Would a patient with severe arthritis, heart failure, chronic obstructive pulmonary disease (COPD), and a history of stroke be a candidate for left ankle and subtalar joint arthrodesis, partial excisional distal fibula surgery?

Heart Failure, COPD, and Stroke History Do Not Automatically Prevent Ankle/Subtalar Arthrodesis Surgery

These comorbidities should not routinely delay or prevent left ankle and subtalar joint arthrodesis with partial excisional distal fibula surgery, but they require careful preoperative optimization and may benefit from delayed surgery with targeted physical therapy, particularly in the case of recent stroke. 1

Guideline Framework for Surgery with Comorbidities

The 2023 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines provide the most relevant framework, recommending proceeding to joint surgery without delay for optimization of non-life-threatening conditions in patients with severe arthritis who have failed nonoperative therapy 1. While these guidelines address hip and knee arthroplasty, the principles apply to other joint arthrodesis procedures in patients with severe symptomatic arthritis.

Key Principle: Non-Life-Threatening Comorbidities

• Heart failure, COPD, and remote stroke history are classified as non-life-threatening conditions that should not routinely delay surgery 1
• The guidelines conditionally recommend proceeding without delay over delaying for optimization of these conditions 1
• Delaying surgery may cause increased pain, loss of function, and paradoxically worsen medical comorbidities due to limited mobility 1

Specific Comorbidity Considerations

Heart Failure

• Heart failure alone does not prevent orthopedic surgery unless the patient has decompensated heart failure or severe valvular disease requiring immediate intervention 1, 2
• Patients with stable, optimally managed heart failure can proceed to surgery 2
• The American Heart Association notes that heart failure is extremely common in patients with arthritis (appearing in the top 10 comorbidities), and routine surgical care must accommodate this population 1
• Medical optimization with ACE inhibitors/ARBs and beta-blockers should continue perioperatively 1

COPD

• COPD does not prevent surgery but increases perioperative risk and requires careful anesthetic planning 1, 2
• COPD patients have increased cardiovascular complications, but this reflects the need for optimization rather than contraindication 1, 3
• The 2018 GOLD guidelines emphasize that COPD patients frequently undergo necessary surgeries with appropriate perioperative management 1
• Ensure optimal bronchodilator therapy and assess for right heart failure, which increases stroke risk in COPD patients 3

History of Stroke

• Recent stroke (within 3-6 months) warrants delay for physical therapy to optimize rehabilitation potential postoperatively 1
• The guidelines specifically state: "patients recovering from medical comorbidities (e.g., stroke) that may limit their rehabilitation postoperatively...may benefit from delaying [surgery] for physical therapy to help improve postoperative outcomes" 1
• Remote stroke history (>6 months) with good functional recovery does not prevent surgery 1
• Stroke is recognized as a common comorbidity in arthritis patients requiring surgical management 1, 2

Algorithmic Approach to Surgical Candidacy

Step 1: Assess Severity and Stability of Each Condition

• Heart failure: Is it compensated? LVEF documented? On guideline-directed medical therapy? 1, 2
• COPD: What is the severity (GOLD stage)? Recent exacerbations? Oxygen-dependent? Evidence of right heart failure? 1, 3
• Stroke: How recent? What is current functional status? Ambulatory? Major lower extremity weakness? 1

Step 2: Identify Absolute Contraindications (Rare)

• Decompensated heart failure requiring immediate intervention 1, 2
• Unstable coronary syndrome 2
• Severe symptomatic aortic stenosis or regurgitation requiring valve surgery 1
• Active COPD exacerbation requiring hospitalization 1
• Stroke within past 3 months with ongoing significant functional impairment 1

Step 3: Determine Timing

Proceed without delay if:

• All conditions are stable and optimally managed 1
• Patient is ambulatory with functional capacity ≥4 METs 2
• No acute decompensation of any condition 1

Consider 3-6 month delay with preoperative physical therapy if:

• Recent stroke (within 6 months) with residual lower extremity weakness 1
• Nonambulatory status from any cause 1
• Major lower extremity muscular weakness that would impair postoperative rehabilitation 1

Delay for medical optimization if:

• Decompensated heart failure requiring medication adjustment 1
• Recent COPD exacerbation requiring change in management 1
• Uncontrolled hypertension or diabetes 1, 2

Common Pitfalls to Avoid

Pitfall 1: Unnecessary Delay for "Optimization"

• The evidence shows that delaying surgery for stable comorbidities causes harm through increased pain, functional decline, and worsening mobility-related complications 1
• Many physicians reflexively delay surgery in patients with multiple comorbidities, but this is not evidence-based for stable conditions 1

Pitfall 2: Underestimating Cardiovascular Risk in Arthritis Patients

• Patients with rheumatoid arthritis have 1.5-fold increased risk of heart failure, 1.3-fold increased risk of atrial fibrillation, and 1.2-fold increased risk of stroke compared to the general population 4, 5, 6
• These cardiovascular comorbidities are often undertreated in arthritis patients 4, 6
• Ensure cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) are identified and treated before surgery 2, 4, 6

Pitfall 3: Failing to Recognize Right Heart Failure in COPD

• COPD patients with right heart failure have a 3-fold increased risk of stroke 3
• Echocardiography should be considered in COPD patients with signs of right heart strain before surgery 3

Pitfall 4: Not Assessing Functional Capacity

• Functional capacity <4 METs (inability to climb one flight of stairs or walk 2 blocks) indicates increased perioperative cardiac risk 2
• This assessment is more predictive than simply having a diagnosis of heart failure or COPD 2

Preoperative Optimization Strategy

For Heart Failure:

• Confirm patient is on guideline-directed medical therapy (beta-blockers, ACE inhibitors/ARBs) 1
• Document LVEF if not recently assessed 1
• Ensure euvolemic status 1

For COPD:

• Optimize bronchodilator therapy per GOLD guidelines 1
• Screen for right heart failure with clinical exam or echocardiography 3
• Consider pulmonary function testing if not recently performed 1
• Ensure no active exacerbation 1

For Stroke History:

• Document current functional status and ambulatory capacity 1
• Assess for lower extremity weakness that would impair postoperative rehabilitation 1
• If stroke was recent (<6 months) and significant weakness persists, delay surgery for 3-6 months of physical therapy 1
• Ensure antiplatelet or anticoagulation therapy is appropriately managed perioperatively 2

Bottom Line for This Patient

A patient with severe arthritis, heart failure, COPD, and history of stroke CAN proceed with left ankle and subtalar joint arthrodesis if:

• Heart failure is compensated and on optimal medical therapy 1, 2
• COPD is stable without recent exacerbations 1
• Stroke is remote (>6 months) with good functional recovery, OR if recent stroke, patient completes 3-6 months of physical therapy first 1
• Patient has functional capacity ≥4 METs 2
• All cardiovascular risk factors are identified and treated 2, 4, 6

The presence of these three comorbidities together does not constitute an absolute contraindication to surgery 1. Rather, they require systematic preoperative assessment, optimization, and appropriate perioperative management. Delaying surgery indefinitely in a patient with severe symptomatic arthritis who has failed nonoperative therapy will likely cause more harm than proceeding with appropriately planned surgery 1.