Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

Abstract

First, thank you to the authors for the verywellwritten and educational article titled, Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous? While local complications such as prosthetic joint infection, periprosthetic fracture, aseptic loosening, and hematoma are common, systemic complications after elective total joint arthroplasty (TJA) also occur and include deep venous thrombosis, pulmonary embolism, myocardial infarction, cerebral vascular accident, renal failure, and, although rare, death [1e3]. With continued pressure to decrease complications from both clinical and cost standpoints, surgeons strive to optimize patients before surgery as risk factors for complications are well established [4]. There are risk factors for elective arthroplasty that are nonmodifiable such as age, sex, renal disease, rheumatologic disease, metastatic tumor, peripheral vascular disease, and valvular disease [4e6]. Most nonmodifiable risk factors can at least be optimized before elective arthroplasty; however, these risks continue to be present to some degree. Documented modifiable risk factors for TJA including diabetes control, elevated basal metabolic index (BMI), smoking or tobacco use, anemia, methicillin-resistant Staphylococcus aureus colonization status, and malnutrition [7e10]. The authors of this study reported in a large database that malnutrition, defined as hypoalbuminemia (<3.5), was the strongest risk factor for all complications evaluated [11]. It has been reported that individuals with obesity are at higher risk of complications; however, surgeons often indicate arthroplasty in patients with BMI over 40 for various reasons [12]. While there is debate regarding strict BMI cutoffs, insistence on smoking cessation, preoperative nutritional optimization, and HbA1C limits of 7.7 or less, the decision to offer a patient elective TJA is ultimately made by the surgeon taking into account the patient’s entire risk profile and potential benefit of surgery [13,14]. TheWorld Health Organization (WHO) declared the outbreak of COVID-19 a global pandemic on March 11, 2020 [15]. Shortly after this declaration, many countries limited or ceased elective orthopedic cases including TJA [16]. With increased risks of thromboembolic disease associated with COVID-19, and association of increased complications in patients with comorbidities, restarting elective TJA has to be done ethically and responsibly [17,18]. Patients with multiple comorbidities scheduled for elective TJA may be at higher risk of succumbing if infected with COVID-19 perioperatively and may also require inpatient recovery in rehabilitation units or nursing homes, further increasing the risk of transmission [16]. With a demonstrated higher complication rate in COVID-19positive patients undergoing hip fracture management, these