Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Complications of Devices, Implants, and Grafts


Related Terms

  • Allograft Rejection
  • Device Rejection
  • Leaking or Deteriorating Breast Implant

Specialists

  • Cardiologist, Cardiovascular Physician
  • General Surgeon
  • Gynecologist
  • Hand Surgeon
  • Internal Medicine Physician
  • Neurosurgeon
  • Ophthalmologist
  • Oral/Maxillofacial Surgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Plastic Surgeon
  • Radiologist
  • Thoracic Surgeon
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

Duration of disability depends on the underlying cause of the disorder being treated with a device, graft, or implant; the type of surgical procedure; and the specific complication(s) that develop as well as the type of treatment for the complication and response to treatment.

Medical Codes

ICD-9-CM:
996.01 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Cardiac Pacemaker (Electrode)
996.02 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Heart Valve Prosthesis
996.03 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Coronary Bypass Graft
996.1 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication of Other Vascular Device, Implant, and Graft; Mechanical Complications involving: Aortic (bifurcation) Graft (Replacement), Arteriovenous Dialysis Catheter, Fistula or Shunt Surgically Created
996.2 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication of Nervous System Device, Implant, and Graft; Involving Dorsal Column Stimulator; Electrodes Implanted in Brain; Peripheral Nerve Graft; Ventricular (communicating) Shunt
996.51 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Corneal Graft
996.54 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Breast Prosthesis
996.59 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Mechanical Complication due to Other Implant and Internal Device, Not Elsewhere Classified
996.61 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Infection and Inflammatory Reaction due to Cardiac Device, Implant, and Graft
996.62 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Infection and Inflammatory Reaction due to Other Vascular Device, Implant, and Graft
996.66 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Infection and Inflammatory Reaction Due to Internal Joint Prosthesis
996.67 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Infection and Inflammatory Reaction Due to Other Internal Orthopedic Device, Implant, and Graft
996.69 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Infection and Inflammatory Reaction Due to Other Internal Prosthetic Device, Implant, and Graft
996.70 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Unspecified Device, Implant, and Graft
996.71 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Heart Valve Prosthesis
996.72 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Other Cardiac Device, Implant, and Graft
996.73 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Renal Dialysis Device, Implant, and Graft
996.74 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Other Vascular Device, Implant, and Graft
996.75 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Nervous System Device, Implant, and Graft
996.76 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Genitourinary Device, Implant, and Graft
996.77 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Internal Joint Prosthesis
996.78 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Other Internal Orthopedic Device, Implant, and Graft
996.79 - Complications Peculiar to Certain Specified Procedures in the Use of Artificial Substitutes, Other Complications Due to Other Internal Prosthetic Device, Implant, and Graft

Overview

Devices, implants, and grafts all refer to surgical placement of a man-made mechanical, synthetic implantable material, or biological implantable material into the body to correct a clinical condition. Advances in technology have dramatically increased the number of surgeries performed each year for grafts, implants, and devices, and improved the outcomes. Complications refer to development of any unexpected or unwanted postoperative conditions related to the device, graft, or implant.

The most common type of grafts are skin grafts and bone grafts. For skin grafts, the graft can be permanent or temporary. In the case of temporary grafts, the grafted material gradually is resorbed and replaced with new growth. For bone, the grafts are gradually broken down and replaced with new bone.

Material to form the graft can come from a variety of natural and synthetic sources. When tissue is removed from one area of the body and grafted into another area, it is called an autograft. When material is removed from another individual of the same species (either living or a cadaver) and used in a second individual, the graft is an allograft. When material is removed from one species and grafted into another species (e.g., grafts of pig skin into humans), the graft is a xenograft.

In addition, graft material can be completely synthetic. Common synthetic grafts are either ceramic-based (calcium phosphate or calcium sulfate) or polymer-based materials. Often grafts are a combination of these different materials. Each type of graft has benefits and drawbacks, along with differences in the incidences of complications.

The majority of implants (e.g., breast and cochlear implants) and surgical devices (e.g., knee and hip prostheses) are synthetic. Implants and devices are commonly made of a combination of metal, ceramic, and polymer plastics. Complications vary with the type of implant or device, its location in the body, the experience of the surgeon, and the health and immunological response of the individual. Metal sensitivity in some individuals may produce a biologic response to implantation of metallic orthopedic devices due to metal ion exposure and release.

Most complications fall into four general categories: bleeding and surgical complications; postoperative infection; immune response and rejection; and device failure.

Bleeding and surgical complications can affect the viability or function of the graft, implant, or device, and may cause damage to the tissues surrounding the surgical site. For example, the most common reason for failure of a skin graft is inadequate contact with the recipient tissue bed; bleeding may cause blood to pool under the graft (hematoma), decreasing contact between the graft and the recipient's tissue. Other complications can arise from technical limitations when the graft or implant must be placed in a difficult or suboptimal location. In some cases the recipient site is not well vascularized, reducing the flow of needed blood and oxygen to tissue and resulting in failure of the graft or implant. As in all surgery, blood clots or thrombophlebitis may develop during or after surgery, increasing the risk of pulmonary embolism or stroke (cerebrovascular accident).

