when a patient turns up with a viral infection, but expects to be given antibiotics. Thankfully gps are a lot more strict about dispensing antibiotics. Sepsis is not uncommon when n you get deep seated infections, so you were lucky. It’s one of the reasons metalwork often needs to be removed, as infections in the joint with metalwork still in situ, are at much greater risk of sepsis. Like you say, it’s also the issue of needing shoes adapted, for the shortening of the limb that occurs after a girdlestone. Sounds like you are coping, allbeit challenging at times. Take care 🤗
It’s a difficult question and I’m 71 too but accept that now other co morbidities might well mean that some things are going to be refused. I’m lucky as have no bone issues. But did break my leg and ankle the other year and was told it might mean surgery although it wasn’t needed. I’ve had the work up for kidney dialysis so expect if needed that surgery would go ahead to facilitate that but I don’t know if that’s because it’s life threatening rather than life enhancing. I wish I could suggest something as my mum had her hip done in her 80’s and made a full recovery and she had RA too as well as Oestoporosis so it doesn’t make sense to me at all. Things seem to have changed a lot recently and this seems so unfair. Just a thought but what if he had an accident and broke his hip? Surely then it’d have to be operated on.?
Runrig’s reply is what mine would be. I too am a retired orthopaedic sister and if the consultants won’t operate due to your father’s co-morbidities and associated risks you won’t find other doctors willing to operate to possibly cause catastrophic results down the line.
They aren’t risk averse and will do their very best for their patients but your dad will have to live with the consequences of any treatment so if lesser measures will provide him with some mobility then they are the ones to pursue. Hope he gains some relief from his pain in future.
The replies you have received are from very knowledgeable people so I have little to add . Sometimes they cannot give a general anasthetic if they feel a patient is at risk so select a spinal anaesthetic but even then there is risk of blood clots etc. They spell out the odds today and it does sound as if they feel the risk is too great. It is important to keep mobile and do upper body exercises with limited leg mobility and to try to keep the weight down and to do activities with your father that lift his spirits.I wish your father all the best.
Hi I'd speak to doc about this for advice ,then the specialists if not done so ,about stopping meds for a month etc ,if you and your father feel ,the hip is greater risk ,than a flare etc ,sounds like it ,
I got mine stopped for 6 weeks and was lucky with the minor flare ,
I know 2 others similar 1 had a bad flare and 1 waa ok ,
It does sound like the hip is urgent ,
If the stopping the meds and they think the infection and risk would decrease id maybe speak about that if not already discussed,would maybe change the specialists minds about the op
As it does sound urgent as you say ,sounds more urgent than a flare maybe ,
I think it's pretty standard for medics to be apprehensive about surgery on complex immunosupressed patients, I'm 68 and have spinal stenosis along with everything else which really requires surgery but my consultant says she is terrified of operating on me because of my medical history and the risks involved !! So back to the pain clinic and physio which only help minimally !! you have my sympathy and hopefully find a way forward to improve quality of life.
Thanks everyone for your responses here. It is greatly appreciated and I have informed my father of what you have all said.
Unfortunately, like I say he is quite a complex case and it isn’t just the standard RA symptoms (although are there any standard symptoms?!..it’s such a horrid disease ) that he is dealing with. I avoided going into detail above as I would be there all day, but in short his chest cavity is also filling with fluid due to the RA which has resulted in a permanent chest drain being put into his chest (this is new ground for the doctors as a permanent chest drain has never been used as a solution for this apparently. But, it’s that or he stops breathing). That coupled with the lack of immune system and a couple of other factors (one of the main ones being that he also has Aspergillosis as a result of RA / lack of immune system) is what is making surgeons nervous.
The problem is he has been given false hope for almost 2 years now re the replacement, and when they stated that surgery now would not happen full stop, it was very difficult for him to take (he’s in extreme pain with his hip and it felt like this was the last resort). He’s also bloomin’ stubborn and will not have his house adapted / use a stair lift / use a buggy etc etc, which is also why he’s still here, so I will not discourage him from being that way.
Anyway, I thought I would see whether other folk had similar experience with refusal of surgery / alternative options. From what I’ve read it seems he needs to now just get on and live as best he can with the situation. He’s now been put onto oral morphine as well as morphine patches, so that’s something at least. He will look into the option of injecting into the joint also.
Thanks again for your responses, it really is greatly appreciated.
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