Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: Orthop Nurs. 2024 Jan-Feb;43(1):2–9. doi: 10.1097/NOR.0000000000000997

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease – Part Three of the Movement is Life Special ONJ Series

Martha Kebeh 1, Chloe C Dlott 1, Donna Kurek 2,3, Jensa C Morris 4,5,6, Charla B Johnson 7, Daniel H Wiznia 1
PMCID: PMC10832337  NIHMSID: NIHMS1940685  PMID: 38266257

Abstract

Background:

Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients’ health and surgical outcomes.

Purpose:

This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA.

Methods:

We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs.

Results:

Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery.

Conclusion:

This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.

Introduction

This article is part three of a series in the Orthopaedic Nursing Journal (ONJ) that explores the role of orthopaedic nurse navigators in preoperative optimization for total joint arthroplasty (TJA) (Figure 1). This article focuses on the management of diabetes and cardiovascular disease (CVD) and provides practical recommendations for optimizing these risk factors through preoperative optimization programs.

Prior research has demonstrated that diabetes and cardiovascular disease are risk factors for suboptimal outcomes (Adie et al., 2019; Al-Otaibi, 2021; Marchant et al., 2009) and greater rates of discharge to nursing facilities or rehabilitation centers (Keswani et al., 2016) after TJA. Diabetes is associated with poor wound healing, increased 30-day readmission rates, increased surgical site infections, and increased overall complication rates (Boraiah et al., 2015; Harris et al., 2013; Yang et al., 2014). Diabetes is a common comorbidity in patients with elevated body mass index (BMI), which may necessitate coordinated management of both conditions in preoperative optimization programs to mitigate the suboptimal outcomes patients may experience (Changulani et al., 2008; Fournier et al., 2016; Wang et al., 2018). A history of CVD has been identified as one of the most significant risk factors for mortality and cardiac complications, such as myocardial infarction or cardiac arrest, within 30 days of TJA (Adie et al., 2019; Belmont et al., 2014). This article synthesizes information regarding current diabetes and CVD management practices to provide recommendations for nurse navigators to use when managing these risk factors prior to TJA.

Methods

Nurse Navigator Perspectives

The introduction to this article series describes the full methodology (Kebeh et al., 2023). We utilized an online forum to contact 25 nurse navigators across the United States who were members of the National Association of Orthopaedic Nurses (NAON). Over the phone or via video conference, we recorded semi-structured discussions regarding their approach to managing diabetes and CVD among patients seeking TJA. Four initial standard questions (Figure 2) were followed by open-ended questions about referral to resources, patient education, and the nurse navigator’s role in optimization. Due to the open-ended nature of these discussions, each featured unique content.

Literature Review

We selected the Scopus and Web of Science databases to conduct a literature review that would capture a variety of journal and article types across disciplines and fields of study. This yielded 18 articles relevant to diabetes and 9 articles relevant to CVD.

Results

Diabetes

Nurse Navigator Perspectives

Nurse navigators described several strategies and resources for diabetes management (Table 1). Ninety-six percent of nurse navigators stated that a member of the surgical care team discussed diabetes with patients who had this diagnosis preoperatively. Twenty percent of nurse navigators stated that discussions or interventions to address diabetes were conducted by the surgeon or surgical pre-admission testing (PAT) unit before the navigator’s initial interaction with the patient. As a result, some nurse navigators were unaware of what measures may have been taken to help patients manage their diabetes or did not have a role in optimizing this area.

Hemoglobin A1c (HbA1c) values often played a role in determining patients’ current candidacy for TJA, with 92% of nurse navigators reporting that specific cutoff values, above which patients were not considered current candidates for surgery, were used at their institutions. These values ranged from an HbA1c of 7% to 8.5%. Eight percent of nurse navigators reported that they were not aware of a specific institution-wide HbA1c cutoff threshold, and individual surgeons determined their own cutoffs. Among the institution-wide cutoff thresholds reported, HbA1c above 8% was the most common, with 48% of nurse navigators stating that their institution used this value. Twenty-four percent of nurse navigators reported cutoff thresholds of HbA1c above 7.5%. Thresholds were also used to initiate referral to endocrinology or consultation with the patient’s primary care provider (PCP).