Infection is a potential complication of all surgical procedures. However, risk is even greater in individuals with burns, where large sections of the air-skin barrier have been breached. In individuals receiving allografts, there is a low but real possibility that the tissue transferred from another individual will cause infection or disease.

An immune response to the graft, implant, or device and subsequent rejection is also a common complication. Autografts are least likely to be rejected, since the tissue being grafted is harvested from the individual receiving the graft and the cells in the graft are still recognized by the immune system as self-cells when the tissue is moved to another place in the body. Occasionally, autograft rejections occur for unknown reasons.

Allograft rejection is more common than autograft rejection. Allograft tissue can come from either a living donor or a cadaver. The tissue is often processed in ways that help to decrease the likelihood of an immune response and rejection by the recipient. An immune response and rejection is even more likely when a xenograft is performed. Rejection also can occur because of sensitivity toward synthetic material used in the implant or device. About 13% of the population has sensitivity to metals such as nickel, cobalt, and chromium (Rabin), which may be used in implants and devices. However, the role of metal sensitivity in device rejection remains controversial; several studies have found that less than 0.1% of device rejection appears to be caused by metal sensitivity (Rabin), making the clinical significance of this reaction unclear.

Finally, devices can fail because they are improperly implanted, break down, wear out, or migrate out of position. For example, the breakdown of silicone breast implants has received extensive coverage in the media. Device failure can occur almost immediately or years after the initial surgery. In addition, implants that are intended as temporary may fail if they are not resorbed by the body as expected.

Incidence and Prevalence: The most common postoperative complication of indwelling devices and implants is infection; nearly half of the 2 million hospital-related infections (nosocomial infections) reported annually are associated with indwelling devices and implants (Daroiche).

Surgical procedures using grafts, implants, and devices are common, with more than 600,000 bone grafts performed in the US annually and 2.2 million worldwide (Laurencin). Skin grafts are commonly used in individuals with burns. Increasingly, grafts and implants are used in the practice of elective cosmetic surgery. Even corneas can be transplanted in a graft procedure.

In 2008, more than 418,000 American women received breast implants; of those, 73% had implant surgery for cosmetic reasons (Brody). It is estimated that there are more than 6 million of women living with breast implants in the US (Brody).

More than 200,000 primary total hip replacement surgeries are performed in the US each year, and 45,000 hip revisions; also, 400,000 primary total knee replacements are done, with more than 36,000 knee revisions (Singh).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk of complications depends on the type of procedure, the experience of the surgeon, the health of the individual and underlying conditions that necessitate the graft, implant, or device. Risk of complications can range from minimal for implantation of a drainage device, to much higher for procedures such as heart valve replacement. The postoperative risk for infection and rejection of devices, implants, and grafts is higher than other possible complications.

Source: Medical Disability Advisor



Diagnosis

History: Signs vary considerably depending on the type and site of the graft, implant, or device. However, when complications such as postoperative infection or immune response and rejection arise, individuals may report redness, pain, and swelling at the site of the graft or implant. In addition, there may be fever and other flu-like symptoms, impairment of the graft's or implant's function, or failure of the original condition to improve.

Physical exam: Physical exam may reveal swelling and inflammation at the site of the graft, implant, or device, sloughing of grafted material, or movement or migration of the device. Fever, generally feeling sick (malaise), weight loss, and / or infections may be observed. Complications may be life threatening.

Tests: Imaging tests (x-ray, computed tomography [CT], magnetic resonance imaging [MRI], or diagnostic ultrasound) are done to examine internally implanted devices. Blood tests and tissue culture may reveal the presence of infection. Metal hypersensitivity may be detected by tracing white blood cell (leukocyte) migration using a test for the lymphokine migration inhibition factor (MIF); the lymphocyte transformation test may also be useful (Rabin). Other tests are specific to the type of device and suspected complication.

Source: Medical Disability Advisor



Treatment

Treatment depends on the type of complication; the type of graft, implant, or device used; and the underlying condition that necessitated the graft or implant. Treatment can range from medications such as antibiotics and immunosuppressive drugs to revision surgery to remove or replace the graft, implant, or device. Pain and fever medications (analgesics/antipyretics) may be given to control symptoms but will not correct the underlying condition.

Source: Medical Disability Advisor



Prognosis

Prognosis depends on the type of complication, the options available for treatment, and the health of the individual. Prompt treatment of the complication tends to improve prognosis. Complications can be fatal.

Source: Medical Disability Advisor



Complications

Each type of graft, implant, or device has specific complications that vary widely according to location.

