What pre-operative tests and evaluations are recommended for open reduction internal fixation (ORIF) surgery?

From the Guidelines

Pre-operative tests and evaluations for open reduction internal fixation (ORIF) surgery should include a thorough medical history review, physical examination, complete blood count, coagulation studies, comprehensive metabolic panel, urinalysis, chest X-ray, and electrocardiogram, with additional imaging studies as needed to assess fracture patterns and plan the surgical approach. When considering the need for pre-operative tests, it's essential to weigh the risks and benefits, particularly in the context of cardiovascular evaluation, as outlined in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. For patients with known coronary heart disease or other significant structural heart disease, a preoperative resting 12-lead ECG is reasonable, except for low-risk surgery, as it provides prognostic information relating to short- and long-term morbidity and mortality 1. However, routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures, as stated in the guidelines with a Class III: No Benefit recommendation and Level of Evidence B 1. The specific tests may vary based on patient age, comorbidities, and the anatomical location of the fracture requiring ORIF. Additional considerations include:

• Medication reconciliation with instructions to discontinue anticoagulants like warfarin 5-7 days before surgery, NSAIDs 7-10 days prior, and certain herbal supplements 2 weeks before surgery.
• Anesthesia evaluation to determine fitness for surgery and appropriate anesthetic approach.
• Blood glucose monitoring and management for diabetic patients. These evaluations help identify risk factors for complications, establish baseline health status, and optimize surgical outcomes. It is also reasonable to consider exercise stress testing for patients with elevated risk and unknown functional capacity, or cardiopulmonary exercise testing for patients undergoing elevated risk procedures, as outlined in the guidelines 1. Ultimately, the goal of pre-operative evaluation is to minimize morbidity, mortality, and improve quality of life for patients undergoing ORIF surgery.

From the Research

Pre-Operative Tests and Evaluations for Open Reduction Internal Fixation (ORIF) Surgery

• The necessity of pre-operative tests and evaluations for ORIF surgery is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, it can be inferred that pre-operative planning and evaluation are crucial for the success of ORIF surgery, as studies emphasize the importance of careful planning and execution to avoid complications such as root injury 2 and wound infection 4.
• In terms of specific pre-operative tests, the studies do not provide clear recommendations, but it is likely that standard pre-operative evaluations, such as laboratory tests (e.g., complete blood count, blood chemistry) and imaging studies (e.g., X-rays, CT scans), would be necessary to assess the patient's overall health and the extent of the fracture or injury.
• Additionally, the patient's medical history, including any pre-existing conditions or medications, should be carefully evaluated to minimize the risk of complications during and after surgery 6.

Laboratory Tests and Evaluations

• While the studies do not specifically address the need for laboratory tests, it is reasonable to assume that certain tests, such as:
  • Complete blood count (CBC) to assess for anemia or infection
  • Blood chemistry tests to evaluate liver and kidney function
  • Coagulation studies to assess bleeding risk
  • may be necessary as part of the pre-operative evaluation.
• The use of anticoagulation therapy, as discussed in study 6, may also require pre-operative evaluation and management to minimize the risk of bleeding complications.

Imaging Studies and Evaluations

• Imaging studies, such as X-rays, CT scans, or MRI, are likely necessary to assess the extent of the fracture or injury and to plan the ORIF surgery 2, 3, 5.
• These studies can help identify any potential complications, such as root injury or wound infection, and guide the surgeon's approach to the surgery.