What are the necessary steps to medically clear a patient for right knee arthroplasty?

Medical Clearance Template for Right Knee Arthroplasty

Preoperative History Assessment

A thorough preoperative evaluation must identify patient- and procedure-related risk factors to optimize surgical outcomes and minimize complications. 1

Essential History Components

• Cardiac history: Document any history of coronary artery disease, heart failure, arrhythmias, or recent cardiac events requiring cardiological workup 1
• Metabolic status: Assess diabetes control (HbA1c), thyroid function, and nutritional status as metabolic optimization is essential 1
• Anemia screening: Identify and treat preoperative anemia, as this significantly impacts outcomes 1
• Infection risk factors: Screen for active infections including urinary tract infections, dental infections, and MRSA colonization 1
• Obstructive sleep apnea: Document presence and treatment status, as this affects perioperative management 1
• Weight assessment: Document BMI and discuss weight control if indicated 1
• Anticoagulation/antiplatelet therapy: Document all medications, particularly those affecting coagulation 2
• Peripheral vascular disease: Specifically assess for claudication, rest pain, or history of vascular procedures 2

Physical Examination Requirements

Musculoskeletal Assessment

• Range of motion: Document active and passive knee flexion/extension 3
• Limb alignment: Assess for varus/valgus deformity and measure degree of deformity 3
• Collateral ligament integrity: Test medial and lateral collateral ligaments to determine constraint requirements 3
• Soft tissue envelope: Evaluate skin integrity, previous surgical scars, and soft tissue quality 3
• Extra-articular deformities: Identify any femoral or tibial shaft deformities 3

Vascular Assessment (Critical for At-Risk Patients)

• Immediate preoperative vascular examination: Perform at time of surgical site marking, particularly in patients with peripheral vascular disease 2
• Palpate pulses: Dorsalis pedis and posterior tibial pulses bilaterally 2
• Ankle-brachial index (ABI): Obtain in patients with vascular disease history, noting that arterial calcification may falsely elevate values 2
• Signs of vascular insufficiency: Assess for skin changes, temperature differences, or delayed capillary refill 2

Laboratory Testing

Routine Preoperative Labs

• Complete blood count: Screen for anemia (treat if present) 1, 4
• Metabolic panel: Including creatinine (exclude if >2 mg/dL or 180 micromol/L) 5
• HbA1c: For diabetic patients or those with risk factors 1
• Coagulation studies: If on anticoagulation or with bleeding history 1

Infection Screening (When Indicated)

• Erythrocyte sedimentation rate (ESR): Has sensitivity 0.63, specificity 0.55 for infection detection 6
• C-reactive protein (CRP): Has sensitivity 0.6, specificity 0.63 for infection detection; CRP >13.5 mg/L has 73-91% sensitivity for periprosthetic infection 6, 7
• Urinalysis and culture: If urinary symptoms present 1
• MRSA screening: Nasal swab for colonization 1

Imaging Requirements

Standard Radiographic Evaluation

• Weight-bearing AP knee radiograph: Essential for templating and assessing alignment 3
• Lateral knee radiograph: Assess tibial slope and implant positioning 3
• Skyline/Merchant view: Evaluate patellofemoral joint 3
• Full-length standing hip-to-ankle radiograph: Required for severe coronal deformities or extra-articular deformities 3
• Known magnification markers: Must be present on all templating films 3

Additional Imaging (When Indicated)

• CT without contrast: For severe bone deficiencies or complex deformities 3
• Vascular imaging: If ABI abnormal or vascular insufficiency suspected 2

Subspecialty Consultations

Cardiology Clearance

• Required for: Patients with active cardiac conditions, recent cardiac events, or significant cardiac history 1
• Optimization: Ensure cardiac medications optimized and any necessary interventions completed 1

Dental Clearance

• Screen for: Active dental infections or significant periodontal disease 1
• Complete treatment: Before proceeding with arthroplasty 1

Vascular Surgery Consultation

• Required for: Patients with abnormal ABI, absent pulses, or history of vascular disease 2
• Timing: Must be completed before surgery; restenosis can occur between clinic visit and surgery date 2

Optimization Protocol Checklist

Modifiable Risk Factors to Address

• Anemia correction: Treat to hemoglobin >12 g/dL if possible 1, 4
• Glycemic control: HbA1c <7-8% preferred 1
• Weight optimization: BMI reduction if significantly elevated 1
• Smoking cessation: Minimum 4-6 weeks preoperatively 4
• MRSA decolonization: If positive screening 1
• Dental treatment: Complete all necessary dental work 1
• UTI treatment: Resolve before surgery 1
• Nutritional optimization: Address malnutrition or vitamin deficiencies 1

Perioperative Medication Management

• Antiplatelet agents: Develop specific plan for perioperative management in consultation with cardiology 2
• Anticoagulation: Bridge therapy plan if needed 2
• Chronic medications: Continue or hold per anesthesia recommendations 1

Contraindications to Proceed

Absolute Contraindications

• Active infection: Local or systemic 1
• Severe peripheral vascular disease: Without revascularization 2
• Uncontrolled medical comorbidities: Requiring stabilization first 1
• Serum creatinine >2 mg/dL (180 micromol/L): Relative contraindication per clinical trials 5
• Platelet count <100,000/mm³: Requires hematology evaluation 5

Relative Contraindications Requiring Optimization

• Poorly controlled diabetes: HbA1c >8-9% 1
• Significant anemia: Hemoglobin <10 g/dL 1
• Morbid obesity: BMI >40-45 1
• Active MRSA colonization: Without decolonization 1

Documentation Requirements

The medical clearance note must document:

• All relevant history and physical examination findings 3, 1
• Laboratory results with interpretation 1, 6
• Imaging review and templating plan 3
• Optimization measures completed 4
• Subspecialty clearances obtained 1
• Risk stratification and mitigation strategies 4
• Patient counseling regarding realistic expectations and potential complications 3

Implementation of evidence-based preoperative optimization protocols has been associated with significant reductions in 90-day complications including ED visits, readmissions, revisions, VTE, and mortality. 4