Nurse navigators described several strategies and resources for diabetes management, including universal patient education regarding the impact of diabetes on postoperative outcomes through joint classes or online patient education platforms, referral to dietitians, and referral to diabetes clinics or intervention programs that provided education, medical management, continuous glucose monitoring, and exercise strategies (Table 1). Those nurse navigators who had multiple contacts with patients prior to TJA utilized subsequent contacts to follow up on patients’ ability to access and benefit from these strategies and resources.

Literature Review

Diabetes is commonly identified as a risk factor that is associated with increased overall complication rates and worse outcomes after TJA (Ahn et al., 2019; Al-Otaibi, 2021; Boraiah et al., 2015; Harris et al., 2013; Marchant et al., 2009; Yang et al., 2014). Management of diabetes has been described as an important aspect of patient optimization protocols with multiple institutions recommending diabetes management in preoperative optimization programs that have demonstrated outcomes such as decreased infection and mortality rates (Adie et al., 2019; Bozic et al., 2012; Marchant et al., 2009; Wang et al., 2018). In our literature search, we found that HbA1c cutoff values for surgical eligibility or delay ranged from 6.5% to 8% (Cross et al., 2014; Dlott et al., 2020; Gottschalk et al., 2014; Johns et al., 2020; Morrell et al., 2019; Nussenbaum et al., 2018). Recommendations for management of diabetes included referral to a PCP or endocrinologist for patients with HbA1c values above 7% to 8% (Bullock et al., 2017; Dlott et al., 2020; Featherall et al., 2018) or other signs of uncontrolled diabetes such as peripheral vascular disease or coronary artery disease (Adie et al., 2019); consideration of bariatric surgery before TJA (Fournier et al., 2016); blood glucose checks on the morning of surgery with a potential delay of TJA for measured values above 200mg/dL (Featherall et al., 2018), and routine postoperative consultation from internal medicine for all patients with diabetes (Gottschalk et al., 2014).

Cardiovascular Disease

Nurse Navigator Perspectives

Ninety-six percent of nurse navigators reported that CVD was discussed with patients prior to TJA, though these discussions often took place with the surgeon or PAT team. As a result, 28% of nurse navigators reported that they were not involved in the optimization of patients’ cardiovascular health. Interventions for assessment and management of CVD by nurse navigators who were involved were based on multiple factors such as patient comorbidities, surgeon and patient preference, and prior history of CVD or procedures. Interventions typically involved referrals to outside resources (Table 2).

Forty-four percent of nurse navigators mentioned referral to cardiology or the patient’s PCP as an intervention for optimization of cardiovascular health. Sixteen percent of nurse navigators indicated that they may communicate with a patient’s cardiologist to express the importance of the patient receiving care before TJA and advocate for a shorter wait time for an appointment, as this was a common concern among patients. Referral to a cardiovascular care coordinator was reported by 4% of nurse navigators.

Literature Review

Cardiovascular events are among the most frequent postoperative complications following TJA (Elsiwy et al., 2020; Featherall et al., 2018). Cardiovascular health is also closely tied to other independent risk factors such as obesity and uncontrolled diabetes (Featherall et al., 2018; Fournier et al., 2016), which may predispose patients to CVD. One study found that older men and patients with more medical comorbidities have a greater risk of acute myocardial infarction after TJA (Menendez et al., 2015). The interventions described for optimization of cardiovascular health as part of preoperative optimization protocols that demonstrated decreased length of stay (LOS) and postoperative emergency department visits included referral to cardiology (Adie et al., 2019; Dlott et al., 2020; Featherall et al., 2018), appraisal of cardiopulmonary function in preoperative assessments (Adie et al., 2019), incorporation of preoperative rehabilitation training (Adie et al., 2019; Wall & de Steiger, 2020), and increased perioperative cardiac monitoring and management for those at risk for CVD (Belmont et al., 2014). Adherence to guidelines for the assessment and management of surgical patients with established or underlying CVD was recommended, including postponement of elective surgery until conclusion of a course of dual anti-platelet therapy following coronary stent placement, continuation of aspirin through elective surgery episodes when possible, and aortic valve replacement for aortic stenosis prior to elective surgery (Adie et al., 2019; Kristensen et al., 2014).

Discussion

The prevalence of diabetes and concern for CVD among patients seeking TJA highlights the importance of screening for these risk factors as part of preoperative optimization protocols (Adie et al., 2019; Al-Otaibi, 2021). Increased ability to optimize patients’ control of their diabetes and cardiovascular health can decrease surgical risks and improve outcomes for many TJA patients. These improvements may be especially important for patients from minority backgrounds, as they have been demonstrated to have worse outcomes following TJA (Dlott & Wiznia, 2022) and face greater comorbidity burdens, which are associated with poor postoperative cardiovascular outcomes (Menendez et al., 2015). Studies have indicated that TJA patients with HbA1c ≥ 7% were more likely to be African American and need medications for diabetes management (Harris et al., 2013), making diabetes an important factor to address preoperatively among the African American patient population seeking TJA.

