Medical optimization readies patients for successful orthopedic surgery

Co-management of medical factors with other departments may help optimize patients.

Preoperative medical optimization of patients is an approach orthopedic surgeons can use to reduce postoperative complications and improve the overall safety of procedures they perform.

“If we asked an individual to run a marathon tomorrow, without any sort of preparation, we would almost certainly be disappointed by the result as their bodies would not be able to handle such a significant stress. Similarly, if we do not prepare our patients’ bodies to be ready for surgery, it likely will not go as well,” George F. “Rick” Hatch III, MD, associate professor of clinical orthopedic surgery at Keck School of Medicine of USC, said.

There are certain patient factors that cannot be modified, such as age, sex, race, history of previous operations, chronic disease and certain required immunosuppressants. However, Hatch told Orthopedics Today that clinical studies have shown that several modifiable risk factors, when optimized, may improve outcomes and decrease health care costs.

Source: Monica M. Shoji, MD

“Classically, we consider substance use (eg, cigarette smoking), diabetes control, mental health disorders and obesity, among others, as modifiable factors that increase the risk of complications in orthopedic surgery,” Hatch said.

When health care professionals do not attempt to improve the modifiable medical risk factors, patients may experience complications. James J. Purtill, MD, said these may include wound healing problems, cardiovascular complications, infection, increased readmission rates, long-term medical problems and worsening of existing medical conditions. Pre-admission testing done well before surgery is scheduled can indicate which patients need to be optimized to possibly mitigate intraoperative or postoperative problems.

“We should do the best we can to help patients optimize their condition when going through elective surgical procedures. While it may take some extra time and effort, that time and effort is well-invested with regard to the patient’s overall well-being,” Purtill, vice chairman of the department of orthopedic surgery at Thomas Jefferson University and Rothman Orthopaedic Institute, told Orthopedics Today.

Weight and nutrition management

Maintaining a healthy weight and eating well are ways patients can be optimized for elective orthopedic surgery. The American Academy of Orthopaedic Surgeons recommends patients with symptomatic hip and knee osteoarthritis and a BMI greater than or equal to 25 kg/m² lose weight.

“In patients who are morbidly obese, they should be encouraged to lose weight and [be] given all the resources that they may need to lose weight to the extent that they can, and to lose weight safely,” Purtill said. “Nutritionists and weight loss programs are beneficial along those lines.”

Patients, regardless of their weight, may also experience malnutrition. This can lead to a significantly higher complication rate, including hematoma formation, infection, renal or cardiac problems, according to Michael M. Kheir, MD, of the department of orthopedic surgery at Indiana University School of Medicine in Indianapolis.

“The literature defines malnutrition as albumin level less than 3.5 g/dL, serum transferrin levels less than 200 mg/dL, serum pre-albumin less than 15 g/dL and a total lymphocyte count less than 1,500 cells/mm,” Kheir said.

Optimizing albumin levels is important because patients with a low albumin level may experience wound complications that can lead to deep infections, Antonia F. Chen, MD, MBA, director of research, arthroplasty services at Brigham and Women’s Hospital at Harvard Medical School in Boston, said.

Some surgeons may be comfortable performing surgery on patients with a lower albumin level, but Chen told Orthopedics Today most surgeons will not perform surgery on patients whose albumin levels are not in the normal range.

Serum albumin can be optimized with protein supplements and vitamin and mineral supplements, particularly vitamin B, iron and zinc, taken at least 14 days before surgery, according to Kheir.

“We optimize them by giving protein shakes, for example, so they can [drink these] twice a day for 2 weeks prior to surgery,” Chen said. “The key factor is to use protein shakes that are low in sugar because you do not want to make a patient hyperglycemic in that time frame.”

Effect of high HbA1c

Diabetes mellitus is a known independent risk factor for periprosthetic joint infection (PJI) after surgery. Therefore, patients with diabetes should undergo monitoring of glucose and HbA1c levels, according to Kheir. Currently, the recommendation for HbA1c levels is about 8% and fasting glucose levels less than 200 mg/dL. Literature has shown HbA1c less than 7.7% is ideal and fasting glucose levels should be 140 mg/dL. These levels should be controlled by about 2 weeks prior to surgery, he noted

“At Hospital for Special Surgery, we will not do elective surgery on anybody with HbA1c that is above 8%,” Joseph M. Lane, MD, professor of orthopedic surgery at Hospital for Special Surgery and Weill Cornell Medicine, said. “We think that the diabetes should be brought under control for elective surgery.”

Anemia management

Obtaining a patient’s hemoglobin level preoperatively can help the health care team determine whether an individual is anemic, which is something that can increase a patient’s risk for perioperative allogenic blood transfusions and PJI after surgery, Kheir said, noting anemia is defined as a hemoglobin less than 12 g/dL in women and less than 13 g/dL in men.

“The recommendation is that patients with a hemoglobin of less than 10 [g/dL] or hematocrit of less than 30% should probably be referred to their primary care physician (PCP) or to a hematologist for work-up of the primary cause, which could be something as simple as a nutritional deficiency,” Kheir said. Such deficiencies are treatable with iron, vitamin B12 or folate supplementation, he noted.

