Is Preoperative Medical Evaluation Really Necessary before Orthopaedic Surgery?

After evaluating a healthy, 58-year-old tennis player, an orthopaedic surgeon determined that the patient’s meniscus tear would require arthroscopic surgery. As the surgeon exited the exam room, he commented, “A preoperative medical evaluation would be required prior to surgery.” The patient replied, “Doc, I’m totally healthy. I just had a check-up a few months ago. I don’t take any medications. Do I really need another doctor’s visit?”

This scenario plays out in thousands of surgeons’ offices multiple times per day, raising the question of the role of preoperative medical evaluation in elective surgery. Although many, if not all, orthopaedic surgeons routinely refer patients for a medical evaluation, the value of these evaluations in otherwise apparently healthy patients is uncertain.

The goal of a preoperative consultation is to reduce surgical morbidity and possibly reduce medical legal liability. Ultimately, the utility of a preoperative consultation is to reduce adverse postoperative outcomes and mortality. The actual effects of this consultation are difficult to study. Only a few clinical trials have tested the validity of preoperative medical testing.

Assessing risk
There have been significant changes in perioperative processes over the past several decades, including a dramatic shift toward outpatient surgery across all orthopaedic surgeries. The risks of sequalae from blood loss have been dramatically reduced. More teams have adopted the use of regional anesthetics and nerve blocks, and anesthetic agents are much safer and shorter acting. The surgeries themselves are less invasive and traumatic to patients. All of these factors have led to significant reductions in risks to patients.

The primary purpose of the preoperative medical evaluation is to make surgery less risky. If one test or intervention can reduce that risk, then steps to reduce risk should be followed. However, for many otherwise healthy patients without identifiable risk factors, the preoperative evaluation may be superfluous. Common tests for preoperative testing include pregnancy tests, electrocardiograms, and, depending on medications, testing of potassium level.

In an interview, internist Fred Taweel, MD, of Reston, Virginia, leader of a large internal medicine group, noted that his group performs many preoperative medical evaluations. For patients with stable medical conditions, he commented, “Preoperative medical evaluations in otherwise healthy and medically stable patients are generally unnecessary. Generally, patients with significant cardiac or pulmonary issues or other serious medical conditions require a preoperative evaluation.” In general, patients with a history of coronary artery disease or arrythmias, ongoing pulmonary issues, uncontrolled hypertension, and poorly controlled diabetes may benefit from a preoperative medical evaluation. When in doubt, ask for help. His plea is that age alone is not an indicator for a preoperative medical evaluation.

Dr. Taweel believes that the future of these evaluations may lie in the use of artificial intelligence (AI). A number of AI applications have been shown to be highly predictive in assessing cardiac and pulmonary risks. Although the studies are still preliminary, AI may become a useful clinical tool to help improve outcomes and patient safety. In the interim, the American College of Surgeons has published a quick and easy surgical risk calculator that is available online at riskcalculator.facs.org. In only a few moments, this simple, free, and accessible website can help determine overall surgical risk and provide an estimate of postoperative complications.

Data from the literature
Recent articles in JAMA Internal Medicine have highlighted the questionable value of preoperative medical evaluations. Beckerleg et al. queried whether preoperative medical consultation reduced adverse postoperative outcomes and found that such consultations were often, at best, nonhelpful and did not result in a reduction in perioperative morbidity. Surprisingly, their study suggested that the patients who had preoperative evaluations had a slight increase in adverse outcomes (i.e., 1-year mortality, 30-day emergency department visits, and stroke), suggesting a need to better refine which patients would benefit from preoperative evaluation.

A 2000 study in the New England Journal of Medicine evaluated nearly 20,000 cataract surgery patients who were randomly assigned to undergo or forgo a battery of preoperative tests. That study confirmed that routine medical testing prior to cataract surgery did not alter the safety or outcomes of the surgery. Although this may not be directly applicable to orthopaedic surgeons, it does raise questions about the value of preoperative testing.

In a healthcare climate with increasing pressure to reduce costs and justify expenditures, insisting on a preoperative evaluation for every patient over a certain age may not be required. Patient selection combined with the nature of the surgery are key. Frail or medically unstable patients or those with known risk factors are clear candidates for preoperative medical evaluation. Higher-risk patients and those with propensity for adverse outcomes can be identified and sent for nonsurgical evaluation prior to surgery. Proper identification of risk factors, other than age, should be performed to determine which patients should be referred for preoperative medical evaluation.

Thomas Fleeter, MD, MBA, FAAOS, is in private practice in Reston, Virginia, with Town Center Orthopaedics. He is a member of the AAOS Now Editorial Board and chair of the AAOS Committee on Professionalism.

References

1. Beckerleg W, Kobewka D, Wijeysundera DN, et al: Association of preoperative medical consultation with reduction in adverse postoperative outcomes and use of processes of care among residents of Ontario, Canada. JAMA Intern Med 2023;183(5):470-8.
2. Schein OD, Katz J, Bass EB, et al: The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. N Engl J Med 2000;342(3):168-75.
3. Riggs KR, Segal JB: What is the rationale for preoperative medical evaluations? A closer look at surgical risk and common terminology. Br J Anaesth 2016;117(6):681-4.