What Are the Most Important Factors in Preop Patient Optimization?

    Dr. Brian Curtin answers questions from ICJR about the key parameters surgeons should consider when optimizing patients for joint replacement surgery.

    ICJR: What is your approach to optimizing patients for total joint replacement surgery? Which parameters are you most interested in improving?

    Brian M. Curtin, MD: At our joint center, we have implemented an agreed-upon list of optimization standards that are both hard stops for some parameters and recommended for others. Hard stops include:

    • Smoking
    • BMI greater than 40 kg/m2
    • Hemoglobin A1c level greater than 8%
    • Albumin level less than 3.5 g/dL

    Other parameters that we attempt to optimize include:

    • Depression – PHQ-9 score less than 10
    • Anemia – Hemoglobin level greater than 12g/dL
    • Social support – Social support for postoperative care helps to avoid subacute nursing facility admissions

    We are most focused on the hard stop criteria because we believe they may have the greatest influence on outcomes (Figure 1). The other given parameters, however, may predispose patients to higher risk of complications as well if not appropriately managed.

    Figure 1. A 52-year-old male patient with poorly controlled diabetes (hemoglobin A1c of 11.6%) and BMI of 55 developed an infection of his left total knee arthroplasty, requiring explant at 6 months. Better optimization before surgery may have avoided this morbidity. Photo courtesy of Brian M. Curtin, MD.

    ICJR: What are your goals for weight/BMI, nutrition markers, and blood glucose – and why are these goals important?

    Dr. Curtin: My BMI cutoff of 40 is certainly not without exceptions, particularly in the large-statured male who is very muscular and whose BMI is probably not the best measurement of excess body mass. However, I stress weight loss to all patients with a BMI greater than 40, and we have a weight-management program in place with our local bariatric surgeons to provide assistance with medical and, potentially, surgical weight loss.

    I find it very important to stress low impact exercise and dietary modification to these patients, with a clear delineation of the risks associated with poor optimization before surgery. Patients must understand that you are on their side, that you want to help, and that you are willing to stand with them. It’s not just, “lose 30 pounds and come back and see me.”

    With regard to nutritional markers, the BMI restriction often eliminates most patients with albumin levels below 3.5, as it has been shown that many morbidly obese patients are malnourished. [1] A low albumin level is often easily corrected with protein supplements and does not delay surgery significantly.

    Blood glucose control has been shown to be very important postoperatively, [2] and it is assumed that preoperative control is likely to be an indicator of postoperative control. A patient with a hemoglobin A1c greater than 8% would be referred back to the primary care physician or endocrinologist for further management. Most often, the patient’s surgery would be delayed by 3 months or potentially more pending blood sugar control changes.

    Postoperatively, we actively attempt to manage blood glucose levels in conjunction with our medical teams. However, with discharge typically occurring on postoperative day 1 in most cases, there really isn’t much of a window to provide blood glucose support – which makes it all the more important for patients to be able to consistently manage their blood glucose at home.


    1. Nelson CL, Elkassabany NM, Kamath AF, Liu J. Low albumin levels, more than morbid obesity, are associated with complications after TKA. Clin Orthop Rela Res. 2015 Oct;473(10):3163-72.
    2. Chrastil J, Anderson MB, Stevens V, Anand R, Peters CL, Pelt CE. Is hemoglobin A1c or perioperative hyperglycemia predictive of periprosthetic joint infection or death following primary total joint arthroplasty?J Arthroplasty. 2015 Jul;30(7):1197-202.

    About the Expert

    Brian M. Curtin, MD, is from the OrthoCarolina Hip & Knee Center, Charlotte, North Carolina.


    Dr. Curtin has no disclosures relevant to this topic.