By Leo Ludwig, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois
The goals of orthopedic surgery are to reduce pain, improve function, and avoid complications. The list of complications includes infection, bleeding, anesthetic complications such as stroke and heart attack, blood clots including pulmonary embolus, and poor postoperative pain control that can lead to difficult rehabilitation and poor functional results.
I like to compare orthopedic surgery to a basketball team with a starting five. The five starters include the patient, the primary care physician, the orthopedic surgeon, support staff such as nurses and physical therapists, and the hospital. Hopefully, when everyone on the team performs their job appropriately, we can reduce the risks of these complications occurring. There are patient specific risk factors that can be modified which can significantly increase the chances of a good result. I would like to discuss 8 risk factors which you, the patient, can modify preoperatively to reduce your risk of complications and improve your outcomes. Like any good basketball team, we have a sixth man. Our sixth man is the Affordable Care Act (ACA) or what is known as Obamacare.
1. OBESITY (Table 1)
This is measured by calculating the BMI (Body Mass Index) which is a combined measure of your height and weight. Table I illustrates the different levels of obesity. Patients with a BMI >40 have a significantly increased risk of infection, bleeding, anesthetic complications, blood clots, and a higher risk of being readmitted to the hospital within 30 days. Many patients with obesity have associated sleep apnea which is an additional risk factor for postoperative complications. Patients falling into this category have the following preoperative treatment options: consultation with their primary care physician and nutritionist, involvement in a pre-surgical optimization program, bariatric surgical consultation, and maintaining a low impact exercise program.
2. DIABETES MELLITUS
Patients with diabetes have an increased risk of infection, postoperative anesthetic complications such as heart attack, and 30 day readmission. The preoperative goals for diabetic patients are a hemoglobin A1c of 7 or less and consistent blood sugars of 180 or less. Patients outside of these control parameters should consult their primary care physician or endocrinologist.
3. TOBACCO USE
The use of tobacco products including smokeless tobacco and e-cigarettes increases the risk of infection, postoperative pulmonary complications such as pneumonia, and blood clots. Nicotine reduces blood flow to the surgical site thus increasing the risk of postoperative infection and wound healing problems. We recommend that patients stop smoking 6-8 weeks preoperatively and maintain smoking cessation for 6 weeks postoperatively. Obviously, quitting altogether would be the best approach. A preoperative consultation with your primary care physician may be helpful.
4. PHYSICAL DECONDITIONING
Many orthopedic patients are physically deconditioned which can make postoperative mobilization harder. This increases the risk of blood clots and the delayed rehabilitation can lead to a poorer functional result. Patients in this category should consider a reconditioning program in physical therapy emphasizing range of motion, strengthening, and, if necessitated by your procedure, training in the use of walking aids. Ideally, this program should be started at least 6 weeks prior to surgery.
Studies have shown that approximately 30-40% of orthopedic surgical patients are malnourished and many of these patients are anemic. Ironically, many of these patients are also obese. Patients in this category have an increased risk of wound healing problems with infection as well as blood transfusions which have been associated with a higher risk of infection. Blood transfusions reduce the immune response which helps prevent infection. Patients should be evaluated preoperatively with appropriate blood tests to check for the level of nutrition as well as anemia. Many patients can be treated with nutritional supplements and iron but some may require preoperative evaluation to determine the cause of anemia as well as consultation with a hematologist for more sophisticated treatment.
6. DENTAL HEALTH
Patients with poor oral health such as gum disease or multiple decaying teeth have an increased risk of postoperative infection and many have undiagnosed heart disease that increases the risk of postoperative anesthetic complications. Orthopedic patients should maintain good dental hygiene with regular brushing and flossing. In addition, most total joint replacement patients should be seen by their dentist preoperatively and have any necessary dental procedures completed prior to proceeding with their total joint replacement.
7. NARCOTIC USE/ALCOHOL USE/
Orthopedic patients who take narcotic pain medications on a routine basis prior to surgery have a higher risk of poor postoperative pain control which leads to a more difficult rehabilitation course. This can lead to a poorer long-term functional result. Patients who drink an excess of alcohol oftentimes have poor nutrition with an increased risk of infection. Pain control issues can also be a problem leading to similar postoperative problems as the patient who takes narcotics. Patients should try to stop or at least significantly reduce their use of preoperative narcotics and alcohol for at least 4-6 weeks preoperatively. The use of postoperative alcohol also increases the risk of falls that can lead to damage at the surgical site. The presence of preoperative psychological issues such as depression can lead to poor postoperative pain control and lack of motivation to participate in physical therapy. Preoperative consultation with a primary care physician or psychiatrist may be necessary.
8. STAPH BACTERIA COLONIZATION
Some orthopedic surgical patients have become colonized with staph. aureus. Some of these patients have a resistant bacteria called MRSA. Currently, patients who are undergoing total joint replacement are tested preoperatively for this bacteria with a nasal culture. If the culture is positive, there is a special preoperative antibiotic protocol that is initiated. Patients can proceed with surgery utilizing this protocol or can be referred to an infectious disease specialist with the goal of eradicating this bacteria.
You might ask “what about our sixth man?” Obamacare is the driving force behind the efforts to work on these modifiable risks. Future payments to both doctors and hospitals will be determined by patient outcomes. Good surgical results usually lead to higher patient satisfaction which will lead to higher future reimbursement under the Affordable Care Act. Good surgical results are easier to obtain with healthier patients. Hospitals are currently financially penalized for higher than average 30 day readmission rates. The next phase of Obamacare provides for bundled payments which will make hospitals financially responsible for all 30 day readmissions, meaning that they will not receive additional funds for providing this care. The bottom line: THERE IS INCENTIVE TO IMPROVE THE HEALTH OF SURGICAL PATIENTS or stated another way THERE IS DISINCENTIVE TO OPERATE ON MORE COMPLEX PATIENTS. Hospitals and orthopedic surgeons have formed co-management committees to deal with these issues and help patients through the process. Some orthopedic surgeons have developed preoperative benchmarks requiring patients to meet certain criteria in the 8 areas that we discussed before scheduling surgery.
I hope that I have provided you with a better explanation of your role on the team.