What preoperative checklist should be completed for a patient undergoing knee or hip replacement before scheduling the surgery?

Preoperative Checklist for Knee and Hip Replacement Surgery

Before scheduling elective total hip or knee arthroplasty, complete a systematic preoperative evaluation addressing medical optimization, infection risk reduction, medication management, and patient education to minimize perioperative morbidity and mortality.

Medical Optimization

Anemia Screening and Correction

• Screen all patients for anemia preoperatively 1
• Investigate the cause (iron deficiency, B12/folate deficiency, chronic disease)
• Correct anemia before surgery using oral or intravenous iron 1
• This reduces postoperative complications, transfusion rates, and mortality

Glycemic Control (Diabetes Patients)

• Delay surgery for improved glycemic control in diabetic patients 2
• While no specific HbA1c threshold is definitively established, optimize glucose management before proceeding
• This conditional recommendation prioritizes reducing infection risk despite low-quality evidence

Smoking Status

• Achieve smoking cessation or reduction before surgery 2
• Ideally 4 weeks or more of cessation to reduce respiratory and wound-healing complications 1
• Even short-term cessation may provide benefit, though evidence is less clear for periods under 4 weeks

Alcohol Use

• Recommend 4 weeks of alcohol abstinence before surgery 1
• Consumption >2 units/day increases postoperative infection risk
• Cessation reduces complications without impacting mortality or length of stay

Obesity Assessment

• Do NOT delay surgery solely to meet rigid BMI thresholds 2
• Educate patients about increased surgical and medical complication risks
• Counsel on weight loss strategies, but proceed with surgery when indicated
• This represents a significant shift from historical practice patterns

Cardiovascular and Pulmonary Assessment

Cardiopulmonary Risk Stratification

• Identify patients at high risk for bone cement implantation syndrome (BCIS): advanced age, male sex, significant cardiopulmonary disease, diuretic use 3
• Consider invasive blood pressure monitoring for high-risk patients 3
• Ensure adequate hydration status before surgery 3

Hypertension Control

• Optimize blood pressure control preoperatively
• Maintain systolic blood pressure within 20% of baseline during surgery 3

Infection Risk Reduction

MRSA Screening and Decontamination

• Screen for MRSA colonization 4
• Perform skin decontamination protocols when indicated

Urinary Tract Infection Screening

• Screen for and treat active UTIs before surgery 4

Dental Evaluation

• Complete dental screening to identify and treat active infections 4

Medication Management

Antirheumatic Medications (for patients with inflammatory arthritis or SLE)

Continue through surgery:

• Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, apremilast 5, 6

Withhold before surgery:

• All biologics: Plan surgery after the next dose is due 5, 6
• JAK inhibitors (tofacitinib, baricitinib, upadacitinib): Withhold ≥3 days before surgery 5, 6
• SLE immunosuppressants (non-severe disease): Withhold mycophenolate, azathioprine, cyclosporine, tacrolimus 1 week prior 5, 6

Resume medications:

• Restart when wound shows healing, sutures/staples removed, no significant swelling/erythema/drainage, no infection (typically ~14 days) 5, 6

Antithrombotic Therapy

Aspirin management:

• Continue aspirin in patients at moderate-to-high cardiovascular risk 7
• Consider stopping 7-10 days before surgery in low-risk patients 7

Warfarin management:

• Stop 5 days before surgery
• For low thromboembolism risk (mechanical valve, atrial fibrillation, VTE): No bridging anticoagulation 7
• For high-risk patients requiring bridging: Stop therapeutic LMWH 24 hours before surgery 7

Coronary stents:

• Defer surgery ≥6 weeks after bare-metal stent placement 7
• Defer surgery ≥6 months after drug-eluting stent placement 7
• If surgery cannot be deferred, continue dual antiplatelet therapy perioperatively 7

VTE Prophylaxis Planning

• Plan for LMWH or adjusted-dose warfarin starting 12 hours before or 12-24 hours after surgery 8
• Minimum duration: 7-10 days for elective hip/knee replacement 8
• Consider extended prophylaxis (minimum 4 weeks) for high-risk patients 8

Patient Education and Preparation

Preoperative Education Program

• Provide oral, written, and/or pictorial education to patient and caregiver 1
• Cover realistic surgical expectations, recovery timeline, pain management, mobilization goals 9
• Patients attending structured education programs demonstrate better correlation between expectations and actual experience 9

Cognitive and Psychiatric Assessment

• Screen cognitive ability to understand postoperative instructions 10
• Assess psychiatric stability and patient motivation 10

Social and Logistical Factors

• Confirm transportation access for surgery and follow-up 10
• Verify ability to recover at home with appropriate support 10
• Assess financial capability for procedure and recovery needs 10

Technical Surgical Planning

Preoperative Imaging and Templating

• Complete digital templating for prosthesis sizing 11, 12
• Review radiographs for deformity, bone loss, or neuropathic joint changes
• Do not delay surgery for severe deformity or bone loss 2

Surgical Team Briefing

• Conduct preoperative team briefing addressing patient-specific risks 3
• Use WHO Safe Surgery checklist "time-out" 3
• Ensure experienced surgeon and anesthesiologist availability 3

Common Pitfalls to Avoid

1. Do not pursue additional nonoperative treatments (physical therapy, NSAIDs, injections) once surgery is indicated—this delays definitive treatment without improving outcomes 2

2. Do not mandate arbitrary weight loss targets—obesity alone should not delay surgery, though risks must be discussed 2

3. Do not continue biologics through surgery—plan surgery timing around dosing schedules to minimize infection risk 5, 6

4. Do not bridge anticoagulation in low-risk patients—this increases bleeding without reducing thromboembolism 7

5. Do not schedule surgery within 6 months of drug-eluting stent placement unless absolutely necessary 7

This systematic approach addresses the major modifiable risk factors while avoiding unnecessary delays that prolong patient suffering without improving outcomes. All recommendations balance infection risk, cardiovascular events, and quality of life considerations.