How to Assess Surgery Risk in Orthopedic Patients

A doctor assesses the surgery risk of her orthopedic patient

Assessing surgery risk in your orthopedic patients is pivotal to reducing complications and improving health outcomes. 

The methods and models we use to assess surgical risk are continuously evolving. Looking to the future, a recent survey found that 58% of orthopedic surgeons at Mass General expect to integrate AI-based risk prediction models into their practice within the next five years. Until that happens, clinicians can choose from a number of methods to manually or automatically process risk factors to determine the best approach to each individual’s healthcare. 

Key Takeaways

  • Preoperative risk assessment informs surgical decisions and helps surgeons to minimize the risk of common complications like surgical site infection. 
  • A preoperative assessment should include collecting a medical history, conducting an exam, and administering tests to collect the relevant data points for your chosen method of risk assessment.
  • Common risk assessment models include SRS, p-POSSUM, and ASAPS.

Why is Preoperative Risk Assessment Important for Orthopedic Patients?

Orthopedic surgery can have a significant impact on a patient’s life. It can improve mobility, reduce pain, and enhance quality of life. But like all surgery, orthopedic procedures carry risks. It’s important for surgeons to understand how risk factors interplay and how it can inform their decisions before, during, and after surgery. That’s why thorough preoperative risk assessment is a vital stage of every orthopedic surgery.

Assessing each patient’s level and type of risk enables informed decision-making. It allows you to:

  • Identify physiological and operational risk factors in advance of surgery
  • Communicate those risks to the entire clinical team
  • Take steps to mitigate those risks
  • Reduce surgical complications
  • Reduce cancellations due to foreseeable patient needs
  • Minimize costs associated with longer hospital stays that result from complications

Common Complications in Orthopedic Surgery

As with all surgeries, orthopedic surgery and the anesthesia and other medication administered for its associated pain management can result in complications. The risk of those complications depends on a number of factors, including the patient’s medical history and the type of procedure being performed.

General risks involved in orthopedic surgery and the risk factors that most commonly influence them include:

    • Surgical site infections (SSIs) are the leading cause of postoperative complications. Risk factors for SSIs include old age, hypertension, diabetes mellitus, and type III incisions.
    • Bleedingrisk of bleeding increases in extensive spinal procedures and total joint arthroplasty. 
    • Nerve injury – certain procedures pose a higher risk of nerve injury than others.
  • Major blood vessel injury
  • Deep Vein Thrombosis and Pulmonary Embolism – Deep Vein Thrombosis is common after orthopedic surgery, but poses a higher risk of developing into a pulmonary embolism in procedures involving spin fracture with paralysis, total hip or knee arthroplasty, and hip fractures.

Preoperative Assessment for Orthopedic Surgery

Preoperative assessments play an important role in surgery risk assessment. They allow surgeons and anesthesiologists to get a better understanding of a patient’s medical history and current health, which can help them better tailor their approach for the procedure being performed.

The preoperative assessment is when a patient’s risk factors are identified. It includes:

  • Collecting the patient’s preoperative medical history
  • Conducting a preoperative examination, both general and airway
  • Completing preoperative testing such as blood count and urinalysis

Methods of Assessing Surgery Risk in Orthopedic Patients

As surgical methods continue to evolve, several risk assessment methods have been developed and tested. In general, these methods aim to collect data points for each patient and compare them against the risk of the procedure being performed to determine the overall risk level of that surgery.

The clinical team can then use that risk level to guide steps designed to mitigate risks, such as performing an additional phone screening, adding in-person preoperative planning, and adding risk-minimizing exercises to the preparation process.

An example of how patient and surgical risk scores are used to determine additional preoperative steps
Source: https://www.uclahealth.org/anes/risk-stratification

Three such methods are the SRS, p-POSSUM, and ASAPS:

SRS: Surgical Risk Score

The Surgical Risk Score (SRS) is a simple and easy to use risk assessment method that assigns a numerical value to the type of procedure.

Procedures range from 1 (very low risk) to 5 (very high risk):

  • 1 – Very Low Risk. Procedures that require minimal to moderate sedation and have few physiologic effects, such as eye surgery and dental procedures.
  • 2 – Low Risk. Procedures with minimal physiologic effect, such as hernia repair and cystoscopy.
  • 3 – Intermediate Risk. Procedures with a moderate change in hemodynamics and risk of blood loss, such as spine surgery and cardiac catheterization procedures.
  • 4 – High Risk. Procedures with the potential for significant effect on hemodynamics and blood loss, such as kidney transplants and major oncologic head and neck surgery.
  • 5 – Very High Risk. Procedures with a major impact on hemodynamics, blood loss, and fluid shifts, such as aortic surgery and major transplant surgery.

P-POSSUM: The Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity

The Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (p-POSSUM) is modified from the original POSSUM method, which uses both physiological and operative parameters to devise its scores.

The physiological parameters are:

  • Age
  • Cardiac signs
  • Respiratory history / chest x-ray
  • Systolic blood pressure
  • Pulse
  • Glasgow coma scale
  • Hemoglobin
  • White cell count
  • Urea
  • Sodium
  • Potassium
  • Electrocardiogram

The operative parameters are:

  • Operative severity
  • Operative urgency
  • Multiple procedures
  • Total blood loss
  • Peritoneal soiling
  • Presence of malignancy
  • Mode of surgery
Source: https://www.researchgate.net/figure/Parameters-for-Calculating-P-POSSUM-Score-a_tbl1_5822552

ASAPS: The American Society of Anesthesiologists Physical Classification System

The physical classification system developed by the American Society of Anesthesiologists uses six categories to communicate each patient’s medical comorbidities. This helps anesthesiologists and the entire clinical team to understand the patient’s pre-anesthesia risk and adjust accordingly.

The ASAPS categories are:

  • ASA 1 – “a normal healthy patient”
  • ASA 2 – “A patient with mild systemic disease”
  • ASA 3 – “A patient with severe systemic disease”
  • ASA 4 – “A patient with severe systemic disease that is a constant threat to life”
  • ASA 5 – “A moribund patient who is not expected to survive without the operation”
  • ASA 6 – “A declared brain-dead patient whose organs are being removed for donor purposes”

An additional E (e.g., ASA 2E) denotes emergency surgery.

How to Efficiently Collect Surgery Risk Assessment Information

Regardless of your chosen risk assessment model, collecting accurate and comprehensive patient information is key to delivery exception care and growing your practice. Wellbe’s personalized guided automation solutions offer flexible and efficient ways to gather patient medical histories and synthesize information in every specialty, from orthopedics to bariatrics. 

Find out how Wellbe can help you better assess surgical risk and protect your patients from complications.

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