Introduction

Orthopaedics involves a variety of treatments on both bones and joints, and also the soft tissues around them. Common procedures might include fracture fixation, joint replacement, joint arthroscopy, repair of injured tendons and muscles as well as correction of limb deformities. The patient’s age ranges from the neonate to the elderly.

Pre-operative assessment

While many procedures are planned as elective admissions, a significant proportion of orthopaedic surgery is performed emergently. The timing of the pre-operative assessment for elective procedures should be about one month before the date of the planned surgery. This allows medication review, investigation and treatment of unstable co-morbidities, and correction of conditions such as anaemia and hypertension (Table 19.1). Drugs commonly modified in the peri-operative period include rheumatoid biologic agents, anticoagulants, oral hypoglycaemics, NSAIDs, MAOI (monoamine oxidase inhibitors) and lithium. Most other medications are continued up to the day of surgery.

Where patients require emergent treatment, delaying surgery may not be an option. Careful modification of peri-operative care is needed, balancing the risks of threat to limb and life.

• Example 1: the patient presents with both a femoral neck fracture and a recent myocardial infarction. A multi-disciplinary approach to treatment options may include proceed with surgery, conservative management, surgery after a delay to allow some degree of scar formation in the new infarct (weeks), lesser surgery to temporise the fracture with a plan for more definitive surgery after a suitable time period (months). In this scenario, a key factor will be the presence of decompensating heart failure.

• Example 2: the trauma patient presenting with an open fracture with vascular compromise (requiring emergent surgery) who has had a recent meal and has a full stomach. The same discussion of life versus limb takes place but a suitable anaesthetic plan needs to be formulated to minimise the risk of aspiration.