Our discussions with nurse navigators indicated that they were less involved in the optimization of diabetes management and cardiovascular health, two highly specialized areas of care, than in some other areas of preoperative optimization (Kebeh et al., 2023). However, nurse navigators have the potential to play a critical role in the ability of patients to connect to educational and supportive resources for management of these risk factors. In order to facilitate this, we provide resources for nurse navigators to use when optimizing these risk factors (Table 3).

Recommendations – Diabetes

We have developed recommendations to assist nurse navigators with diabetes management (Table 4). We strongly recommend that nurse navigators maintain awareness of PAT protocols and discuss the inclusion of blood glucose and HbA1c measurements with surgeons and medical directors, including for patients who are overweight but do not have an established diabetes diagnosis (Wiznia et al., 2021). Care teams should work with patients to achieve goals in HbA1c reduction rather than imposing strict cutoffs, and nurse navigators should help keep patients oriented towards these goals. Given that strict cutoffs can disadvantage vulnerable patient populations from accessing TJA (Chun et al., 2021) and a HbA1c value less than 7 may be unattainable for some patients (Giori et al., 2014; Harris et al., 2013), we recommend that nurse navigators collaborate with the patient and their PCP to achieve the safest HbA1c value for each individual rather than broadly applying strict cutoffs. For patients with comorbid diabetes and overweight or obesity, nurse navigators should also be aware of the recommendations of the American Society for Metabolic and Bariatric Surgery regarding weight-loss medications such as glucagon-like protein-1 (GLP-1) agonists. A trial of these medications is recommended prior to weight loss surgery among patients with overweight (BMI 25–29.9 kg/m2) or class I obesity (BMI 30–34.9 kg/m2) (Eisenberg et al., 2022).

While nurse navigators are not always directly implementing protocols for diabetes management, they should coordinate with surgeons, endocrinologists, PCPs, or diabetes management programs to support patients in receiving specialist care. We recommend nurse navigators use joint class presentations and asynchronous online or app-based patient education platforms such as Wellbe™, CareSense, HealthLoop, or Care Companion to provide evidence-based education regarding the surgical risks accompanying uncontrolled diabetes, such as increased risk of wound infection (Harris et al., 2013; Yang et al., 2014), share information about diabetes support groups or the American Diabetes Association’s education programs, and describe strategies for lifestyle changes such as alcohol cessation or routine exercise when counseling patients. Nurse navigators can share the Substance Abuse and Mental Health Services Administration website or hotline to provide patients with resources for smoking and alcohol cessation (SAMHSA - Substance Abuse and Mental Health Services Administration). Nurse navigators should collaborate with nutritionists, dietitians, and PCPs to share information from these providers about meal planning and following diabetic or ketogenic diets. In addition, nurse navigators should be aware of potential comorbidities affecting diet and exercise ability such as CVD and collaborate with PCPs or physical therapists when supporting patients in making lifestyle changes. Because these lifestyle interventions can benefit a majority of patients seeking TJA, they should be discussed universally in joint classes. Digital resources should be utilized in addition to joint classes rather than as a replacement, as some TJA patients may be unable to access the internet or successfully utilize these resources (Mamedova & Pawlowski, 2018).

Nurse navigators should encourage surgeons to recommend that patients use continuous glucose monitoring so that they are better able to track their blood glucose levels as they work to attain preoperative HbA1c goals. Nurse navigators should be aware of guidelines regarding perioperative management of diabetes medications so that they can discuss management strategies provided by the patient’s PCP or endocrinologist. For example, guidelines indicate that patients should not take metformin on the day of surgery or sodium-glucose cotransporter-2 (SGLT-2) inhibitors in the 3 to 4 days prior to TJA (ADA, 2020; Himes et al., 2020; Wiznia et al., 2021). Perioperative measures of blood glucose should remain below 200mg/dL (Gottschalk et al., 2014). If using Enhanced Recovery After Surgery (ERAS) protocols, perioperative carbohydrate-loading should be adjusted for patients with diabetes. Patients with diabetes should also receive consultation with internal medicine providers to monitor their blood glucose levels in the perioperative period and told to follow up with their PCP or endocrinologist 1 to 3 weeks after TJA (Featherall et al., 2018; Wiznia et al., 2021). While nurse navigators are not prescribing medications or deciding which management interventions are to be implemented, background knowledge can be utilized to more effectively collaborate with patient care providers who are making these decisions.

