Updated: 8/6/2020

Arthroplasty Preoperative Medical Optimization

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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
  • Expecations
    • 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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