Consult for TKR, polymorbidity

73-year-old man referred by medical team for consideration of TKR. Previously considered too high risk for surgery but had recent CABG with uneventful perioperative journey.


  • Osteoarthritis knee – wheelchair-bound
  • Paroxysmal AF – Warfarin and Bisoprolol
  • Chronic Renal Disease – Stage 2
  • Chronic bilateral lymphoedema
  • Pseudogout
  • Inflammatory arthritis – two previous episodes of septic arthritis in Right knee
  • Increased BMI


  • IHD – Stable disease post-surgical revascularisation. Emergent procedure in setting of NSTEMI. 
  • Poor Glycaemic Control – HbA1c on last admission 9.8% (in context of recent major surgery). Random BSL at clinic 16 mmol/L.
  • Deconditioning and significant immobility 
  • Chronic pain – On hydromorphone. Unable to tolerate NSAID’s due to renal disease.


Recent Cardiac Revascularisation

  • Cardiology review and echocardiogram normal
  • CABG done in setting of NSTEMI and refractory angina requiring GTN infusion
  • Currently on aspirin and warfarin
  • Timeframe post-NSTEMI should be considered despite surgical revascularization.

Glycaemic control for major joint surgery

  • The current guidelines are HbA1c<7.5% for major joint replacement.
  • SGLT-2 or GLP-1 receptor agonist are excellent options to improve glycaemic control and aid weight-loss. This should be physician-led.

Increased BMI and Immobility

  • Limited due to OA and knee pain
  • Dietician – very difficult to access at present. GP/endocrinologist most effective pathway
  • Physiotherapy input. Consider cardiac rehabilitation programme?
  • Currently awaiting appointment with HIPs – will have access to allied health also.

Physician-led referral

  • Excellent opportunity for perioperative optimisation in conjunction with medical team
  • Difficult to prepare a patient for surgery until we know he is a candidate
  • Issues are mainly surgical, suitability for procedure can only be assessed by surgeon


  • Refer to physician with above recommendations to optimise for surgery
  • Recommend surgical review