Preoperative Evaluation and Postoperative Care of the Orthopaedic Patient
Ian M. Duensing, MD
James A. Browne, MD
Dr. Browne or an immediate family member has received royalties from DJ Orthopaedics; serves as a paid consultant to or is an employee of DJ Orthopaedics, Kinamed, and OsteoRemedies; has stock or stock options held in Radlink; and serves as a board member, owner, officer, or committee member of American Association of Hip and Knee Surgeons, American Joint Replacement Registry (AAOS), and Southern Orthopaedic Association. Neither Dr. Duensing nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
ABSTRACT
Careful preoperative evaluation and thoughtful postoperative treatment of orthopaedic surgical candidates is essential to successfully minimizing intraoperative and postoperative complications while maximizing postoperative improvement and function. This starts with meticulous preoperative assessment to identify comorbidities that often are not readily apparent in asymptomatic patients but may affect surgical success and risk profiles. Cardiac and frailty risk indices provide objective data that can help surgeons navigate patients through appro-priate stratification and preoperative testing, which occasionally leads to specialist consultation and advanced workup. Cardiac risk assessment is based heavily on patients’ prior history of cardiac disease and/or myocardial infarction. Treatment of patients who have undergone cardiac stent placement can be nuanced and requires collaboration with a cardiol-ogist. A broader understanding of unique risks and management challenges faced with nonelective and emergent cases allows for comprehensive care of all orthopaedic patients. An understanding of individu-alized perioperative pain management strategies and utilization of multimodal pain regimens can lead to improved treatment of patients with postoperative pain and help minimize narcotic use and abuse.
Keywords: multimodal pain regimen; orthopaedic triage; postoperative management; preoperative optimization; risk index
Introduction
Rising numbers of orthopaedic procedures and an aging population create a demand for careful perioperative management, particularly with a trend toward enhanced recovery pathways and same-day discharges. Preoperative care before elective procedures can be complex and requires a multidisciplinary approach to ensure appropriate risk stratification, patient education, and optimization. This includes preoperative screening tests and risk index calculations as well as optimization of medical comorbidities.
Importance of Optimization
Personal subjection to risk has always been associated with surgery, with historically poor predictability leaving patients and surgeons with a sense of uncertainty. The evolution of formal risk prediction has allowed for quantifiable risk assessment and informed surgical decision making. Surgical risk is individualized from patient to patient and influenced by a number of static and dynamic factors; some of these are modifiable, some are not. The care team should work to influence variables that are modifiable to ensure risk to the patient is as low as possible and the likelihood of success is high. This is important not only for patient success, satisfaction, and quality of life but also for improving the value and cost of care in an already strained health care system.
Pairing Risk With the Surgical Intervention
Perioperative risk spans a spectrum of severity ranging from minor setbacks to devastating complications up to and including death or permanent disability. Each case must be evaluated independently as the complication profile is uniquely different and influenced by individual patient risk and is compounded by complexity of surgery. Most orthopaedic procedures are typically considered to be intermediate risk (>1% but <3% risk for major cardiac events); however, this level can vary.1 High-risk surgery is typically seen as a binary variable, yes or no, based on the aforementioned cutoff value of 3% risk.2 This knowledge, supported with quantitative risk scoring systems and prediction models, helps patients and families set realistic expectations related to mobility, expected recovery, discharge timing, morbidity, and mortality rates. A more comprehensive understanding of the potential for harm allows patients to make better decisions regarding their willingness to proceed with elective surgery.
Preoperative Assessment
Historically, individual risk has been evaluated by surgeons’ gut feeling or clinical gestalt and relied heavily on surgeon experience, comfort level, and the ability to manage complications or escalate care including critical care support.3 Objective risk scoring systems provide/augment/support physicians with quantifiable, evidence-based data for informed decision making. There are many risk calculators available that simplify the process of quantifying risk assessment and allow for immediate data return.