If the anemia is caused by iron deficiency, patients can either be prescribed a 325-mg iron supplement three times per day for 3 to 5 weeks before surgery or receive IV iron supplementation, “which may be needed in a trauma setting for hip fracture patients,” Kheir said.

Vitamin D deficiency

In clinical practice guidelines, the Endocrine Society defines vitamin D deficiency as when 25-hydroxy-vitamin D (25(OH)D) is below 20 ng/mL and vitamin D insufficiency as 25(OH)D that is 21 ng/mL to 29 ng/mL. Patients at risk for vitamin D deficiency should be screened prior to surgery and be optimized if their vitamin D levels are under 30 ng/mL, according to the guidelines.

Particularly in elective surgery, it is best for a patient’s vitamin D level to be about 30 ng/mL, according to Lane. “[That] would be an ideal situation, particularly if there is bone healing,” he said.

Patients who are thin, who have been ill or who are obese are at risk for low vitamin D. In addition, African Americans have been found to have lower vitamin D levels, Lane said.

“They often have low vitamin D, but African Americans have, on the whole, better bone than Caucasians,” Lane said.

Lane told Orthopedics Today, individuals with low vitamin D levels have a greater chance of falls and lower rates of bone healing. However, vitamin D levels below 30 ng/mL can be optimized within 2 weeks by prescribing 2,000 to 4,000 units of vitamin D, he said.

“You need vitamin D to mineralize your bone and if you do not have vitamin D, you cannot mineralize your bone,” Lane said. “People with low vitamin D are going to be low healing.”

Testosterone affects muscle mass

Studies have shown the trauma of surgical repair can lead to the loss of muscle mass and strength, as well as mobility limitations postoperatively. Some research has associated preoperative rehabilitation or prehabilitation with faster return to sports.

Hatch and his colleagues have studied the effect of intramuscular testosterone on outcomes. In a study published in The Orthopaedic Journal of Sports Medicine in 2017, they found male patients who received 200 mg intramuscular testosterone weekly for 8 weeks, beginning 2 weeks before they underwent ACL reconstruction surgery, had an increase in lean muscle mass 6 weeks after surgery.

The optimal dosage of the administered testosterone and serum testosterone levels to prevent breakdown are currently unknown. Therefore, Hatch said this remains an active area of research at Keck School Medicine of USC.

“After performing the first clinical study of anabolic steroids for ACL reconstruction surgery, we are now investigating its use in augmenting recovery following rotator cuff repair in a double-blind, randomized, controlled, clinical trial,” Hatch said. “This research is ongoing as we hope to explore the diligent and proper use of these medications to enhance recovery times and optimize outcomes in our patients undergoing these procedures.”

Smoking, alcohol cessation

It is widely known that patients who smoke have increased postoperative morbidity and mortality. For that reason, Kheir said smoking cessation should be encouraged.

According to Chen, although there are no specific guidelines related to how long a patient should stop smoking before surgery, she said smoking cessation should ideally occur at least 6 weeks prior to surgery.

“Smoking leads to microvascular constriction. If you decrease smoking or stop smoking, you improve circulation, so you have better wound healing. However, that can take up to 6 weeks to occur,” Chen said.

Excessive alcohol consumption can also lead to dysfunction of the immune response and metabolic stress response. “[These conditions] can augment the physiological stress from the surgical procedure,” increase bleeding and infection risk, and may result in a longer hospital length of stay and increased costs, Kheir said.

“A good history intake of the patient includes quantifying how much alcohol they use, and this is because many patients will underestimate how much they drink,” he said. “The current recommendation is to have a cessation period of at least 4 weeks prior to surgery in order to reverse any physiological abnormalities.”

Optimize all medical conditions

Surgeons should also optimize preoperatively other medical conditions.

According to Kheir, patients with rheumatoid arthritis (RA) have been shown to have an increased risk for PJI. In 2017, the American College of Rheumatology and the American Association of Hip and Knee Surgeons released guidelines that address management of antirheumatic medication usage in patients with RA, spondyloarthritis, juvenile idiopathic arthritis or systemic lupus erythematosus prior to undergoing total hip arthroplasty or total knee arthroplasty. Those recommendations include continuing the use of drugs commonly taken by patients with inflammatory rheumatoid diseases, such as methotrexate, while specifying a dosing plan for withholding biologic medication prior to THA or TKA and performing the surgery at the end of the dosing cycle, Kheir said.

“For patients who have many flares, we work on optimizing the timing of medications they take to minimize flares while minimizing the risk of PJI. By doing so, you can improve their outcomes to some degree,” Chen said.

Patients should also be screened for MRSA and MSSA prior to surgery, according to Chen, and they should be decolonized if the screen is positive.

“On the day of surgery, MRSA-positive patients should receive vancomycin and cephazolin. Those who are MSSA-positive and MRSA-negative should just receive cefazolin,” Kheir said.

Chen said patients with depression have higher cytokine levels, which can lead to a higher rate of infection.

