Optimization of Orthopedic patients
Optimization of a patient awaiting for an orthopedic procedure is seen by orthopedic surgeon as essential for a good outcome in the surgical treatment. This will reduce post-operative complications and enhance the benefits and the overall safety during and after the procedure.
Can we ask an athlete to run the 100 meter without any physical preparation? He will fail badly in front of well-prepared athletes and his performances will not be the best one. This is the same for the orthopedic patient ready to have a major surgical treatment in Orthopedics. I would certainly make sure that all co-morbidities are well controlled. Obesity, Diabetes Mellitus, Peripheral Vascular disease, High Blood Pressure, Mental Health Disorders and so many factors.
When we neglect to have patients ready for surgical treatment, we can be certain to experience all kind of complications related to specific factors including delayed wound healing, infection and wound dehiscence. There has been an increase in re-admission with more burden for the Emergency room physician because the DRG request an implementation of a shorter stay in the hospital. So the healthier is the patient, the better will be the post-operative and recovery period.
The primary care physician generally schedules all preadmission testing and will make sure that any pre admission consultation deem necessary, is obtained prior to clearing patient for surgical treatment. We will do the best to optimize the patient condition especially when an elective surgery is planned. We do understand that factors like age, sex, race, history of previous operations, chronic disease, psychiatric problems can’t always be modified but each of them may be improved with the optimization and certainly will minimize cost to the healthcare system.
It appears easier when a patient is keeping a healthy weight in trying to eat well and in performing exercises keeping his BMI around 25 kg/m2. In an obese patient, nowadays, it may be difficult to make them understand that they need to lose weight for a better outcome of their next surgery especially if a total knee replacement is being contemplated. Perhaps, they will understand better the need to obtain a bariatric consultation and/or undergo by-pass surgery to lose weight.
Remember that, no matter how obese or thin they are, we can find patient experiencing malnutrition and if it is not treated in the pre-operative period, we may have some surprises with proper wound healing. Mainly, malnutrition is recognized when the albumin level drops below 3.5 g/dl, with a serum transferrin level at less than 200 mg/dl, and a serum pre-albumin at less than15g/dl, and finally a total lymphocyte count less than 1,500 cells/mm (Kheir).
Exceptionally, surgeons may have no other choice than to perform surgical treatments on a patient with a low serum albumin in case of emergency. I prefer to normalize the albumin with protein supplement, vitamins and minerals particularly like Zinc and Vitamin B for 2 to 3 weeks in elective cases, prior to perform the surgical treatment. Unfortunately, all patients are not elective and the debilitated patient who present himself as an urgent case will require a different approach and the optimization will certainly present a challenge to the medical and surgical teams. Protein shakes, low in sugar, twice a day for 2 weeks prior to surgery, can be beneficial if surgical procedure can be delayed.
Many will suffer from complications related to an uncontrolled Diabetes while monitoring the glucose and the Hb A1c. A high rate of peri-prosthetic infections may be contemplated in the post-operative period. It is recommended to keep the HbA1c level at about 8% with a fasting blood sugar of 200 mg/dL. Statistics have shown that a Hb A1c of 7.7% is ideal with a fasting glucose level of 140mg/dL, controlled for 2 weeks prior to perform the surgical treatment. Above 8.8% HbA1c, surgical treatment is placed on hold. Joseph Lane MD from the Hospital for Special Surgery recommend to avoid surgery if the diabetes is not under control.
A level of Hemoglobin above 12g/dL is warranted with a hematocrit above 30 or patient is referred to his PCP or to a hematologist for a work up. B 12 vitamins may be needed as well as folate supplementation. If the anemia is caused by an Iron deficiency, we will add 325 mg of iron supplement three times a day for around one month.
