70-year-old lady for revision TKR. Fall and periprosthetic distal femur fracture in 2020
- 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
- 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.
- 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
- High risk patient and complex operation
- RCRI = 4
- 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.
- Discussed at cardiology MDT – high-risk, on optimal therapy
- Echocardiogram – IHD, orthopnoea and peripheral oedema.
- Symptoms could be attributed to BMI, deconditioning, and immobility.
- 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
- 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.
- Postpone for 6 weeks pending prehab and endocrine review