Perioperative Management of the Orthopedic Patient Taking Antipsychotics: A Narrative Review

Purpose: Antipsychotic prescribing continues to rise among older adults, the group most likely to present for orthopedic surgery, and orthopedic surgeons now operate regularly on patients taking these agents. Guidance for managing them around an operation sits largely in the psychiatric, anesthesiology and pharmacologic literature rather than the surgical one. This narrative review gathers the orthopedic-specific evidence and organizes it by whether a finding reflects the medication or the psychiatric illness for which it was prescribed. Findings: Antipsychotic exposure is associated with higher all-cause revision and periprosthetic fracture after total knee arthroplasty, and second-generation exposure raises all-cause and aseptic revision after shoulder arthroplasty independent of psychiatric diagnosis. Venous thromboembolism roughly doubles after primary total knee arthroplasty. Among geriatric hip fracture patients antipsychotics are the only medication class independently linked to in-hospital falls, and preoperative use independently predicts postoperative delirium that prophylaxis does not prevent. Spine, sports medicine and trauma surgery all show worse outcomes in patients carrying a psychiatric diagnosis, yet none of those literatures disentangles the drug from the disorder. Thromboembolism and the shoulder revision signal are the clearest drug-attributable exceptions. Hyperprolactinemia-mediated hypogonadism, metabolic derangement and impaired fracture healing remain plausible but unproven. Nearly all available evidence is retrospective. Conclusion: Antipsychotic therapy should continue through the perioperative period unless a specific reason exists to stop it. Abrupt discontinuation risks psychiatric relapse, which is harder to manage than the perioperative risks the drugs themselves carry. Low bone mineral density, poor glycemic control and thromboembolic risk are all worth addressing before surgery, drawing on psychiatry and internal medicine. Antipsychotics are not recommended for delirium prophylaxis. Whether altering therapy improves orthopedic outcomes has not been studied prospectively.