Recommendations – Cardiovascular Disease

We recommend that nurse navigators advocate for the consideration of CVD in preoperative optimization protocols at their institutions and have developed recommendations for managing patients with CVD-related risks (Table 5). While this is another area that may require specialized intervention from other providers, we recommend nurse navigators offer education and support to patients by incorporating information about cardiovascular health and CVD-related risks into joint classes, such as the association between a history of CVD and the postoperative increased risk of a major cardiac event (Belmont et al., 2014). In addition, we recommend nurse navigators help patients address difficulties with receiving specialty care through advocacy for expedited cardiology appointment scheduling and referral to a care coordinator when available.

Patients with CVD will likely have questions related to medication regimens and uncertainty about how they should adjust these regimens prior to TJA. Current guidelines that nurse navigators should be familiar with and be prepared to discuss with PCPs and cardiologists include that hypertension medications such as beta blockers, angiotensin II receptor blockers (ARB), and angiotensin-converting enzyme (ACE) inhibitors can be continued perioperatively, as can statins or aspirin taken for cardiac protection (Fleisher et al., 2014; Strong for Surgery: Medication Checklist, 2017; Wiznia et al., 2022). Additionally, continuation of anticoagulants and non-steroidal anti-inflammatory agents in the 2 weeks prior to TJA should be discussed with the patient’s PCP or cardiologist (Fleisher et al., 2014; Strong for Surgery: Medication Checklist, 2017). Though the patient’s PCP or cardiologist will be making these decisions, knowledge of these recommendations can improve communication and coordination with the patient’s other providers and allow the nurse navigator to better support the patient.

Patients with CVD can benefit from lifestyle modifications. We recommend nurse navigators support patient efforts to achieve weight loss, follow meal plans such as diabetic or ketogenic diets, and adopt low-impact exercise routines as recommended by the patient’s PCP or cardiologist. This may require exercise testing of cardiopulmonary function and interpretation by a cardiologist to determine safe and effective forms of exercise for patients. Exercise testing should be performed at the discretion of the patient’s PCP or cardiologist for patients with elevated cardiac risk due to coronary artery disease (CAD), arrythmias, congestive heart failure (CHF), or other CVD (Fleisher et al., 2014). Cessation of smoking and alcohol use are important interventions for patients with CVD. Nurse navigators should remain aware of these potential interventions so that they can suggest them for consideration by the patient’s PCP or cardiologist for patients with ongoing CVD, history of CVD, or elevated risk for CVD.

For patients with a history of CVD, arrhythmias, or peripheral vascular disease, nurses should be aware that there is a moderate level of evidence for conducting a 12-lead electrocardiogram during PAT and cardiologists may recommend this (Fleisher et al., 2014). There is also evidence that patients should not undergo TJA within 3 to 6 months of a myocardial infarction (MI) and should receive approval from a cardiologist before proceeding with TJA after this period (Fleisher et al., 2014). Patients with a recent cardiovascular intervention should postpone TJA according to the corresponding recommendations of the American College of Cardiology and American Heart Association. For example, patients should not receive TJA within 6 months of a stent placement (Fleisher et al., 2014). In addition, patients with CHF should prioritize working with a cardiologist and their PCP to stabilize their condition before considering TJA (Fleisher et al., 2014). Nurse navigators should note these findings in the literature regarding CVD management so that they can raise these concerns in support of shared decision-making, patient education, and appropriate management decisions by the surgeon, PCP, and cardiologist prior to surgery.

Conclusion

Preoperative optimization programs are dependent on nurse navigators for implementation and coordination of interventions that improve patients’ overall health status and TJA outcomes. The information gathered from our discussions with nurse navigators and literature review have yielded practical recommendations regarding strategies for optimization of diabetes management and cardiovascular health.

