Preparing for Joint Replacement: Screening to Recovery

Preparing for joint replacement surgery has two parts: screening, to find any medical illness or source of infection that would make the operation unsafe, and optimisation, to correct what can be corrected, such as a low haemoglobin, before the patient reaches the theatre. Dr. Ishwar Bohra applies the same preparation to every major hip, knee and shoulder replacement, followed by the right investigations, a clean theatre and planned post-operative care.

Dr. Ishwar Bohra, Senior Director - Joint Replacement Programme, BLK-Max Super Speciality Hospital, New Delhi, India, answered a run of questions on this subject from international doctors during his May 2024 Jivo Masterclass. Their questions were practical: how much preparation is needed, what a hospital must have in place, whether patients who refuse blood transfusion can be operated on, how infection is kept down, and what part nutrition plays. This article brings his answers together. When a joint needs replacing is covered in the complete guide to when joint replacement is needed, and the technology used in the operation in the article on AI, navigation and the direct anterior approach.

Preparing for joint replacement surgery: five conditions to screen for

The first step for any major joint replacement is screening the patient for medical conditions that raise the risk of the operation. Dr. Bohra named five things that must be screened out:

1. Diabetes, particularly when it is uncontrolled.
2. Uncontrolled hypertension.
3. Coronary artery disease.
4. Autoimmune or other systemic disease.
5. Any potential source of infection, such as an existing pneumonia, a skin infection or a fungal infection.

The fifth item deserves emphasis, because an infection anywhere in the body can seed a new joint through the bloodstream. A chest infection, an infected skin lesion or a fungal skin infection is a reason to treat first and operate later.

What haemoglobin level is needed before joint replacement?

Haemoglobin should ideally be 13 grams per decilitre or more before a major joint replacement, and Dr. Bohra treats a level below 10 as a firm reason to optimise before operating. He named haemoglobin as the key vital parameter to optimise. Screening identifies the problems; optimisation corrects them. He added a caveat that matters to doctors in different countries: the parameters differ from country to country, because populations differ in their usual haemoglobin levels and other values. The threshold is a guide to be read against the local population, not a fixed universal number.

A patient who falls short is treated before surgery. Dr. Bohra's approach is to give haematinics (medicines that support red blood cell production, such as iron) or iron injections, together with dietary support, and to wait a couple of weeks for the haemoglobin to reach a good level.

Investigations and imaging before surgery

Once the patient has been screened and optimised, the routine pre-operative investigations follow. Dr. Bohra noted one addition that depends on the technique: if the surgeon wants to use newer technology for the operation, a CT scan or MRI of the joint may be needed for planning. The AI-guided technique he favours avoids that step, which is one of its advantages, as explained in the article on AI in joint replacement.

What a hospital needs before it offers joint replacement

Preparing the patient is half the work; the other half is preparing the hospital. Dr. Bohra's list of requirements is a useful checklist for any doctor deciding whether a case can be done locally or should be referred:

• A clean theatre and good, trained theatre staff.
• Good post-operative care, including a good intensive care unit (ICU) and a good anaesthetist.
• A cardiologist on standby, able to take care of the patient if something happens.
• A blood bank, or at least some arrangement for blood transfusion, which he regards as desirable.

Joint replacement without donor blood: Jehovah's Witness patients

A hip or knee replacement is possible for a patient who cannot accept a donor blood transfusion, Dr. Bohra said, through two steps: optimising haemoglobin before surgery and, if needed, transfusing the patient's own stored blood. Some patients decline transfusion for religious reasons, Jehovah's Witnesses among them, and Jivo Healthcare receives such enquiries regularly.

First, optimise before surgery. If the patient's haemoglobin is not adequate, give haematinics or iron injections and dietary support, and wait a couple of weeks for the haemoglobin to reach a good level. A patient who enters the operation with a healthy haemoglobin is less likely to need blood at all.

Second, if that is not enough, use the patient's own blood. The option is autologous transfusion: the patient's own blood is collected and stored in the blood bank under temperature control, and, if it is needed, the same blood is given back to the same patient. Because it is the patient's own blood, no cross-matching is required.

Acceptance of stored autologous blood varies among Jehovah's Witness patients, many of whom decline blood that has been removed from the body and stored, so the plan for each patient is agreed with that patient in advance of surgery.

How high is the infection risk after joint replacement?

Across published series, periprosthetic joint infection, meaning infection of the replaced joint, complicates roughly 1 to 2 percent of primary hip and knee replacements, and it is among the most serious complications of the operation. In Dr. Bohra's own setting, the risk of infection is practically very low. He was careful not to call it zero, because infection does occur, and he identified two groups of factors that drive it.

Patient factors

The patient's own condition determines much of the risk. Patients who are immunocompromised, who have comorbidities such as uncontrolled diabetes, or who carry hepatitis B, HIV or another viral disease, and who still need surgery, are at high risk of infection.

Surgeon and setting factors

The rest of the risk lies with the surgical team and the environment. Infection becomes more likely if the operation is not done well, if the theatre, its operating conditions and its working culture are not good, if adequate medication is not available, or if post-operative care is poor.

Why each factor matters

Screening, theatre discipline and post-operative care carry so much weight because each addresses one of the factors above. Recovery and infection prevention after knee replacement are also discussed in Dr. Rakesh Mahajan's article on knee replacement recovery.

Nutrition before and after joint replacement

Nutrition bears on joint replacement at two points, in Dr. Bohra's account: long-standing gut disorders are linked with arthritis in the first place, and a good protein diet after surgery helps the patient regain immunity. A question from a clinician in Ghana on nutrition drew one of the most detailed answers of the session.

The gut-joint axis

Dr. Bohra pointed to the gut-joint axis, a recent theory that places the gut at the centre of the health of the whole body, including in people who never have a joint replacement. Coeliac disease and inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, are linked with inflammatory arthritis, and the gut's role in osteoarthritis is under active study. For the doctor taking a history, a long-standing gut disorder is therefore part of the joint story.

Why protein matters after surgery

After the operation, nutrition becomes a matter of recovery. Any major surgery temporarily lowers the patient's general immunity. During that period the patient is in a hypercatabolic state, in which the body breaks down its own protein faster than usual. A good protein diet compensates for that loss:

• Milk and milk products.
• Protein powder.
• Vegetarian sources of protein.
• An increase in total calories.

The aim, in his words, is that the patient regains immunity as soon as possible after surgery. Better immunity in those weeks is also a defence against the infection discussed above.

When resources are limited: the duty to counsel

A doctor working with limited resources asked how to proceed when a procedure is complicated. Dr. Bohra's answer was direct. If the doctor knows from the outset that there is a problem in performing or completing the procedure with a good result, it would be unfair to the patient to go ahead.

Even at the highest level of care, he noted, there are procedures his own team does not do, for one of two reasons: the resources are limited, or the outcome is uncertain. Where the outcome is not likely to be good, the right course is a meeting with the patient, the family and the attendants, at which the doctor explains honestly what can be delivered, what the limitations are, and how much benefit the patient can expect. Only if the patient, fully aware of all of this, still wishes to proceed should the procedure go ahead.

For the referring doctor, that principle is the bridge between this checklist and a referral: a case that the local theatre, ICU, blood bank or infection control cannot support is a case for a centre that can. The doctors' questions from the session, including those on preparation and infection, are on the Live Discussion page. Indicative costs are on Jivo Healthcare's pages for unilateral total knee replacement and bilateral total knee replacement.