Potential complications of cardiac grafts such as coronary artery bypass graft (CABG) include heart attack (myocardial infarction), stroke, hemorrhage, infection, memory and comprehension difficulties, poor concentration, and obstruction of the graft. Complications of cardiac implants such as prosthetic heart valves include irreversible dilation of an artery due to infection (mycotic aneurysm), inflammation of the kidney (glomerulonephritis), metastatic abscesses, valve failure, endocarditis, and bleeding secondary to anticoagulants or thromboembolism. Complications of cardiac pacemakers include malfunction, under- or over-sensing, loss of capture, incorrect heart rate, poor lead position, improper mode, generator failure, elevated heart rate, and poor electrode placement. Other complications that can occur during placement or removal of the pacemaker include injury to blood vessels or the heart (perforation, hemorrhage), infection, blood in the chest (hemothorax), air in the chest (pneumothorax), cardiac tamponade, blood clot, and avulsion of right ventricular myocardium.

Complications of vascular implants, such as inferior vena cava filters, include migration of the filter causing obstruction of blood flow, misplacement of the filter, perforation of adjacent structures such as the duodenum or ureter, and bleeding. Other complications include blood clot formation at the insertion site and lower extremity edema and skin ulcers (postphlebitic syndrome).

Complications of corneal grafts include graft rejection, graft failure, infection, perforation, vision loss, and scarring.

Complications of brain shunts include bleeding, infection, malfunction, and seizures.

Complications associated with orthopedic implants, such as ankle, knee, hip, and shoulder prostheses used in joint replacement, include infection, loosening of the device, dislocation, blood vessel or nerve injury, pain, and poor wound healing.

Intrauterine devices may cause perforation of the uterus, increased chance of ectopic pregnancy, increased menstrual blood flow, and painful menstruation; the device also may be expelled, leading to unintended pregnancy.

Complications of a type of genitourinary implant, the urethral sling, include erosion of the urethra or vagina, loosening of sutures, infection, implant rejection, and sexual dysfunction.

Some women experience complications from breast implants including pain, edema, infection, changes in skin color, lack of breast symmetry, blisters, and tissue death (necrosis). Also, some implants may leak, rupture, or migrate out of place.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Return to work restrictions and accommodations must be determined on an individual basis depending on the type and location of the complication as well as the underlying condition necessitating the original procedure. Additional time off may be necessary if further surgery must be performed.

Risk: Risk is dependent on the cause of the complication.

Capacity: Capacity is determined by the location, cause, and the severity of the complication.

Tolerance: Tolerance is affected by pain which is impacted by the capacity, which is determined by location, cause, and the severity of the complication.

Accommodations: Employers able to accommodate physical demands are more likely to have individuals return to work sooner.

Source: Medical Disability Advisor



Maximum Medical Improvement

60 to 180 days.

Source: Medical Disability Advisor



Regarding diagnosis

Regarding diagnosis:
  • What was the cause of the complication? Did individual have bleeding or surgical complication, postoperative infection, immune response and rejection, or device failure?
  • Did individual report redness, pain, and swelling at the site of the graft or implant?
  • Does individual complain of fever and other flu-like symptoms?
  • Does individual have a decrease of the graft or implant's function, or failure of the original condition to improve?

Regarding treatment:

  • Is individual receiving appropriate medications such as antibiotics and immunosuppressive drugs?
  • Were analgesics/antipyretics needed for pain and fever?
  • Was revision surgery to remove or replace the graft, implant, or device necessary?

Regarding prognosis:

  • What type of complication did the individual have?
  • What options were available for treatment?
  • Did individual receive prompt treatment of the complication?
  • Does individual have any conditions that may affect ability to recover?
  • Can individual's employer accommodate any necessary restrictions?

Source: Medical Disability Advisor



References

Cited

Brody, Garry S. "Silicone Breast Implant Safety and Efficacy." eMedicine. Eds. James Neal Long, et al. 25 Apr. 2012. Medscape. 13 May 2014 <http://emedicine.medscape.com/article/1275451-overview >.

Darouiche, Rabih O. "Treatment of Infections Associated with Surgical Implants." New England Journal of Medicine 350 14 (2004): 1422-1429. New England Journal of Medicine. 25 Mar. 2009 <http://content.nejm.org/cgi/content/extract/350/14/1422>.

Jacobson, Jon A. "Hip Replacement Imaging." eMedicine. Eds. Felix S. Chew, et al. 25 Sep. 2013. Medscape. 13 May 2014 <http://emedicine.medscape.com/article/398669-overview>.

Laurencin, Cato T. "Bone Graft Substitute Materials." eMedicine. Eds. Jason H. Calhoun, et al. 4 Dec. 2013. Medscape. 13 May 2014 <http://emedicine.medscape.com/article/1230616-overview>.

Rabin, Steven, et al. "Immune Response to Implants." eMedicine. Eds. Jason H. Calhoun, et al. 4 Sep. 2013. Medscape. 13 May 2014 <http://emedicine.medscape.com/article/1230696-overview >.

Singh, Jasvinder A. "Epidemiology of Knee and Hip Arthroplasty: A Systematic Review." Open Orthopedic Journal 51 (2011): 80-85.

Source: Medical Disability Advisor






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