Acknowledgements

This article is part of a series describing contributions of nurse navigators to patient optimization for total hip and knee arthroplasty. This series was developed in coordination with Movement is Life, a group comprised of healthcare professionals whose mission is to eliminate musculoskeletal healthcare disparities. The authors would like to thank the nurse navigators who participated in discussions and provided their perspectives on each of the topics discussed in the series: Paulina Andujo BSN, RN, ONC, Christopher Bautista BSN, RN-BC, Emily Belcher RN, Kerry Boyer MSN, APRN, FNP-C, Pam Cupec BSN, MS, RN, ONC, CRRN, ACM, Madonna Doyle RN, Dawn Ellington MBA, BSN, ONC, Sara Holman RN, MSN, MBA, Diane Marie Jeselskis BSN, RN, ONC, Jillian Knudsen RN, MSN, CMSRN, ONC, CNL, CPHQ, Melissa A. Lafosse RN, ONC, Lyndee Leavitt RN, BSN, ONC, MaryHellen Lezan MS, MSN, APRN, FNP-C, JoAnn Miller-Watts RN, BSN, ONC, Christen Nelson RN, BSN, ONC, Kara Orr MSN, RN, CNL, Misty Robbins RN, Nicole Sarauer APRN, CNS, ONC, Heather Schulte BSN, Kathy Steffensmeier RN, BSN, Ashley Streett MSN, RN, ONC, CCRN, Naomi Tashman RN, BSN, ONC, Maureen Wedopohl BSN, RN, ONC, and Rhyana Whiteley MN, RN, ONC.

Footnotes

Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to declare. Support for the conduct of this research was provided by the National Heart, Lung and Blood Institute of the National Institutes of Health. This content does not represent the views of the National Institutes of Health.

