There are multiple risk factors for complications following elective total joint replacement (TJR) surgery. Certain risk factors, including operating time, implant choice, component positioning, and intraoperative difficulties (e.g., fracture, nerve and vascular damage), are related to the surgeon’s experience and decision-making and are not patient dependent. However, many risk factors for complications after TJR are patient dependent. Bacterial colonization, diabetes control, body mass index (BMI), smoking status, fall risk, narcotic and/or alcohol dependence, physical conditioning, neurocognitive disorders, nutritional status, cardiovascular status, nongenetic thromboembolic risk, and anemia all represent potentially modifiable factors that increase the risk of complication with TJR.

Orthopaedic surgeons routinely perform TJR on patients who have one or more of the above-mentioned risk factors. However, this is elective surgery, and some of these risk factors are modifiable prior to surgery. As a result, ethical questions arise. Should patients address these risk factors prior to undergoing TJR, and to what extent should the physician, payer, and health-care institution require the patient to do so? Furthermore, should payers and health-care institutions require that surgeons and patients attempt to modify risk factors prior to these interventions that improve quality of life? If modification of risk is in the best interest of both the patient and the healthcare delivery system, the criteria of sufficient patient participation that should be required and what should be done for patients unable to accomplish sufficient risk modification remain unclear. Additionally, who pays for risk factor modification and just how surgeons and patients can be incentivized to maximize the health status of the patient prior to surgery remain unclear. For example, heavy smokers and patients with uncontrolled diabetes have good reasons to improve their health status before surgery. However, is there a moral obligation to ensure that the patient makes every attempt or a minimal attempt to modify risk factors even if this means delaying surgery? Must a certain threshold of acceptable risk be met to deem a patient eligible for surgery? We provide a brief overview of the evidence regarding modifiable risk factors and an ethical and economic argument that could support such a policy. We argue that patients should be expected to take a more active role in decreasing the risks for complication prior to elective TJR surgery.