ICJR REWIND: Helping Patient Reduce Their Risks Before Total Joint Arthroplasty
Dr. Bryan Springer reviews 7 modifiable risk factors for complications in patients undergoing total hip and total knee arthroplasty, including malnutrition, smoking, and vitamin D deficiency, in an article originally published on October 1, 2018.
Patients scheduled for total joint arthroplasty can have dozens of risk factors for complications after surgery. In his presentation at ICJR’s 6th Annual ICJR South Hip & Knee Course, Bryan D. Springer, MD, from OrthoCarolina Hip & Knee Center in Charlotte, North Carolina, focused on 7 common modifiable risk factors surgeons can address to help their patients reduce the chances of developing serious, potentially life-threatening complications.
The stress of surgery antagonizes insulin, predisposing total joint arthroplasty patients – diabetics and non-diabetics alike – to hyperglycemia, which puts them at risk for infection and other complications. The goal, Dr. Springer said, is to maintain the glucose level at less than 200 mg/dL perioperatively.
What about preoperatively? The best marker of glycemic control is controversial, as the optimum hemoglobin A1C level for surgery is unclear. When a patient’s high hemoglobin A1C is trending downward preoperatively, the magnitude of the decrease may be more relevant to the decision on whether to operate than an arbitrary number, Dr. Springer said.
The latest test for preoperative glycemic control, Dr. Springer said, is the serum fructosamine level, a simple and inexpensive test that may be a better indicator than hemoglobin A1c. 
Obesity is another controversial area: Surgeons are not good at discussing obesity and weight loss with their patients, often preferring to punt to their medical colleagues or avoid discussing it altogether, Dr. Springer said.
But the literature shows it’s a serious risk factor, with concerning complications related to obesity. [2-5] The inflection point for these complications seems to be a body mass index (BMI) of 40, Dr. Springer said, and the American Association of Hip and Knee Surgeons (AAHKS) issued a consensus statement that surgeons should consider delaying joint replacement in patients with a BMI over 40, particularly in patients with other comorbidities. 
Dr. Springer said that malnutrition is fairly rampant among total joint arthroplasty patients, but surgeons may not know their patients are malnourished unless they test for it. He obtains a serum albumin level on all his patients, as well as a total lymphocyte count if he’s also doing a complete blood count. 
He cautioned surgeons to pay particular attention to malnutrition in obese patients. They are often paradoxically malnourished due to high calorie intake coupled with low protein intake, putting them at high risk for complications.
Current smokers have a well-documented higher risk for complications after total joint arthroplasty than non-smokers, Dr. Springer said, due to local tissue hypoxia, lower collagen production, and lower T cell function, all of which can lead to poor wound healing and increased infection risk.  Getting smokers to quit is very difficult, however, and the length of time they need to refrain from smoking before surgery is unclear.
Surgeons can determine if their patients actually took their advice and stopped smoking by evaluating the serum cotinine level before surgery. Cotinine is a metabolite of nicotine that is present at high levels in patients who have smoked within the past week. The level should be less than 10 mg/mL.
Vitamin D Deficiency
Dr. Springer began testing his patients for vitamin D deficiency about a year ago, and he was surprised to find out how many were deficient. Vitamin D plays a major role in immune system modulation, Dr. Springer said, with vitamin D deficiency identified as a cause of perioprosthetic joint infection. 
The level should be above 30 ng/mL. A lower level can be easily and rapidly corrected, typically with oral supplements, Dr. Springer said.
MRSA and MSSA Screening
Routine preoperative screening for methicillin-resistant Staphylococcus aureus (MRSA)
and methicillin-susceptible Staphylococcus aureus (MSSA) colonization is also controversial. There are logistical and cost issues, as well as the fact that many people are carriers: 30% of the population in the US for MSSA and 4% for MRSA.
Despite that, a meta-analysis of 16 studies with more than 56,000 total joint arthroplasty patients found value in screening, with the study authors reporting a 54.6% decrease in the risk of surgical site infections, compared with controls, as a result of nasal decolonization.