Evaluation/Predictors of Risk
Cardiac Risk Indices
Major adverse cardiac events (MACEs) are prognostically important in patients not undergoing cardiac surgery and frequently occur in asymptomatic individuals. In a 2020 study of more than 2,000 high-risk patients undergoing noncardiac surgical procedures, MACE rates were 15.2% at 30 days and 20.6% within 1 year,4 with a cardiovascular death rate in this group of 1.2% at 30 days and 3.7% at 1 year. The original Cardiac Risk Index (CRI), the CRI in non-cardiac surgery or Goldman Risk Index, weighed patient demographic data, general medical conditions and comorbidities, clinical signs of heart failure, electrocardiographic manifestations, and procedural risk to assign a risk class to these patients.5 This tool has become antiquated with more recent iterations of risk indices and is now of historic relevance only.
Revised Cardiac Risk Index
The Revised Cardiac Risk Index (RCRI) was developed more than 20 years after the original CRI. It is simple, easy to use, and brief, consisting of only six equally weighted components.6 The input variables are specifically centered around a history of cardiac comorbidities and those caused by microvascular and macrovascular disease.7 Table 1 details the components of the RCRI. According to the original description of this risk index, a score of 0 carries a major cardiac event risk of 0.4%, whereas a score of 3 or greater carries a risk of greater than 10%.
Acute Coronary Syndrome, Postmyocardial Infarction, and Cardiac Risk
A prior cardiovascular event elevates the risk of recurrent acute coronary syndrome, particularly in those with multiple prior myocardial infarctions, yielding a recurrence rate of 24.4% within 2 years.8 Survivors of myocardial infarction undergo a transition of risk magnitude as they progress from the acute phase to a more stable chronic phase. Although still at increased risk in comparison with control patients who have not experienced myocardial infarction, there is a well-documented risk regression seen in those with multiple myocardial infarctions, with increasing length of time from event, with risk normalization at around 3 to 4 months.9 The increasing population of patients who have experienced a cardiac event has led to the development of secondary prevention risk indices such as the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention, which evaluates nine clinical variables that can predict up to a fivefold gradient of risk of recurrent acute coronary syndrome, can stratify by magnitude of
risk (low, intermediate, and high), and has been validated in large cohort studies.10
risk (low, intermediate, and high), and has been validated in large cohort studies.10
Table 1 Revised Cardiac Risk Index | ||||||||||||||||
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Total Joint Arthroplasty CRI
General noncardiac risk prediction models may not be as accurate as procedure-specific and population-specific tools. The total joint arthroplasty CRI, which consists of three equally weighted variables (age older than 80 years, history of cardiac disease, and history of hypertension), was developed to better stratify undergoing elective joint replacement,11 with a score of 3 equating to an adjusted odds ratio of 11.19 and 16.27 for cardiac complication after total knee arthroplasty and total hip arthroplasty, respectively. Recently, experts have expressed concerns over this model’s simplicity, citing the importance of sex, family history, ejection fraction, dyspnea, anemia, dialysis, and cardiac and pulmonary comorbidities, which have been independently associated with a postoperative cardiac event after total joint arthroplasty.12 Although validation and further study is needed, identification of these variables should be recognized and potentially included in future prediction models.
Modified Frailty Index
Objective cardiac risks identified by predictive modeling fail to adequately represent a complete picture of total patient risk. Frailty, or a state of vulnerability secondary to accumulation of physiologic deficits and loss of reserve,13 has become an area of interest across surgical specialties and has been heavily studied in orthopaedics as a potential negative modifier of outcomes.13 Two variations of the Modified Frailty Index (mFI) have been validated, the older 11-point model (mFI-11) and a newer 5-point model (mFI-5). The variables included were based on preoperative conditions registered in the American College of Surgeons National Surgical Quality Improvement Program database and extrapolated to fit a more concise model.13 The mFI-5 is a simple tool that looks at five domains which are listed in Table 2.14 Both the mFI-11 and the mFI-5 have been useful across many of the orthopaedic subspecialties and have been shown to be equally effective in predicting 30-day morbidity, postoperative complications, and mortality with excellent concordance in orthopaedics as a whole.14,15
American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator
The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator was created in 2013 as a means to use data collected from the National Surgical Quality Improvement Program database to facilitate decision making in the preoperative setting by assessing surgical appropriateness and safety based on a number of preoperative risk factors.16 The index was formed based on variables from more than 1.4 million patients and include a number of binary variables (yes or no) including presence of diabetes, dyspnea, steroid use, hypertension, congestive heart failure, and smoking (Table 3). Validation of this model has shown high concordance with excellent predictive probability for morbidity, mortality, and surgical and nonsurgical complications.16 An online tool to complete this risk assessment is available at https://riskcalculator.facs.org/RiskCalculator/.
