PIG Meeting: 22nd April 2021

64-year-old lady for a Left TKR. Currently housebound and immobile following right TKR.

Background

• Right TKR in 2018 complicated by femoral condyle fracture intraoperatively
• Partial weight-bearing postoperatively and unable to participate in rehabilitation
• Currently housebound, no physical activity
• Multiple previous postponements from perioperative clinic and one cancellation on day of surgery for medical optimisation

Issues

• Morbidly obese, BMI 50
• Very complex social situation, husband working full time and is her carer
• Bilateral rotator cuff tears – may not be able to use forearm support frame postoperatively
• Attended rehabilitation last year and engaged well with services
• Lost 30kg with diet and exercise program
• Stopped attending due to distance – patient is from Taree and was travelling to Newcastle
• Poor understanding of perioperative risk.
• Patient and husband very keen for surgery to proceed

Discussion

1. Should surgery proceed?

• High risk for postoperative complications including joint infection
• Unlikely to be physically fit to participate in rehabilitation in current condition
• Surgical team unaware of booking for surgery and thought ‘she hadn’t been cleared by anaesthetics to proceed.’

2. Can this patient be optimised preoperatively?

• Immobility – re-engage with physiotherapy and rehabilitation services
• Previous effective weight loss with dietician input, new referral
• Social issues, is husband struggling to cope? Would help from outside the home alleviate some stressors?
• Consider home modifications to help patient to manage ADL’s alone

Plan

• Multi-disciplinary input required from physio, OT, dietician, and social work.
• Review in 6 weeks