Vitamin D deficiency is noted when 25-hydroxy-vitamin D (25(OH)D) is below 20ng/ml and Vitamin D Insufficiency when 25(OH) D is between 21ng/mL and 29 ng/mL should be corrected to a level of 30ng/mL prior to surgical treatment. According to Joseph Lane MD, this bring the optimal level to facilitate any bone healing. African American have been found to have low level of Vitamin D while Blacks in general exhibit better bone stock than Caucasians. The lower the vitamin D level, the lesser chance of healing bone. You, definitely, need vitamin D to mineralize bone and heal fractures.
Testosterone affects muscle bulk while the trauma of a surgical repair lead to a waste of muscle mass and strength. This is why many of our pre-surgical programs for total joint by example, enforce the need to attend some kind of rehabilitation. Discussed in the Orthopedic Journal of Sport Medicine in 2017, it was encouraged to recipients undergoing ACL reconstruction surgery to receive 200 mg of testosterone intramuscularly, weekly until surgery is performed. It is not known how much testosterone is needed to satisfy the muscle but researchers have kept an interest in this topic.
The same goes for anabolic steroids used in ACL reconstructive surgery. Some have even stipulated to use it in Rotator cuff surgery. Hatch believes that it will enhance the recovery time and optimize the outcomes of patient undergoing such repair.
We know for longtime that smokers have an increase in post-operative morbidity and mortality. We do encourage cessation of smoking as part of a counseling process in the preoperative period and if possible for at least 6 weeks prior to any surgical treatment. Smoking encourage microvascular constriction.
Excessive alcohol consumption triggers a dysfunction of the immune system and influence our metabolic stress response to the surgical procedure, facilitating bleeding or infection which carry a longer hospital stay at increased cost. Patients should be encouraged to stop drinking at least 4 weeks prior to undergoing surgical treatment.
Many suffering from other medical conditions may also benefit from optimization. Conditions such as Juvenile Rheumatoid arthritis, Rheumatoid arthritis, Lupus will require a continuation of their medications like Methotrexate etc. No interruption of the medication should be accepted while planning to undergo Total Hip or Total Knee replacement.
Patients should be screened for MRSA and MSSA prior to surgical treatment but if the screening is positive, then, treatment must be offered for a decolonization prior to the planned surgical treatment. By example, once patient is scheduled for the surgical procedure, Vancomycin or Cephazolin should be given to any MRSA positive patient while Cephazolin alone is used for the MSSA positive and MRSA negative patients.
A patient suffering from Depression have a high level of cytokines. They should not be overlooked because they carry with them a higher rate of infection, once they are undergoing a surgical procedure. Psychiatric consultation may include behavioral therapy as well as psychotherapy. If more time is needed for a medical clearance, we should not hesitate to delay any surgical treatment until the patient’s mental health is managed.
Age and Comorbidities as well as the complexity of the cases can affect the success of any surgical case. We need to monitor the patient’s efforts to lose weight or to control their blood pressure or even to stop smoking. This is our responsibility as physicians to optimize any patient with the only goal to avoid or decrease the peri-operative complications. Often, it will take a team of specialists to optimize a patient with health problems. Uncontrolled Diabetes, Hormonal imbalance, Auto-immune disease, Rheumatoid problems, cardiopulmonary problems are known to require a smooth cooperation between the Primary Care Physician, the Cardiologist, the Pulmonologist, the Rheumatologist, the Psychiatrist etc. On the same token, patients should understand the need for their participation in the process. Motivation will render them more in control as well.
Still, many patients will represent challenges to the process of optimization and we will have to affront them individually.
Maxime Coles MD
Levy N, Kilvet A, et al. NHS Diabetes guidelines for perioperative management of the adult patient with Diabetes. Diabet Med 2012:29: pp 420-433.
Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and media analysis. Am J Med 2011: 124: pp144-154.
Kwon S, Thompson R, Florence M, et al> Beta blocker continuation after non-cardiac surgery, a report from the surgical care and outcomes assessment program. JAMA Surg 2012:147 pp 467-473.
Orthopedic Today: Co-management of Medical factors… to optimize patients. Dec 2019