Revision TKR, polymorbidity

Gabrielle Morris

70-year-old lady for revision TKR. Fall and periprosthetic distal femur fracture in 2020

Background:

  • R Arm Amputation in 2015 – Necrotising Fasciitis. Long, complex ICU admission
  • Recurrent falls – multifactorial aetiology; UL amputation, charcot foot, hypoglycaemia, and knee locking.
  • BMI 44
  • Chronic pain – Migraines, phantom limb pain, and CRPS, medical marijuana and PRN opioids.
  • Subclinical hypothyroidism
  • TIA 2019
  • Chronic iron deficiency anaemia – managed by GP, regular Fe infusions

Issues:

  • IHD
    • 2 previous AMI with minimal symptoms. 
    • Sestamibi in 2019 showed a small area of fixed perfusion defect in LAD territory. 
    • Ongoing stable angina. 
    • Lifelong DAPT
    • Clinically bilateral pitting oedema to mid-shins 
    • 2-pillow orthopnoea. 
    • Last echo 2020 normal biventricular function.
  • IDDM
    • HbA1c 7.9%. 
    • Severe bilateral peripheral neuropathy. 
    • Frequent hypoglycaemic episodes. 
    • Regular endocrinologist review. 
  • Wheelchair-bound – since femur fracture last year. 
    • NDIS care-package in place, requires assistance with all ADL’s. 
    • Physiotherapy included in package, engaging with physio recently.
    • Previously able to walk 50m on flat

Discussion:

Risk assessment

  • High risk patient and complex operation
  • RCRI = 4 
Table Description automatically generated
  • NSQUIP – above average for all variables, 70% discharge to nursing home/rehab facility.
  • Risks conveyed to patient, wishes to proceed. States she would never want to be in a nursing home long-term.

Cardiac optimisation

  • Discussed at cardiology MDT – high-risk, on optimal therapy
  • Echocardiogram – IHD, orthopnoea and peripheral oedema. 
  • Symptoms could be attributed to BMI, deconditioning, and immobility.

Diabetes

  • Reasonable HbA1c, unlikely to improve
  • Hypoglycaemic episodes ongoing
  • Preoperative endocrine consult – HbA1c above cut-off value for major joint surgery
  • High-risk for perioperative joint infection

Medical Marijuana

  • Prescribed by GP. Patient declining cessation in hospital
  • Endocrinologist recommended cessation – falls and hallucinations
  • Pharmacy contacted and IPU form completed

Decreased Exercise Tolerance

  • Discussed with surgeon, requests that patient can mobilise preoperatively
  • Rehabilitation will be difficult with current level of immobility/deconditioning
  • Referred to Kaden centre for prehabilitation in conjunction with Dr Jen Mackney and patients own physiotherapist.

Plan

  • Postpone for 6 weeks pending prehab and endocrine review