What are the key considerations for preoperative, perioperative, and postoperative care in orthopaedic surgery?

How I Can Help You as an Orthopaedic Surgeon

I provide evidence-based guidance across the entire perioperative spectrum of orthopaedic care, drawing from current guidelines and high-quality research to optimize patient outcomes in terms of morbidity, mortality, and quality of life. 1, 2

Preoperative Optimization

Patient Assessment and Risk Stratification

• Measure preoperative range of motion and quadriceps strength - an extension deficit is a major risk factor for postoperative extension problems, and quadriceps weakness >20% predicts poor outcomes at 2 years 1
• Screen for nutritional risk using validated tools (NRS) at least 10 days before surgery - preoperative muscle mass is critical to postoperative outcomes, and sarcopenic obesity independently predicts complications 1
• Assess for modifiable risk factors including smoking, alcohol use, undiagnosed hypertension, diabetes, and anemia 2
• Evaluate co-morbidities systematically - approximately 70% of elderly orthopaedic patients are ASA 3-4, with cardiovascular disease (35%), respiratory disease (14%), and cerebrovascular disease (13%) being most common 1

Preoperative Conditioning

• Refer patients with ROM deficits or significant strength asymmetries to physical therapy for prehabilitation - this ensures better self-reported knee function up to 2 years after surgery 1
• Implement conditioning regimens during the preoperative period rather than waiting until after surgery 1

Patient Education

• Provide preoperative education in oral, written, and pictorial formats to both patient and caregiver covering walking with crutches, early postoperative exercises, and the rehabilitation timeline 1, 2
• Establish clear discharge plans preoperatively - this is particularly important given long travel distances and poor transport access in some settings 1
• Build a strong partnership with patient and family to prepare for potentially complicated postoperative courses 1

Laboratory and Diagnostic Work

• Obtain full blood count and urea/electrolytes routinely - approximately 40% of patients have preoperative anemia and 40% have renal dysfunction (GFR <60 mL/min/1.73m²) 1
• Order coagulation studies and chest radiography only when clinically indicated 1

Perioperative Management

Anesthesia and Analgesia

• Use regional anesthesia over general anesthesia when possible - femoral or fascia iliaca blocks can be administered by appropriately trained staff 1
• Implement multimodal opioid-sparing analgesia combining paracetamol and NSAIDs, reserving opioids as last resort in low doses 2
• Prescribe simple analgesics like paracetamol regularly unless contraindicated 1
• Use opioids cautiously until renal function is confirmed - non-steroidal anti-inflammatory drugs are relatively contraindicated in renal dysfunction 1

Surgical Considerations

• Administer prophylactic antibiotics (cefazolin 1 gram IV) 30-60 minutes prior to incision to ensure adequate tissue levels at the time of surgical exposure 3
• For lengthy procedures (≥2 hours), redose cefazolin 500 mg to 1 gram intraoperatively 3
• Continue prophylactic antibiotics for 24 hours postoperatively (every 6-8 hours dosing) 3
• For high-risk procedures (open-heart surgery, prosthetic arthroplasty), consider extending prophylaxis to 3-5 days 3
• Maintain core temperature ≥36°C through active warming for operations >30 minutes 2
• Apply the WHO Surgical Safety Checklist to ensure standardized safety protocols 2

Thromboprophylaxis

• Administer fondaparinux 2.5 mg subcutaneously once daily starting 6-8 hours after surgery once hemostasis is established for hip fracture, hip replacement, and knee replacement surgery 4
• Never administer fondaparinux earlier than 6 hours postoperatively - this significantly increases major bleeding risk 4
• Continue thromboprophylaxis for 5-9 days for standard cases 4
• Extend prophylaxis up to 24 additional days (total 32 days) for hip fracture surgery 4

COVID-19 Specific Precautions (When Applicable)

• Screen all patients for COVID-19 symptoms and exposure history preoperatively 1
• Use N95 respirators or PAPRs, face shields/goggles, fluid-resistant gowns, and double gloves when operating on suspected/confirmed COVID-19 patients 1
• Dedicate separate ORs with negative pressure or portable HEPA filtration for COVID-19 cases 1
• Limit OR personnel to essential staff only with one runner nurse maximum 1
• Request the most experienced anesthesiologist for intubation to minimize airway manipulation time 1
• Prefer regional over general anesthesia when feasible - patients must wear surgical masks throughout 1

Postoperative Care

Early Recovery Protocols

• Remove urinary catheters within 24 hours for most patients 2
• Initiate oral fluids as soon as patient is lucid, and solids after 4 hours 2
• Promote early mobilization - 30 minutes on day of surgery, then 6 hours daily 2
• Continue multimodal analgesia with regular pain assessments using validated scoring systems, including those for cognitively impaired patients 1, 2

Monitoring Requirements

• Routine orthopaedic surgery patients do not require telemetry monitoring - the incidence of clinically important arrhythmias is <2% 5
• Monitor patients with cardiovascular risk factors for 12-24 hours postoperatively if indicated 5
• Use structured telephone support or telemonitoring for higher-risk patients as an alternative to continuous inpatient monitoring 5

Rehabilitation

• Continue rehabilitation for 9-12 months depending on return-to-work or return-to-play goals 1
• Recognize that only 65% of athletes return to preinjury sport level - men are 1.4 times more likely than women to return 1
• Address psychological factors - high self-efficacy, internal locus of control, and low fear levels are associated with better return to play 1

Complications Surveillance

• Monitor for postoperative delirium using multimodal prevention strategies especially in elderly or high-risk patients 2
• Use CRP profiling as a marker for surgical complications - inflammation predicts adverse outcomes 1
• Recognize that high blood glucose in previously normoglycemic patients is associated with increased complications 1

Discharge Planning

• Ensure reciprocal information flow between patient, caregivers, and primary/secondary care services 2
• Consider telemedicine for postoperative follow-up particularly for maintaining social distancing or when travel is difficult 5
• Provide clear emergency contact details and transport plans especially for patients with long travel distances 1

Special Populations

Geriatric Patients

• Assume elderly patients have mental capacity unless clearly demonstrated otherwise 2
• Implement early orthogeriatric input rather than limiting geriatrician involvement to postoperative rehabilitation 1
• Use the Nottingham Hip Fracture Score to predict postoperative mortality and facilitate informed consent discussions 1
• Review polypharmacy carefully - 20% of patients >70 take more than 5 medications, and 80% of adverse drug reactions are potentially avoidable 1

Patients with Hematologic Disorders

• Manage patients with hemophilia and complex hematologic disorders at or in consultation with a comprehensive hemophilia center 6
• Assemble a multidisciplinary team including experienced orthopaedic surgeon, anesthesiologist, and hematologist 6

Key Pitfalls to Avoid

• Avoid excess 0.9% saline - fluid overload >2.5L is associated with adverse outcomes 1
• Do not allow surgical patients to remain NPO when eating is permitted - those who don't eat when allowed have increased length of stay 1
• Recognize that postoperative fatigue inhibits voluntary exercise and immobilization induces anabolic resistance - the lower the anabolic response to feeding, the higher the muscle loss 1
• Never expel the air bubble from fondaparinux prefilled syringes - this causes drug loss 4
• Avoid administering fondaparinux intramuscularly - it must be given subcutaneously only 4
• Be aware of spinal/epidural hematoma risk with fondaparinux in patients receiving neuraxial anesthesia - monitor frequently for neurologic impairment 4