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  • Introduction
    • Overview
      • preoperative optimization of the patient who is planned for a THA or TKA is critical to improving outcomes
    • Optimization can be broken down into the following categories
      • medical optimization
      • preoperative counseling
      • VTE prophylaxis
      • anesthesia plan
      • pain management plan
  • Medical optimization
    • The goal is to identify possible risk factors that increase the risk of complications postoperatively
      • Diabetes
        • Screening patients with hyperglycemia with HbA1C testing
        • HbA1C> 6.7 is associated with an increased risk of wound complications
        • Exact HbA1C target (roughly <8) varies by surgeon and hospital
          • Not all patients will be able to achieve target
      • Obesity
        • Consistently shown to increase the risk of postoperative complications
          • acute kidney failure, CV complications, wound complications, infection
        • BMI >40 has been used in many studies as having an increased risk of complications, but this is a continuous variable without a clear cutoff
        • Weight loss of >5% may be needed to decrease risk
        • Bariatric surgery may have a role
      • Cardiovascular disease
        • Preoperative cardiovascular disease and older age are major risk factors for postoperative cardiovascular events
        • Delay elective surgery in patients whose dual antiplatelet therapy will be stopped within
          • 30 days from bare-metal stent (BMS)
          • 12 months after drug-elution stent (DES)
        • Clopidogrel management should be discussed with a cardiologist and restarted as soon as possible
          • Stopping 7 days preop can lower bleeding events and the need for transfusion without increasing perioperative cardiovascular events.
      • Blood transfusion
        • perioperative blood transfusions are associated with higher rates of postoperative complications
      • Renal disease
        • Patients on dialysis at time of THA or TKA have a 10-20 times increased risk of complications
        • ESRD patients may have improved outcomes if they undergo elective kidney transplant prior to arthroplasty
          • have to weigh risk of transient septicemia from dialysis versus immunosuppression following transplant
      • Methicillin-Resistant Staphylococcus aureus
        • some screen for MRSA colonization and decolonize with mupirocin ointment or chlorhexidine wipes
        • some implement a universal decolonization protocol which has some evidence to be cost-effective
      • Tobacco abuse
        • Increased risk of postoperative complications and infection
        • Referral to formal smoking cessation program
        • 6 weeks of cessation
          • nicotine testing pre-operatively
      • Illicit drug use
        • History of substance abuse/misuse have a 5x increase risk of mortality
          • increased risk of infectious and non-infectious complications as well
        • Higher risk of mortality, readmission, and reoperation in patients who failed a toxicology screen
  • Preoperative counseling
    • Expectations
      • Patient satisfaction after arthroplasty may be heavily based on expectations rather than functional outcome
      • Patients tend to be overly optimistic and have too high of expectations
      • Preoperatively setting expectations for pain, functional outcomes, and possible complications can help make expectations more realistic
    • Social support
      • Preoperative assessment of social support may allow for optimization and discharge planning prior to surgery
      • Psychologic distress may impact pain management postoperatively
        • absence of anxiety may lead to lower pain scores and better functional outcome postoperatively
      • social support can affect length of stay, readmission rates, and non-home discharge
  • VTE prophylaxis
    • Balance in each individual patient weighing the risk of bleeding versus postoperative VTE event and subsequent complications or mortality
      • ACCP recommends mechanical compression devices plus one of the following:
        • vitamin K antagonists (warfarin)
        • low-molecular-weight heparins (enoxaparin)
        • aspirin
        • factor Xa inhibitors (apixaban or rivaroxaban)
        • pentasaccharides (fondaparinux)
        • direct thrombin inhibitors (dabigatran)
      • AAOS recommends a pharmacologic agent, mechanical compression device, or both for VTE prophylaxis in patients with no increased risk of VTE event
      • Aspirin is preferred by many surgeons given its oral route, compliance rates, cost, and low bleeding rates
  • Anesthesia
    • Neuraxial anesthesia (e.g. spinal) is felt to lower postoperative complications due to lower stress than general anesthesia
    • Retrospective studies have shown neuraxial anesthesia to have lower surgical time, infection, postoperative CV events, transfusion rates, and length of stay
  • Pain management plan
    • The goal is adequate pain control for early mobilization, improved patient-reported outcomes and shorter length of stay
    • Mutlimodal approach
      • Oral medications
        • Preoperative
          • NSAIDs (COX-2 inhibitors) and pregabalin given preoperatively decreased opiate consumption, lower pain scores, and improve range of motion without affecting bleeding
        • Postoperative
          • continuation of the above with the addition of judicious use of oral opiate medication with different durations of action
          • Opiate-related adverse drug events have been found to cause up to 50% or postarthroplasty complications
      • Periarticular injections
        • Concoction often of local anesthetic, opiates, and NSAIDs injected into the capsule and soft tissues around a THA or TKA
        • In TKA, periarticular injections have been shown to be equally as effective as femoral nerve blocks and may be cheaper, safer, and easier
        • In THA, periarticular injections are felt to decrease opioid, improve pain control and improve function postoperatively
      • Peripheral nerve block
        • Excellent for pain control but depending on nerve may affect muscle function and recovery
          • THA
            • lumbar plexus blocks, psoas, femoral nerve, sciatic nerve block
          • TKA
            • femoral nerve, adductor canal, sciatic nerve block
              • adductor canal - gives similar pain control to femoral block without causing quad weakness
              • sciatic nerve - may help posterior knee pain but can affect muscle function significantly
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