References

  1. ADA. (2020). Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021. Diabetes Care, 44(Supplement_1), S211–S220. 10.2337/dc21-S015 [DOI] [PubMed] [Google Scholar]
  2. Adie S, Harris I, Chuan A, Lewis P, & Naylor JM (2019). Selecting and optimising patients for total knee arthroplasty. Medical Journal of Australia, 210(3), 135–141. 10.5694/mja2.12109 [DOI] [PubMed] [Google Scholar]
  3. Ahn A, Ferrer C, Park C, Snyder DJ, Maron SZ, Mikhail C, Keswani A, Molloy IB, Bronson MJ, Moschetti WE, Jevsevar DS, Poeran J, Galatz LM, & Moucha CS (2019). Defining and Optimizing Value in Total Joint Arthroplasty From the Patient, Payer, and Provider Perspectives. Journal of Arthroplasty, 34(10), 2290–2296.e2291. 10.1016/j.arth.2019.05.024 [DOI] [PubMed] [Google Scholar]
  4. Al-Otaibi ML (2021). Predictive Factors in Selecting Patients with Knee Osteoarthritis for Knee Replacement: A Single Center Experience. Bahrain Medical Bulletin, 43(4), 682–688. <Go to ISI>://WOS:000743490400007 [Google Scholar]
  5. Belmont PJJ, Goodman GP, Kusnezov NA, Magee C, Bader JO, Waterman BR, & Schoenfeld AJ (2014). Postoperative Myocardial Infarction and Cardiac Arrest Following Primary Total Knee and Hip Arthroplasty: Rates, Risk Factors, and Time of Occurrence. JBJS, 96(24), 2025–2031. 10.2106/jbjs.N.00153 [DOI] [PubMed] [Google Scholar]
  6. Boraiah S, Joo L, Inneh IA, Rathod P, Meftah M, Band P, Bosco JA, & Iorio R (2015). Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty: A Readmission Risk Assessment Tool. JBJS, 97(23), 1921–1928. 10.2106/jbjs.N.01196 [DOI] [PubMed] [Google Scholar]
  7. Bozic KJ, Lau E, Kurtz S, Ong K, & Berry DJ (2012). Patient-related Risk Factors for Postoperative Mortality and Periprosthetic Joint Infection in Medicare Patients Undergoing TKA. Clinical Orthopaedics and Related Research®, 470(1). https://journals.lww.com/clinorthop/Fulltext/2012/01000/Patient_related_Risk_Factors_for_Postoperative.16.aspx [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bullock MW, Brown ML, Bracey DN, Langfitt MK, Shields JS, & Lang JE (2017). A Bundle Protocol to Reduce the Incidence of Periprosthetic Joint Infections After Total Joint Arthroplasty: A Single-Center Experience. The Journal of Arthroplasty, 32(4), 1067–1073. 10.1016/j.arth.2016.11.028 [DOI] [PubMed] [Google Scholar]
  9. Changulani M, Kalairajah Y, Peel T, & Field RE (2008). The relationship between obesity and the age at which hip and knee replacement is undertaken. The Journal of Bone and Joint Surgery. British volume, 90-B(3), 360–363. 10.1302/0301-620x.90b3.19782 [DOI] [PubMed] [Google Scholar]
  10. Chun DS, Leonard AK, Enchill Z, & Suleiman LI (2021). Racial Disparities in Total Joint Arthroplasty. Current reviews in musculoskeletal medicine, 14(6), 434–440. 10.1007/s12178-021-09718-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cross MB, Yi PH, Thomas CF, Garcia J, & Della Valle CJ (2014). Evaluation of Malnutrition in Orthopaedic Surgery. JAAOS - Journal of the American Academy of Orthopaedic Surgeons, 22(3), 193–199. 10.5435/jaaos-22-03-193 [DOI] [PubMed] [Google Scholar]
  12. Dlott CC, Moore A, Nelson C, Stone D, Xu Y, Morris JC, Gibson DH, Rubin LE, & O’Connor MI (2020). Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients. J Arthroplasty, 35(6), 1508–1515 e1502. 10.1016/j.arth.2020.01.083 [DOI] [PubMed] [Google Scholar]
  13. Dlott CC, & Wiznia DH (2022). CORR Synthesis: How Might the Preoperative Management of Risk Factors Influence Healthcare Disparities in Total Joint Arthroplasty? Clin Orthop Relat Res, 480(5), 872–890. 10.1097/CORR.0000000000002177 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Eisenberg D, Shikora SA, Aarts E, Aminian A, Angrisani L, Cohen RV, De Luca M, Faria SL, Goodpaster KPS, Haddad A, Himpens JM, Kow L, Kurian M, Loi K, Mahawar K, Nimeri A, O’Kane M, Papasavas PK, Ponce J, . . . Kothari SN. (2022). 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases, 18(12), 1345–1356. 10.1016/j.soard.2022.08.013 [DOI] [PubMed] [Google Scholar]
  15. Elsiwy Y, Symonds T, Doma K, Hazratwala K, Wilkinson M, & Letson H (2020). Pre-operative clinical predictors for cardiology referral prior to total joint arthroplasty: the ‘asymptomatic’ patient. Journal of Orthopaedic Surgery and Research, 15(1), 513. 10.1186/s13018-020-02042-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Featherall J, Brigati DP, Faour M, Messner W, & Higuera CA (2018). Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications. The Journal of Arthroplasty, 33(6), 1675–1680. 10.1016/j.arth.2018.01.038 [DOI] [PubMed] [Google Scholar]
  17. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, & Wijeysundera DN (2014). 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(22), e77–e137. 10.1016/j.jacc.2014.07.944 [DOI] [PubMed] [Google Scholar]
  18. Fournier MN, Hallock J, & Mihalko WM (2016). Preoperative Optimization of Total Joint Arthroplasty Surgical Risk: Obesity. The Journal of Arthroplasty, 31(8), 1620–1624. 10.1016/j.arth.2016.02.085 [DOI] [PubMed] [Google Scholar]