Management of Anti-rheumatic Medications
The use of anti-rheumatic medications has been linked to periprosthetic joint infection following total joint arthroplasty. The American College of Rheumatology and AAHKS developed and published consensus guidelines for the management of patients taking anti-rheumatic medications to help orthopaedic surgeons and rheumatologists reduce this infection risk.  Dr. Springer was the co-principal investigator for the guideline project.
The guidelines they developed include 8 recommendations for when to continue, withhold, and re-start anti-rheumatic medications, including disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids, in total joint arthroplasty patients who have any of the following:
- Rheumatoid arthritis
- Spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis
- Juvenile idiopathic arthritis
- Systemic lupus erythematosus
Among the main recommendations: 
- Discontinue biologic therapy prior to surgery in patients with inflammatory arthritis.
- Withhold tofacitinib for at least 7 days prior to surgery in patients with rheumatoid arthritis, spondyloarthritis, or juvenile idiopathic arthritis.
- Withhold rituximab and belimumab prior to surgery in all patients with systemic lupus erythematosus patients undergoing arthroplasty.
- Withhold biologic medications as close to 1 dosing cycle as scheduling permits prior to elective total joint arthroplasty and then restart them after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.
Click the image above to watch Dr. Springer’s presentation and get more advice on modifiable risk factors in total joint arthroplasty patients.
Dr. Springer has disclosed that he is a consultant for Stryker Orthopedics and ConvaTec; that he is on the speaker’s bureau for CeramTec; and that he receives research support from DePuy Synthes, Wright Medical, Zimmer Biomet, and Pacira.
- Shohat N, Tarabichi M, Tischler EH, Jabbour S, Parvizi J. Serum fructosamine: a simple and inexpensive test for assessing preoperative glycemic control. J Bone Joint Surg Am. 2017 Nov 15;99(22):1900-1907. doi: 10.2106/JBJS.17.00075.
- Wern BC, Evans CL, Carothers JT, Browne JA. Primary total knee arthroplasty in super-obese patients: dramatically higher postoperative complication rates even compared to revision surgery. J Arthroplasty. 2015 May;30(5):849-53. doi: 10.1016/j.arth.2014.12.016. Epub 2014 Dec 19.
- D’Apuzzo MR, Novicoff WM, Browne JA. The John Insall Award: Morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res. 2015 Jan;473(1):57-63. doi: 10.1007/s11999-014-3668-9.
- Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI. J Arthroplasty. 2015 Sep;30(9 Suppl):42-6. doi: 10.1016/j.arth.2015.03.045. Epub 2015 Jun 3.
- Wagner ER, Kamath AF, Fruth K, Harmsen WS, Berry DJ. Effect of body mass index on reoperation and complications after total knee arthroplasty. J Bone Joint Surg Am. 2016 Dec 21;98(24):2052-2060. doi: 10.2106/JBJS.16.00093.
- Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty. 2013 May;28(5):714-21. doi: 10.1016/j.arth.2013.02.011. Epub 2013 Mar 19.
- Huang R, Greenky M, Kerr GJ, Austin MS, Parvizi J. The effect of malnutrition on patients undergoing elective joint arthroplasty. J Arthroplasty. 2013 Sep;28(8 Suppl):21-4. doi: 10.1016/j.arth.2013.05.038. Epub 2013 Aug 30.
- Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol. 2011 Sep;38(9):1824-34. doi: 10.3899/jrheum.101221. Epub 2011 Jun 1.
- Hegde V, Dworsky EM, Stavrakis AI, et al. Single-dose, preoperative vitamin-d supplementation decreases infection in a mouse model of periprosthetic joint infection. J Bone Joint Surg Am. 2017 Oct 18;99(20):1737-1744. doi: 10.2106/JBJS.16.01598.
- Goodman SM, Springer B, Guyatt G. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. J Arthroplasty. 2017 Sep;32(9):2628-2638. doi: 10.1016/j.arth.2017.05.001. Epub 2017 Jun 16.