What are the risks for a 59-year-old female with morbid obesity, well-controlled Type 2 Diabetes Mellitus (T2DM), and Chronic Kidney Disease (CKD) stage 3 undergoing right knee replacement surgery?

From the Guidelines

This patient requires a comprehensive preoperative assessment and optimization before undergoing right knee replacement surgery due to her multiple comorbidities, including morbid obesity, CKD stage 3, and well-controlled diabetes type 2. Given her complex medical history, a thorough evaluation of her cardiac function, including ECG, echocardiogram, and possibly stress testing, is essential to stratify her perioperative risk 1. Her morbid obesity and CKD stage 3 increase her risks for perioperative complications, such as acute kidney injury, wound infections, and cardiopulmonary events 1. However, her well-controlled diabetes is a favorable factor, and maintaining glycemic control with a target HbA1c <7.5% is crucial to reduce her perioperative risks 1. Preoperative optimization should also include a nephrology consultation to assess kidney function stability and evaluation of her current medications, including holding metformin 48 hours before surgery to prevent lactic acidosis risk due to her CKD 1. Perioperative venous thromboembolism prophylaxis is essential, typically with enoxaparin 40mg daily, with possible dose adjustment for kidney function, starting 12 hours postoperatively 1. Multimodal pain management should be planned with reduced doses of renally-cleared medications to minimize her risk of acute kidney injury 1. Postoperatively, early mobilization, careful fluid management, and vigilant monitoring of renal function are crucial to prevent complications and improve surgical outcomes 1. Key considerations for her perioperative management include:

• Comprehensive cardiac evaluation
• Preoperative optimization of glycemic control and kidney function
• Perioperative venous thromboembolism prophylaxis
• Multimodal pain management with reduced doses of renally-cleared medications
• Postoperative monitoring of renal function and careful fluid management.

From the Research

Risk Stratification for Right Knee Replacement

The patient in question is a 59-year-old female with morbid obesity, well-controlled diabetes type 2, and chronic kidney disease (CKD) stage 3. To assess the risks associated with right knee replacement, we can look at the following factors:

• Diabetes and CKD: A study published in 2017 2 found that CKD is associated with a higher risk of complications, including urinary tract infections, myocardial infarction, and all-cause mortality, after total knee arthroplasty (TKA) in diabetic patients.
• Diabetes and Outcomes: A 2020 study 3 found that patients with diabetes mellitus had a lower adjusted odds ratio for mortality and no significant difference in total hospital charges and length of hospital stay after TKA. However, another study published in 2021 4 found that diabetes mellitus blunts the symptoms, physical function, and health-related quality of life benefits of TKA.
• Metformin Use: A 2021 study 5 found that metformin use is associated with fewer complications, including periprosthetic joint infection and 1-year revision rates, in patients with type-2 diabetes undergoing TKA.
• Functional Outcome: A 2012 study 6 found that patients with type 2 diabetes mellitus have a worse functional outcome post-knee arthroplasty, with significant differences in maximal flexion, total range of movement, and Knee Society Score at 1,5, and 10 years post-procedure.

Key Considerations

Some key considerations for the patient's risk stratification include:

• The presence of CKD stage 3, which may increase the risk of complications after TKA
• The patient's well-controlled diabetes type 2, which may still affect outcomes after TKA
• The potential benefits of metformin use in reducing complications after TKA
• The potential for a worse functional outcome after TKA due to the presence of diabetes mellitus

Potential Risks

Potential risks associated with the patient's right knee replacement include:

• Urinary tract infections
• Myocardial infarction
• All-cause mortality
• Periprosthetic joint infection
• 1-year revision rates
• Worse functional outcome, including reduced maximal flexion, total range of movement, and Knee Society Score