Table 2 Five-Factor Modified Frailty Index | ||||||||||||||
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Preoperative Testing: American College of Cardiology/American Heart Association Guidelines
Presurgical screening frequently yields identification of discrete comorbid conditions that require medical workup and optimization, but more often identifies high-risk individuals in whom further testing may be beneficial. Orthopaedic surgeons and other noncardiac, nonvascular surgeons often rely on the guidance of the 2014 American College of Cardiology/American Heart Association (ACC/AHA).17 Utilization trends of preoperative cardiac testing over the past decade have shown a decline because of increased focus on appropriate use criteria and greater awareness of cost-containment issues.18
Electrocardiogram
Preoperative electrocardiogram (ECG) is a supplemental, noninvasive test that has been heavily relied on perioperative testing for its simplicity and utility in
identification of potentially threatening rhythm abnormalities. Current recommendations for obtaining preoperative resting 12-lead ECG are based on urgency of surgery and functional capacity of the patient, which is expressed as metabolic equivalent tasks (METs),17 or the basal oxygen consumption for a 70-kg male; a MET of greater than 10 implies excellent functional capacity, whereas a MET of less than 4 suggests poor functional capacity.17 This stratification allows determining which patients should proceed with preoperative testing.
identification of potentially threatening rhythm abnormalities. Current recommendations for obtaining preoperative resting 12-lead ECG are based on urgency of surgery and functional capacity of the patient, which is expressed as metabolic equivalent tasks (METs),17 or the basal oxygen consumption for a 70-kg male; a MET of greater than 10 implies excellent functional capacity, whereas a MET of less than 4 suggests poor functional capacity.17 This stratification allows determining which patients should proceed with preoperative testing.
Table 3 The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator | ||||||||||||||||||||||||||||||||||||||||||||||
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Who Needs It
ECG is thought to be of little use and rarely indicated for asymptomatic patients without cardiac history, those undergoing a low-risk procedure, or those who can perform greater than 4 METs1 because it has a low likelihood of changing management. It should, however, be considered for all other groups, including those with known coronary artery disease, peripheral arterial disease, clinically significant arrhythmia, cerebrovascular disease, or other structural heart disease and for any patient undergoing any high-risk procedure.17
When to Seek Cardiac Clearance
Referral restriction and resource preservation is important in patients for whom cardiology referral is necessary. Concerns about ECG findings or appropriateness may be answered through telephone consultation with cardiology to appropriately stratify patients while limiting traffic through heavily sought-after specialists. Reasonable referrals according to the ACC/AHA guidelines17 include:
Patients with cardiac history and new findings on screening ECG if comparison is available or any abnormal findings if prior studies are not available. This is particularly important for patients who are undergoing major or high-risk procedures. A history of coronary artery disease with ST segment changes translates to greater than 11% chance of myocardial infarction or death postoperatively compared with a rate of 2.6% in those without ST segment changes
Patients with clinically significant sustained arrhythmias especially with hemodynamic fluctuations
Patients with conduction abnormalities such as high-grade heart blocks
Patients of any age with family history of sudden cardiac death
Exceptions include a known history of atrial fibrillation that is hemodynamically stable and unchanged from prior assessments or single premature ventricular tachycardia events and nonsustained tachyarrhythmias without hemodynamic compromise.17
Effectiveness as a Screening Tool
Although unlikely to change management significantly most of the time, it meets many of the criteria for a useful screening tool. It is simple to administer, inexpensive, and noninvasive and has the potential to identify high-risk patients. Adherence to the ACC/AHA guidelines for those who should undergo preoperative ECG and appropriate consultation criteria can maximize the utility of the ECG while minimizing inappropriate referral patterns.
