What are the recommendations for pre-surgical clearance in orthopedic cases?

Recommendations for Pre-Surgical Clearance in Orthopedic Cases

Pre-surgical clearance for orthopedic procedures should focus on identifying and optimizing conditions that increase perioperative morbidity and mortality, rather than performing routine standardized testing for all patients. 1

Risk Assessment and Targeted Testing

Cardiovascular Evaluation

• Electrocardiography (ECG):
  • Recommended for patients undergoing high-risk surgery
  • Recommended for patients undergoing intermediate-risk surgery who have additional risk factors
  • Not required for patients undergoing low-risk surgery 1

Pulmonary Evaluation

• Chest Radiography:
  • Only indicated for patients at risk of postoperative pulmonary complications if results would change perioperative management
  • Not recommended as routine screening 1

Laboratory Testing

• Complete Blood Count (CBC):

  • Indicated only for patients with diseases that increase risk of anemia
  • Indicated when significant perioperative blood loss is anticipated 1

• Electrolytes and Creatinine:

  • Perform only in patients with underlying chronic disease
  • Perform in patients taking medications that predispose to electrolyte abnormalities or renal failure 1

• Glucose Testing:

  • Random glucose testing only in patients at high risk of undiagnosed diabetes
  • A1C testing in patients with diagnosed diabetes only if results would change perioperative management 1

• Coagulation Studies:

  • Reserved for patients with history of bleeding
  • Indicated for patients with medical conditions predisposing to bleeding
  • Indicated for patients taking anticoagulants 1

• Urinalysis:

  • Recommended only for patients undergoing invasive urologic procedures
  • Recommended for patients undergoing implantation of foreign material 1

Thromboprophylaxis for Orthopedic Surgery

• Major Orthopedic Surgery:

  • All patients should receive prophylaxis with either:
    • Pharmacologic agent (LMWH, aspirin) OR
    • Intermittent pneumatic compression device (IPCD)
  • Minimum duration: 10-14 days
  • Consider extending to 35 days 1

• Patients at Increased Bleeding Risk:

  • Use IPCD or consider no prophylaxis 1

• Knee Arthroscopy:

  • No thromboprophylaxis needed for patients without history of VTE 1

Special Considerations

Timing of Surgery

• For patients with symptomatic moderate-to-severe osteoarthritis or advanced osteonecrosis who have failed nonoperative therapy:
  • Proceed to total joint arthroplasty without arbitrary delay periods 1
  • No need to mandate a 3-month "cooling off" period 1

Obesity Management

• For patients with BMI ≥35, including those with BMI ≥50:
  • Proceed to total joint arthroplasty without delaying for weight reduction 1
  • Educate patients about increased risks but avoid mandatory weight loss requirements 1

Glycemic Control

• For patients with poorly controlled diabetes:
  • Delay surgery to improve glycemic control 1
  • Target optimal glucose levels before proceeding with elective orthopedic procedures 1

Nicotine Dependence

• For patients with nicotine dependence:
  • Recommend cessation prior to surgery 1
  • Provide resources to assist with cessation 1

Polytrauma Patients

• Consider damage control orthopedics (DCO) approach for polytrauma patients 2
• Employ staged approach with temporary stabilization followed by delayed definitive fixation 2

Pre-Assessment Surgical Screening Clinics

• Consider using dedicated Pre-Assessment Surgical Screening (PASS) clinics as an alternative to primary care evaluation 3
• PASS clinics have been shown to be effective even for patients with higher comorbidity burdens 3

Common Pitfalls to Avoid

1. Overreliance on routine testing: Avoid ordering standard batteries of tests for all patients regardless of clinical indication 1

2. Underestimating thrombosis risk: Ensure appropriate VTE prophylaxis for major orthopedic procedures 1

3. Unnecessary surgical delays: Don't mandate arbitrary waiting periods for patients who have already failed conservative management 1

4. Ignoring modifiable risk factors: Address poorly controlled diabetes and nicotine use prior to elective procedures 1

5. Inadequate perioperative planning: Ensure multidisciplinary management with surgical and perioperative medical teams for high-risk patients 1

By following these evidence-based recommendations, clinicians can optimize patient outcomes while avoiding unnecessary testing and delays in orthopedic surgical care.