What are the considerations for primary care when granting surgical clearance for orthopedic procedures?

Key Considerations for Primary Care When Granting Surgical Clearance for Orthopedic Procedures

Primary care physicians should conduct a thorough cardiovascular risk assessment, optimize modifiable risk factors, and provide specific recommendations for perioperative management rather than simply stating a patient is "cleared for surgery" to minimize morbidity and mortality associated with orthopedic procedures. 1

Cardiovascular Risk Assessment

Essential Components

• Identify serious cardiac conditions that increase perioperative risk:
  • Unstable coronary syndromes
  • Decompensated heart failure
  • Significant arrhythmias
  • Severe valvular disease 1

Risk Stratification

1. Functional capacity evaluation:

   • Document in metabolic equivalents (METs)
   • <4 METs (inability to climb a flight of stairs) indicates higher risk

   • 10 METs (participation in strenuous sports) indicates lower risk 1

2. Surgical risk assessment:

   • Orthopedic procedures, particularly those involving prolonged immobilization, carry increased thrombotic risk 2
   • Major orthopedic surgeries (joint replacements, spine surgeries) carry higher cardiovascular risk than minor procedures

Preoperative Testing

Laboratory Testing

• Essential baseline tests:
  • Complete blood count
  • Basic metabolic panel
  • Coagulation profile (especially if on anticoagulants)
  • ECG for patients ≥50 years old 1

Additional Testing Based on Risk Factors

• Cardiac testing only if results would change management:

  • Stress testing for patients with poor functional capacity and multiple risk factors
  • Echocardiogram for patients with known or suspected valvular disease or heart failure

• Special considerations for specific conditions:

  • Myeloproliferative disorders: Coagulation tests to evaluate for acquired von Willebrand disease in patients with elevated platelet counts 2
  • Duchenne muscular dystrophy: Pulmonary function testing and cardiac evaluation 2

Medication Management

Anticoagulants

• Warfarin management:
  • For high thrombotic risk procedures (including orthopedic surgery), consider bridging with LMWH
  • Monitor PT/INR closely before surgery
  • Resume therapy based on bleeding risk assessment 3

Antiplatelet Therapy

• Aspirin:
  • Consider withholding in patients with bleeding risk
  • May be continued for vascular surgery patients 2
  • Discuss with surgical team regarding timing of discontinuation

Other Medications

• Document all medications including:
  • Prescription medications
  • Over-the-counter medications
  • Herbal supplements (many can affect coagulation) 1, 3

Special Patient Populations

Elderly Patients

• Higher risk for complications due to:
  • Multiple comorbidities
  • Decreased physiological reserve
  • Polypharmacy 4
• Consider more conservative medication dosing and more frequent monitoring 3

Patients with Myeloproliferative Disorders

• Thrombosis and bleeding risk should be well-controlled prior to elective orthopedic surgery
• Consider extended prophylaxis with LMWH for procedures with high VTE risk
• Normalize or near-normalize CBC without causing prohibitive cytopenias 2

Pediatric Patients

• Specific considerations for children with:
  • Developmental dysplasia of the hip
  • Limb deformities
  • Neuromuscular conditions
  • Sports injuries 2

COVID-19 Considerations

During pandemic conditions:

• Preoperative screening according to institutional protocols
• Multidisciplinary management with surgical and perioperative medical teams
• Consider geographic segregation of staff when possible 2

Documentation and Communication

Effective Documentation

• Avoid phrases like "cleared for surgery"
• Provide specific recommendations for perioperative management 1
• Document cardiac risk category and specific recommendations

Communication

• Direct communication with surgeon and anesthesiologist
• Discussion with patient and family about risks 1

Common Pitfalls to Avoid

1. Ordering unnecessary tests that won't change management
2. Using vague terminology like "cleared for surgery"
3. Failing to communicate directly with the surgical team
4. Overlooking functional capacity assessment
5. Incomplete medication reconciliation 1

Postoperative Considerations

• Plan for appropriate level of postoperative care
• Anticipate potential complications based on preoperative risk assessment
• Consider extended VTE prophylaxis for high-risk orthopedic procedures 2

By following these guidelines, primary care physicians can optimize patient outcomes and minimize perioperative morbidity and mortality for patients undergoing orthopedic procedures.