Echocardiogram
Heart failure remains a significant cause of perioperative morbidity and mortality. Transthoracic echocardiogram (TTE) is the study of choice when evaluating structural heart disease, specifically, left ventricular morphology assessment (wall thickness and chamber size), ventricular function (filling pressures and ejection fraction), and valvular abnormalities (stenosis versus regurgitation).19
Preoperative Left Ventricular Function
2014 ACC/AHA guidelines recommend17 preoperative assessment of left ventricular function in the following conditions:
New onset dyspnea of unknown etiology in patients without history of heart failure
Presence of clinical signs and symptoms of heart failure
Worsening dyspnea or clinical deterioration in patients with known heart failure
History of valvular heart disease or heart failure without a TTE in the past year
Clinical suspicion of moderate to severe valvular dysfunction
Identification of structural heart problems is critical because left ventricular systolic dysfunction, severe mitral regurgitation, and aortic stenosis were strongly associated with perioperative MACE1 although adherence to ACC/AHA guidelines can be variable.
Specialist Driven
Information guiding the necessity of additional testing is contradictory and often confusing with discrepancies seen even among cardiologists, a subset of whom are culpable of ordering rarely appropriate TTEs with no difference in clinical outcomes.20 The decision for additional cardiac workup and further testing is often identified on preoperative screening by orthopaedic surgeons and anesthesiologists. These visits may prompt referral emphasizing the need for knowledge of these guidelines.
Stress Test
The purpose of the cardiac stress test performed before elective noncardiac surgery is to identify and optimize high-risk patients, particularly those who have abnormal initial screening tests (ECGs or TTEs).18 According to ACC/AHA 2014 guidelines for preoperative evaluation,17 routine screening exercise ECG/TTE or dobutamine stress echo testing is not recommended but is deemed reasonable for patients who are at elevated risk and have poor or unknown functional capacity if it will either change management or help in the assessment for underlying myocardial ischemia.
Chest Radiograph
There is a lack of supportive evidence guiding the use of preoperative chest radiograph before noncardiac surgery because results frequently do not change clinical course. The 2016 updates to the National Institute for Health and Care Excellence guidelines as well as other guidelines recommend against routine preoperative chest radiographs.21 Preoperative chest radiograph may be indicated in patients who are at risk of postoperative pulmonary complications, including individuals older than 60 years, chronic lung disease, American Society of Anesthesiologists class 2 or greater, functional dependence, and hypoalbuminemia (<35 g/L).22
Pulmonary Testing
Pulmonary function testing can identify patients with poor pulmonary reserve and therefore may be useful in detecting those at risk of postoperative pulmonary compromise. However, many of these tests are dependent on patient effort and are difficult to interpret. National Institute for Health and Care Excellence guidelines based on low-quality evidence recommend against routine testing in healthy patients or those undergoing low-risk surgery.21 Pulmonary testing may be indicated in patients with a history of known respiratory disease or those undergoing major or complex surgery with greater risk.21
Use of Beta Blockers
Despite early support in the late 1990s and early 2000s, unacceptably high rates of perioperative hypotension, bradycardia, stroke, and death have resulted in waning enthusiasm for the use of beta blockers.23 Most recent ACC/AHA guidelines17 reflect a much more cautious approach toward the preoperative administration of beta blockers. According to these guidelines, perioperative beta blockers should be avoided in patients within 24 hours of noncardiac surgery if not already taking these medications but should be continued in patients taking these medications chronically. Initiation of beta-blocker therapy may be favored in patients at high or intermediate risk of MACE or in those with three or
more risk factors on the RCRI, but should be initiated more than 48 hours before surgery to assess safety and tolerability of the medication.17
more risk factors on the RCRI, but should be initiated more than 48 hours before surgery to assess safety and tolerability of the medication.17
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