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
- 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.
- 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