Preoperative Risk Stratification and Risk Reduction for Total Joint Reconstruction

Demand for primary total hip arthroplasty and demand for total knee arthroplasty in the United States are anticipated to grow by 174% and 673%, respectively, over the next twenty years1. Satisfaction rates are good to excellent in most patients2-4. Modern techniques and perioperative care have reduced systemic and local complications5-7. Nevertheless, the risks of major adverse outcomes (2.2% to 7.4%)8-10 and death (0.1% to 0.8%)5,7-9,11-19 remain real. Careful preoperative clearance and targeted therapeutic interventions are necessary to minimize complications. Studies have demonstrated total joint arthroplasty to be a highly cost-effective procedure. Nevertheless, many payers, especially the U.S. Centers for Medicare & Medicaid Services (CMS), have targeted total joint arthroplasty for cost control20. Adoption of a pay-for-performance program by CMS21 has created a zero-sum game to reward overachievers and penalize underachievers. The current literature lacks a detailed, comprehensive approach for risk-stratifying total joint arthroplasty patients and a systematic method for preoperatively allaying these risks. Popular tools such as the American Society of Anesthesiologists (ASA) classification system may be effective in predicting the overall outcome of surgery, but they cannot predict specific complications22 and they do not facilitate further preparatory action23-25. Although medical evaluation should be performed in collaboration with the internist, evidence-based guidelines provide standardization and comprehensiveness. Conditions necessitating postponement or cancellation of total joint arthroplasty are present in approximately 4% of patients26. Complications related to the cardiovascular system represent 42% to 75% of major systemic adverse events and deaths following total joint arthroplasty7,13,27,28, and cardiovascular comorbidities are a significant risk factor for these events14,29. Intramedullary instrumentation …