Perioperative medical comorbidities in the orthopaedic patient

Analysis of the reasons why patients cancel shoulder surgery despite recommendation

Background

To determine the reasons and factors that contribute to the cancellations of shoulder surgeries at a tertiary referral center and to analyze the characteristics of these patients.

Methods

Patients scheduled for shoulder surgery from June 2017 to July 2019 were allocated to a surgery group (n=224) or a cancellation group (n=96). These groups were compared with respect to patient characteristics, types of surgery, distance from patient’s home to the hospital, traveling time to the hospital, and waiting period before surgery. Reasons for cancellation and responses were acquired using a telephone interview and were subsequently analyzed.

Results

The cancellation group was older, had a less frequent history of trauma, and had a lower proportion of patients undergoing arthroscopic rotator cuff repair than the surgery group (p=0.009, p=0.014, and p=0.017, respectively). In addition, mean distance from the patients’ homes to the hospital and preoperative waiting time were both longer in the cancellation group (p=0.001 and p<0.01, respectively). The most common reason given for cancellation was another medical condition (28.1%).

Conclusions

Older age, need for arthroscopic rotator cuff repair surgery, longer distance from the patient’s home to the hospital, and longer waiting period significantly increased the chance of cancellation. The main reason for canceling surgery was a concurrent medical condition. Therefore, identification of other medical conditions in advance is an important consideration when surgeons recommend shoulder surgery to patients. Surgeons should also consider patient's age, type of surgery, distance from the hospital, and waiting time when assessing the possibility of surgery cancellation.

Orthopaedic Nursing and Heart Failure: A Review of Pathophysiology and Management

Heart failure prevalence increases with age and is one of the most common reasons for inpatient hospitalizations. There are many opportunities for orthopaedic nurses to recognize the risks and symptoms of heart failure during an episode of orthopaedic care. In the context of bundled care, the orthopaedic nurse plays a key role in the prevention and early identification of complications that can prolong hospitalization and increase hospital readmission. This article presents two cases of patients with heart failure. The pathophysiology and management of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction are reviewed. Opportunities for orthopaedic nurses to impact care of patients at risk for or with heart failure are also highlighted.

Preoperative Risk Stratification: Who Needs Medical Consultation?

STUDY DESIGN

Spine update.

OBJECTIVE

The purpose of this study is to provide a review of preoperative clearance and optimization, before elective spine surgery.

SUMMARY OF BACKGROUND DATA

Patient optimization preceding elective surgery is critical to ensure the best possible outcome.

METHODS

Historical and current literature pertaining to patient clearance and optimization, before elective surgery, was reviewed. These data were then synthesized and assessed to provide a balanced view on current trends in regards to preoperative management and optimization.

RESULTS

The American Academy of Cardiology defines spine surgery as "intermediate" risk, and thus patients are permitted to forgo formal cardiac evaluation if they have no active cardiac condition and demonstrate adequate functional capacity; however, those with active or chronic medical conditions require further investigation before elective operations.

CONCLUSION

Overall, preoperative screening and optimization of comorbidities are vital to ensure positive outcomes in elective spine surgery, and the aforementioned criteria must be considered on an individual basis. Further research into specific preoperative optimization guidelines would help to ensure successful outcomes for those undergoing spine surgery.

LEVEL OF EVIDENCE

N/A.

Perioperative Management of the Rheumatoid Patient

Rheumatoid arthritis is a complex disease state with multiple associated comorbidities. Perioperative evaluation of the rheumatoid patient from a multidisciplinary approach is necessary to achieve favorable outcomes. A complete history and physical, laboratory, cervical, cardiovascular, pulmonary, and medication assessment before surgery should be performed. Educating the patient on potential complications, such as wound dehiscence, infection, and venous thromboembolism, as well as general postoperative expectations, is essential when evaluating the rheumatoid patient for surgery.

Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease

INTRODUCTION

The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases.

MATERIALS AND METHODS

The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event.

RESULTS

Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3).

CONCLUSIONS

The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.

Patient-related medical risk factors for periprosthetic joint infection of the hip and knee

Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.

Perioperative management of patients with rheumatic diseases

This paper aims to explore the assessment of patients with rheumatologic diseases, especially rheumatoid arthritis (RA), before undergoing orthopedic surgery. Perioperative assessment ensures an early diagnosis of the patient's medical condition, overall health, medical co-morbidities, and the assessment of the risk factors associated with the proposed procedures. Perioperative assessment allows for proper postoperative management of complications and of the management of drugs such as disease-modifying anti-rheumatic drugs (DMARD) and anti-platelets, and corticosteroids. The assessment also supports follow up plans, and patient education. Perioperative assessment enables the discussion of the proposed treatment plans and the factors associated with them in each case among the different specialists involved to facilitate an appropriate early decision-making about the assessment and treatment of patients with rheumatologic diseases. It also enables the discussion of both condition and procedure with the patient to ensure a good postoperative care. The article identifies the components of perioperative medical evaluation, discusses perioperative management of co-morbidities and the management of specific clinical problems related to RA, systemic lupus erythematosus, the management of DMARDs, like methotrexate (MTX) and biologic therapies, prophylactic antibiotics, and postoperative follow up, including patient education and rehabilitation.

Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher

Context:

Effort thrombosis, or Paget-Schroetter’s syndrome, is a rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion. It is occasionally associated with pulmonary embolism. This case of effort thrombosis and pulmonary embolus was in a 25-year-old major league professional baseball pitcher, in which the only presenting complaints involved dizziness and shortness of breath without complaints involving the upper extremity—usually, a hallmark of most cases of this condition. The patient successfully returned to play for 5 subsequent seasons at the major league level after multimodal treatment that included surgery for thoracic outlet syndrome.

Objective:

Though rare, effort thrombosis should be included in the differential diagnosis of throwing athletes with traditional extremity-focused symptoms and in cases involving pulmonary or thoracic complaints. Rapid diagnosis is a critical component of successful treatment.