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 login to view 1 more bullet obesity Consistently shown to increase the risk of postoperative complications login to view 1 more bullet 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 login to view 2 more bullets Clopidogrel management should be discussed with a cardiologist and restarted as soon as possible login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 1 more bullet illicit drug use History of substance abuse/misuse have a 5x increase risk of mortality login to view 1 more bullet Higher risk of mortality, readmission, and reoperation in patients who failed a toxicology screen Inflammatory arthritis Biologic medications should generally be held before surgery 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 login to view 1 more bullet postoperative login to view 2 more bullets 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 login to view 13 more bullets