Introduction Overview preoperative optimization of the patient who is planned for a THA or TKA is critical to improving outcomes Optimization can be broken down into the following categories medical optimization preoperative counseling VTE prophylaxis anesthesia plan pain management plan Medical optimization The goal is to identify possible risk factors that increase the risk of complications postoperatively Diabetes Screening patients with hyperglycemia with HbA1C testing HbA1C> 6.7 is associated with an increased risk of wound complications Exact HbA1C target (roughly <8) varies by surgeon and hospital Not all patients will be able to achieve target Obesity Consistently shown to increase the risk of postoperative complications acute kidney failure, CV complications, wound complications, infection BMI >40 has been used in many studies as having an increased risk of complications, but this is a continuous variable without a clear cutoff Weight loss of >5% may be needed to decrease risk Bariatric surgery may have a role Cardiovascular disease Preoperative cardiovascular disease and older age are major risk factors for postoperative cardiovascular events Delay elective surgery in patients whose dual antiplatelet therapy will be stopped within 30 days from bare-metal stent (BMS) 12 months after drug-elution stent (DES) Clopidogrel management should be discussed with a cardiologist and restarted as soon as possible Stopping 7 days preop can lower bleeding events and the need for transfusion without increasing perioperative cardiovascular events. Blood transfusion perioperative blood transfusions are associated with higher rates of postoperative complications Renal disease Patients on dialysis at time of THA or TKA have a 10-20 times increased risk of complications ESRD patients may have improved outcomes if they undergo elective kidney transplant prior to arthroplasty have to weigh risk of transient septicemia from dialysis versus immunosuppression following transplant Methicillin-Resistant Staphylococcus aureus some screen for MRSA colonization and decolonize with mupirocin ointment or chlorhexidine wipes some implement a universal decolonization protocol which has some evidence to be cost-effective Tobacco abuse Increased risk of postoperative complications and infection Referral to formal smoking cessation program 6 weeks of cessation nicotine testing pre-operatively Illicit drug use History of substance abuse/misuse have a 5x increase risk of mortality increased risk of infectious and non-infectious complications as well Higher risk of mortality, readmission, and reoperation in patients who failed a toxicology screen Preoperative counseling Expectations Patient satisfaction after arthroplasty may be heavily based on expectations rather than functional outcome Patients tend to be overly optimistic and have too high of expectations Preoperatively setting expectations for pain, functional outcomes, and possible complications can help make expectations more realistic Social support Preoperative assessment of social support may allow for optimization and discharge planning prior to surgery Psychologic distress may impact pain management postoperatively absence of anxiety may lead to lower pain scores and better functional outcome postoperatively social support can affect length of stay, readmission rates, and non-home discharge VTE prophylaxis Balance in each individual patient weighing the risk of bleeding versus postoperative VTE event and subsequent complications or mortality ACCP recommends mechanical compression devices plus one of the following: vitamin K antagonists (warfarin) low-molecular-weight heparins (enoxaparin) aspirin factor Xa inhibitors (apixaban or rivaroxaban) pentasaccharides (fondaparinux) direct thrombin inhibitors (dabigatran) AAOS recommends a pharmacologic agent, mechanical compression device, or both for VTE prophylaxis in patients with no increased risk of VTE event Aspirin is preferred by many surgeons given its oral route, compliance rates, cost, and low bleeding rates Anesthesia Neuraxial anesthesia (e.g. spinal) is felt to lower postoperative complications due to lower stress than general anesthesia Retrospective studies have shown neuraxial anesthesia to have lower surgical time, infection, postoperative CV events, transfusion rates, and length of stay Pain management plan The goal is adequate pain control for early mobilization, improved patient-reported outcomes and shorter length of stay Mutlimodal approach Oral medications Preoperative NSAIDs (COX-2 inhibitors) and pregabalin given preoperatively decreased opiate consumption, lower pain scores, and improve range of motion without affecting bleeding Postoperative continuation of the above with the addition of judicious use of oral opiate medication with different durations of action Opiate-related adverse drug events have been found to cause up to 50% or postarthroplasty complications Periarticular injections Concoction often of local anesthetic, opiates, and NSAIDs injected into the capsule and soft tissues around a THA or TKA In TKA, periarticular injections have been shown to be equally as effective as femoral nerve blocks and may be cheaper, safer, and easier In THA, periarticular injections are felt to decrease opioid, improve pain control and improve function postoperatively Peripheral nerve block Excellent for pain control but depending on nerve may affect muscle function and recovery THA lumbar plexus blocks, psoas, femoral nerve, sciatic nerve block TKA femoral nerve, adductor canal, sciatic nerve block adductor canal - gives similar pain control to femoral block without causing quad weakness sciatic nerve - may help posterior knee pain but can affect muscle function significantly