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.

Background

• 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

Issues

• 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.

Discussion

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

Plan

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