Knee Infection* Where to go to fix a serious infection after TKR

rvl3240

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Request: Where in the United States could we go to get the most effective and EXPERIENCED infectious disease specialist and surgeon to fix a really bad periprosthetic joint infection (PJI) after a total knee arthroplasty (TKA)? I want to maximize the chance of a good outcome and avoid options like fusing the knee, or god forbid - amputation.

Condition: Serious bacterial infection of left knee several months after TKA. Infection has not progressed to the blood, or spread to other places in the body at this point, but it is doing real damage to his knee and overall health. It has definitely taken its toll - he is extremely weak & fatigued, can't stand, walk or even roll over. Looks terrible like he's been aged 10 years. His right leg/foot is also swollen. Genitals swollen. After months of misery he's really depressed and feels like he's dying.

We've started a 2-stage replacement, prosthesis removed. Surgeon is not confident he can fix the knee and is already talking about amputation...

The surgeon seems competent but I don't think he's handled a lot of cases like this.

Details about the patient:
  • Age: turning 71
  • Sex: male
  • Height: 6'1
  • Weight: 240 - (normally like 220, think he's gained weight during this period with all the swelling, and being immobilized for 8 months)
  • Race: white
  • Duration of complaint: infection for at least a month, 4 knee surgeries since November
  • Location (Geographic and on body): eastern US, knee
  • Any existing relevant medical issues:
  1. aneurysm on ascending aorta, size does seem stabilized
  2. enlarged prostate
  3. in the 1990s he had chondrosarcoma in the neck which was cured
  4. some of the fibula from left leg was actually removed and used to fuse vertebrae in his neck
  5. had thryroid removed as the result of the radiation treatments^
  • Current medications:
  1. warfarin (new blood thinner, previously xarelto)
  2. levothyroxine (thyroid)
  3. alfuzosin (prostate)
  4. losartan potassium (blood pressure)
  5. testosterone injections
General info: before this knee-replacement nightmare he was in good health for an old man; he got groceries & cooked every day, rode a motorcycle, and went to the gym 3-4 times per week. He's been a bodybuilder his whole life.

Sequence of events:
  • 2018 - My dad's knees were just worn out after an active life. No cartilage left, bone on bone, can barely walk anymore. He wanted to get them both replaced, so he could continue being active and independent.
  • November - TKA on left leg. He was not taken off of Xarelto (blood thinner) so there was a tremendous amount of bleeding and swelling during/after the operation. He was in the hospital for a week and had a very long recovery. Extensive hematoma running all the way up to his waist and private parts, all black. Massive amounts of swelling, so much so that the incision wouldn't heal. He was in REALLY bad shape for several months. This was very unexpected.
  • February/March - Once he finally got things under control, the patella came lose and was dislocated.
  • April - This required a revision surgery. The recovery from this was a little better, but he was still in the hospital for a week
  • late June - He finally seemed to be doing pretty well and could walk around.
  • Early July - Then suddenly a switch flipped and there was a massive relapse in one day. Unable to walk, confusion, excruciating pain, extreme swelling of knee. Doctors aspirated the knee and determined there was an infection. On approximately July 9th he had a surgery to wash-out the joint.
  • Suspected pathogen: staphylococcus aureus, but it could be anything. They were unable to tell me.
  • Initiated IV antibiotics for about a week, infection worsening. He looks seriously sick, is demoralized. Doctors say: "the infection is winning."
  • July 26 - Docs execute a 2-stage replacement
  • After the 1st stage the surgeon says it's one of the worst cases he's ever seen, the infection has eaten away a massive amount of tissue. He has removed the prosthesis, cleaned out the joint as much as possible, and filled it with a spacer and antibiotic cement. Scheduled for 6-10 weeks of antibiotics. Surgeon is not optimistic about being able to cure the infection and install a new prosthetic joint.
The hospital: I've really lost confidence in this hospital after what seems to be some seriously "botched jobs." The hospitals in this state have some of the worst records for MRSA infections, and the doctors give me vague answers when asked about rates of infection in the hospital. They seem to be badly understaffed, and some of the nurses have terrible attitudes and are borderline incompetent. We go for hours with alarms blaring from machinery without being able to find a nurse. The bed is broken and doesn't adjust. The IV machine only works intermittently or they neglect to hook it up... It's crazy. He is constipated for a week at a time and bladder balloons to 1000cc. There have been multiple incidents with nurses trying (unsuccessfully) to forcefully jam catheters inside of him even after they've been explicitly told it can't be done except by his urologist with special tools. (because of his swollen prostate). Could this have been the pathway of infection?

If family members weren't there advocating/taking care of him around the clock... I'm not sure what would happen to him......

Worse, I never felt there was an urgency to get this infection addressed. They sent us off for several weeks without an appointment, no doctoring, until we finally demanded to be seen.

In conclusion:

My dad broke his neck when he was young and was exposed to tons of x-rays. It's suspected this was the cause of his neck cancer later in life. Anyways, in the 1990s when he had cancer surrounding his spinal cord he was in big trouble. He had a doctor who was planning to give him the standard chemotherapy treatments. My dad had been doing research in a library, looking up names of doctors, calling them... until he found out about some new technology/techniques being used by a doctor at Mayo Clinic - using a cyclotron. He spoke up about it and it turned out his doctor had studied under the Mayo Clinic guy. He asked the doctor, "where would YOU go?"

The doctor said, "I'd go to that guy...."

Long story short, he applied for the program at Mayo Clinic and was completely cured against the odds.

This is what he needs for this knee. Where can I find the most advanced care, the most experienced infection guy & surgeon who handles serious cases like this all day long. I don't care how much money it is, I've got to save my dad's leg!
 

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Wow! Your dad has been though it all. I'll keep him in my prayers.

My suggestion would be to get him to Dr. Gerhard Maale in Texas. @Jamie may have some better (or closer) ideas for you.
 
Dr. Maale is the best. He's the one you need to get to....as soon as you can.

Dr. Gerhard Maale
Plano, Texas (Dallas/Fort Worth area)
Deals with biofilm infections and revisions; problem cases
 
@rvl3240 , I just read your post and wanted to offer all of my prayers to your father!!! How scary this must be for all of you!
 
I can't agree more with the recommendation to see Gerhard Maale. You can do no better anywhere.
 
Prayers for your dad.
My first knee surgery (2010) was by a then Air Force surgeon at Langley AFB/NASA, a Dr Topolski. Truly excellent. Operated w highest praise on astronauts, fighter pilots, etc (and on a space available basis, people like me w aging knees, hips, etc).
Since then, he has been hired by the Mayo Clinic. If you decide they are your choice, consider looking him up.
 
I have no answers but just want to offer virtual support. Are you able to get dad to Texas? PLEASE keep us posted.
 
I suggest Mayo. Dr Beauchamp and his team at the Phoenix Mayo saved my leg.
 
NYC
Calin Moucha Mount Sinai
Patrick Meere NYU
They say Hospital for Special Surgery is the best in the nation but the
consultants were too quick to want to fuse my wife's leg. Her leg was ultimately reconstruction after more than 6 months with a 2 stage revision and a large skin graft after massive tissue destruction from the infection.
---The Cleveland Clinic is supposed to be one of the best as well--
 

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