However, Kheir said patients with depression and those with higher cytokine levels should not be overlooked as surgical candidates “because prior studies have shown that improvement in their functional score between preoperative and postoperative timepoints are comparable with patients without psychiatric conditions.”

Optimization of patients with depression may include preoperative counseling about their expectations for surgery, he said.

“Treatment can include cognitive behavioral therapy or psychotherapy. It may be beneficial to delay the elective procedure until the patient’s mental health is well-managed,” Kheir said.

Surgical delay

Patients who present with abnormal levels after preoperative testing may be required to delay surgery until their conditions are optimized, according to Purtill.

Hatch said, “Factors such as age, comorbidities and case complexity all affect complication risk, and the increased risk from each of these factors should be relayed to the patient to engage them in the decision of whether or not to delay surgery. Ultimately, these decisions should be made through an informed conversation between the patient and provider and must be determined on a case-by-case basis.”

Although it may be difficult to motivate some patients to control their diabetes, lose weight or stop smoking, most patients “are genuinely curious about what they can do to improve their health,” Hatch said.

“I have never had a patient complain about saying we want to have a better result with less complication,” Lane said.

However, it is up to surgeons to monitor their patients’ optimization efforts to ensure patients are being optimized in such a way that does not cause more damage or health problems.

According to Chen, patients who are obese should not lose weight in a manner that would cause them to become malnourished. Orthopedic surgeons may be unable to tackle all areas of optimization. Therefore, they should focus their efforts on areas that stand to make the most impact on outcomes, she said.

Departmental collaboration

Co-management of orthopedic patients with the help of other departments may be necessary for optimal optimization to be achieved. A study published in The Journal of Arthroplasty by Fitzgerald and colleagues showed implementation of a hospitalist-orthopedic team co-management model improved quality, cost effectiveness and value among patients undergoing THA and TKA compared with a traditional consultation-only model.

“Collaboration with other specialists is important for optimizing comorbid patient conditions,” Hatch said. “The majority of currently known risk factors for orthopedic complications can be addressed with the help of specialists in other fields.”

Uncontrolled diabetes, hormonal imbalances and autoimmune disorders can be mitigated preoperatively by endocrinologists and rheumatologists who can also “advise on the tricky preoperative management of immune-modifying medications used to treat these conditions,” Hatch said.

Cardiopulmonary variables and important surgery risk assessments for patient counseling can be provided by PCPs, cardiologists and pulmonologists, Hatch said, whereas mental health disorders, addiction and social barriers can be addressed by psychiatrists, psychologists and social workers.

Chen said she will send patients with high BMI to a nutritionist for help with their diet.

“Geriatricians can address issues associated with old age and serve as a contact point for the patient and family,” Hatch said. “Pain management specialists are critical to striking the right balance between treating pain while limiting opiate abuse.”

To optimize a patient’s operative success, Hatch said surgeons should have timely and regular communication with care team members and try to understand how a patient’s factors affect their operative risk.

Patient education about how specific factors can affect overall outcomes may help motivate patients to become optimized prior to an orthopedic procedure, Lane said.

“The real point is not whether we have specialists involved in a patient’s care, because that goes on a case-by-case basis, but how well-managed that patient is in addition to how compliant the patient is with their physician’s recommendations,” Purtill said. – by Casey Tingle

Editor’s note

This Cover Story is the first in a two-part series that focuses on how addressing and managing modifiable risk factors in patients prior to orthopedic surgery can lead to better clinical outcomes. In the January 2019 Orthopedics Today Cover Story, sources will discuss the role of metal hypersensitivity testing performed prior to total joint arthroplasty and elective trauma surgery.

• Reference:
• Fitzgerald SJ, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.03.029.
• Goodman SM, et al. Arthritis Care Res (Hoboken). 2017;doi:10.1002/acr.23274.
• Holick MF, et al. J Clin Endocrinol Metab. 2011;doi:10.1210/jc.2011-0385.
• Tarabichi M, et al. J Arthroplasty. 2017.doi:10.1016/j.arth.2017.04.065.
• Wu B, et al. Orthop J Sports Med. 2017;doi:10.1177/2325967117722794.

• For more information:
• Antonia F. Chen, MD, MBA, can be reached at 75 Francis St., 2nd Floor, Boston, MA 02115; email: afchen@bwh.harvard.edu.
• George F. “Rick” Hatch III, MD, can be reached at 1975 Zonal Ave., Los Angeles, CA 90033; email: meg.aldrich@med.usc.edu.
• Michael M. Kheir, MD, can be reached at 340 W. 10th St., #6200, Indianapolis, IN 46202; email: mikemkheir@gmail.com.
• Joseph M. Lane, MD, can be reached at 475 E. 72nd St., New York, NY 10021; email: ironsm@hss.edu.
• James J. Purtill, MD, can be reached at 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; email: jamespurtill@msn.com.

Disclosures: Hatch reports he is a consultant for Arthrex and his institution receives fellowship educational support from Arthrex. Chen, Kheir, Lane and Purtill report no relevant financial disclosures.

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