Polodoc: Complication After Surgery

Dr.med. Andreas Krüger is a Swiss board orthopaedic and trauma surgeon in Zurich, who specialises in knee and shoulder surgery. Andi is a second generation of tournament doctors for equine sports, known as Polodoc since 2013 and affiliated with Polo Park Zurich

Complications After Surgery

Infection diagnosis & treatment

It started with a slight pain in the shoulder after a fall and ended with three operations and six weeks of antibiotics. Even a simple injury can dramatically change your sport, life and health. A possible scenario with every sport injury, but how can you lower the risk of such a negative outcome?

Injury pattern

The latest scientific work from Ludwig Neumayr in 2019 proves that the upper extremity is the most predominantly injured area (42% of all injuries in polo). Secondly

67% of all injuries in this study were classified as major. Two possible materials can be injured; most often the bone is the centre of breakage, but also the peripheral soft tissue can be damaged (ligaments or tendons). Most often a fracture is involved and must be fixed due to their dislocated position or comminution.

Problem

Surgery has a principal in-built risk of infection. Open reduction and stabilisation are the golden standard to repair the injury. Despite advances in minimally invasive surgery and aseptic techniques, infection remains an all too common complication after medical device implantation. Systemically administered antibiotics are largely ineffective for peri-implant infections due to bacterial drug resistance, poor drug penetration, and suboptimal bioavailability at the site of infection. Signs of infection can be non-healing, ongoing pain, reddening or sinus track with pus drain.

Diagnosis

The diagnosis of infection has several steps. First a test is done by blood examination (CRP, white blood count). A precise radiological follow-up with X-ray and MRI/CT or even very elaborated Scintigraphy or even PET/CT (Positron Emission Tomography – Computed Tomography (PET/CT) examination can be performed to find the nest of bacteria.

In most cases a mini invasive biopsy or punction is needed to name the pathogen correctly. Also, the possible antibiotic cure will be adjusted to these findings.

Treatment

If the infection takes hold, the implant will typically have to be removed, the infected

Shoulder MRI post-opertive after plate fixation. Fluid collection below the deltoid muscle and large bursitis. Healing of the initial bone injury.

Proof of bone healing with X-ray after plate fixation for humerus fracture

Ortema® is specialized for protection in high impact sports with built-in memory foam

tissue resected, and surrounding tissue cleaned with antibacterial agents prior to surgical revision.

The surgical intervention can be demanding due to extensive approach or persisting instability or non-healing in combination of bone stock loss.

A germ adapted antibiotic treatment is one of the essential pillars of the healing after analyzing the intra-operative tissue probes.

Prevention

First of all, perfect fitness is always a protection shield with a muscular cushion and stabilisation of joint and bone. The technique of falling from the horse and the landing can be trained. If surgery is needed for a swift recovery, modern techniques can help to minimise surgical site infection. In the rare case of infection, a medical expert

Expert Opinion for Internal Medicine Dr. Anna Erat (MD/PhD)

Specialist in internal medicine and sports medicine, and is a medical director at Hirslanden Klinik Zurich

Postsurgical complications such as infections can be highly demanding – both physically and mentally – due to the extensive antibiotic regime and inability to move and exercise normally. Despite antibiotics being crucial in treating a wound infection following surgical complications, antibiotic side effects can occur and have a negative impact on general health. Finally, bacteria can develop resistance to antibiotics and complicate the wound healing even further. When antibiotics are applied appropriately, however, most of them are safe, effective and show few side effects. Most people show few side effects and tolerate antibiotic therapies well. Common mild side effects include mild allergic reactions such as a slight skin rash, urogenital yeast infections, headaches, dizziness, photosensitivity or gastrointestinal manifestations such as stomach pain, nausea, vomiting and diarrhoea. Most allergic reactions against antibiotics are mild. Yet, a small fraction of the population can develop severe allergy with difficulties breathing, swelling of the face, lips and tongue and finally an anaphylactic shock, which is a life-threatening condition. About five percent to 25 percent of patients may develop antibioticassociated mild diarrhoea, since the antibiotic regime leads to the eradication of the normal, protective gut flora resulting in an overgrowth of infectious bacteria. Hence, if the diarrhoea is severe, bloody, contains pus, is accompanied by febrile temperatures or stomach cramping, a physician should be contacted.

How to prevent complications and minimize side effects?

• Healthy habits: Important for general health, regardless of whether one is going through post-surgical complications or not. Yet, there are also specific preventive measures that are important following surgery.

• Taking care of the gut: Probiotics found in foods such as yogurt may rebalance the healthy bacteria in the digestive tract. Over the counter probiotics such as Saccharomyces boulardii are at times also used to prevent antibiotic-associated diarrhoea despite a lack of a consensus within the medical community.

• Energizing the body and boosting with vitamins: Furthermore, one should avoid beverages that are high in sugar or caffeine, which can worsen your symptoms. It is also wise to stay away from fatty or spicy foods. Supplements such as vitamin D3 may be needed particularly for vegans or patients that have limited exposure to sunlight. For the wound healing, vitamin c and zinc may be beneficial.

• Regular check-ups: Some antibiotics should not be taken together with alcohol due to the interference with bioavailability, metabolism and potential liver toxicity. Furthermore, since longterm antibiotic treatments can lead to liver, kidney and heart toxicity, it is important to have regular medical check-ups, including ECGs and blood-works, during long-term antibiotic regimes.

• Mental power: Longer treatment regimes may also be mentally tolling and lead to depression. Hence, it is important to take care of both body and soul. Regular adapted exercise for at least 150 minutes per week, spending daily time outside (with sun-protection), cultivating social interactions, and getting enough sleep (at least seven hours per night), all improve mental resilience and health.

@dr_erat

team is needed to work on the problem and find a precise and individual solution. New protection gear should be considered to reduce the force of impact. For more information on Polodoc contact Andreas Krüger at drmedkrueger@gmail.com or www.polodoc.ch