  19. Giori NJ, Ellerbe LS, Bowe T, Gupta S, & Harris AHS (2014). Many Diabetic Total Joint Arthroplasty Candidates Are Unable to Achieve a Preoperative Hemoglobin A1c Goal of 7% or Less. JBJS, 96(6). https://journals.lww.com/jbjsjournal/Fulltext/2014/03190/Many_Diabetic_Total_Joint_Arthroplasty_Candidates.10.aspx [DOI] [PubMed] [Google Scholar]
  20. Gottschalk MB, Johnson JP, Sadlack CK, & Mitchell PM (2014). Decreased infection rates following total joint arthroplasty in a large county run teaching hospital: A single surgeon’s experience and possible solution. The Journal of Arthroplasty, 29(8), 1610–1616. 10.1016/j.arth.2014.03.012 [DOI] [PubMed] [Google Scholar]
  21. Harris AHS, Bowe TR, Gupta S, Ellerbe LS, & Giori NJ (2013). Hemoglobin A1C as a Marker for Surgical Risk in Diabetic Patients Undergoing Total Joint Arthroplasty. The Journal of Arthroplasty, 28(8, Supplement), 25–29. 10.1016/j.arth.2013.03.033 [DOI] [PubMed] [Google Scholar]
  22. Himes CP, Ganesh R, Wight EC, Simha V, & Liebow M (2020). Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clinic Proceedings, 95(12), 2760–2774. 10.1016/j.mayocp.2020.05.004 [DOI] [PubMed] [Google Scholar]
  23. Johns WL, Layon D, Golladay GJ, Kates SL, Scott M, & Patel NK (2020). Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review. The Journal of Arthroplasty, 35(11), 3353–3363. 10.1016/j.arth.2020.05.074 [DOI] [PubMed] [Google Scholar]
  24. Kebeh M, Dlott CC, Kurek D, Morris JC, & Wiznia DH (2023). Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use. Orthop Nurs, 42(6), 334-343. 10.1097/nor.0000000000000983 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Kebeh M, Dlott CC, Tung WS, Kurek D, Johnson CB, & Wiznia DH (2023). Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Improving Patient Access to Musculoskeletal Care. Orthop Nurs, 42(5), 279–288. 10.1097/nor.0000000000000968 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Keswani A, Tasi MC, Fields A, Lovy AJ, Moucha CS, & Bozic KJ (2016). Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends. The Journal of Arthroplasty, 31(6), 1155–1162. 10.1016/j.arth.2015.11.044 [DOI] [PubMed] [Google Scholar]
  27. Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, . . . Archbold A (2014). 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). European Heart Journal, 35(35), 2383–2431. 10.1093/eurheartj/ehu282 [DOI] [PubMed] [Google Scholar]
  28. Mamedova S, & Pawlowski E (2018). A Description of U.S. Adults Who Are Not Digitally Literate [Electronic Article]. Statistics in Brief(161). https://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2018161 [Google Scholar]
  29. Marchant MHJ, Viens NA, Cook C, Vail TP, & Bolognesi MP (2009). The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty. JBJS, 91(7), 1621–1629. 10.2106/jbjs.H.00116 [DOI] [PubMed] [Google Scholar]
  30. Menendez ME, Memtsoudis SG, Opperer M, Boettner F, & Gonzalez Della Valle A (2015). A nationwide analysis of risk factors for in-hospital myocardial infarction after total joint arthroplasty. International Orthopaedics, 39(4), 777–786. 10.1007/s00264-014-2502-z [DOI] [PubMed] [Google Scholar]
  31. Morrell AT, Golladay GJ, & Kates SL (2019). Surgical selection criteria compliance is associated with a lower risk of periprosthetic joint infection in total hip arthroplasty. Arthroplasty Today, 5(4), 528–531. 10.1016/j.artd.2019.10.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Nussenbaum FD, Rodriguez-Quintana D, Fish SM, Green DM, & Cahill CW (2018). Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population. The Journal of Arthroplasty, 33(1), 10–13. 10.1016/j.arth.2017.07.031 [DOI] [PubMed] [Google Scholar]
  33. SAMHSA - Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov [Google Scholar]
  34. Strong for Surgery: Medication Checklist. (2017). American College of Surgeons. https://www.facs.org/media/oddozkg4/medication_checklist.pdf [Google Scholar]
  35. Wall C, & de Steiger R (2020). Pre-operative optimisation for hip and knee arthroplasty: Minimise risk and maximise recovery. Australian Journal for General Practitioners, 49, 710–714. https://www1.racgp.org.au/ajgp/2020/november/pre-operative-optimisation-for-hip-and-knee-arthro [DOI] [PubMed] [Google Scholar]
  36. Wang AY, Wong MS, & Humbyrd CJ (2018). Eligibility Criteria for Lower Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities. Clinical Orthopaedics and Related Research®, 476(12), 2301–2308. 10.1097/corr.0000000000000511 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Wiznia DH, Jimenez R, & Harrington M (2021). Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus. J Am Acad Orthop Surg. 10.5435/jaaos-d-21-00425 [DOI] [PubMed] [Google Scholar]
  38. Wiznia DH, Santos EM, & Morgan RC Jr. (2022). Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Cardiovascular Health Disparities. J Am Acad Orthop Surg. 10.5435/jaaos-d-21-00920 [DOI] [PubMed] [Google Scholar]
  39. Yang Z, Liu H, Xie X, Tan Z, Qin T, & Kang P (2014). The influence of diabetes mellitus on the post-operative outcome of elective primary total knee replacement. The Bone & Joint Journal, 96-B(12), 1637–1643. 10.1302/0301-620X.96B12.34378 [DOI] [PubMed] [Google Scholar]

RESOURCES