were former professional athletes who were very healthy overall."
Gabrielle White, RN, CASC, executive director of ambulatory servic-
es and network development at the Orthopedic Surgery Center of
Orange County in Newport Beach, Calif., notes that her center's guide-
lines call for a BMI upper limit of 32 for total joint replacement.
"Though the patient could be a 33 or a 34, and just carry their weight
in a certain area or be very muscular," she adds. In these borderline
cases, the center trusts the surgeons and anesthetists to make the
final call.
Comorbidities
As a growing number of younger individuals require total joint
replacement, the population of healthy, active patients is plentiful.
That can make the patient selection process easy, says Dr. Buch.
"Someone in their 50s who hasn't had a heart attack, isn't diabetic
and doesn't smoke, will usually need only a lab test to ensure every-
thing is OK before surgery," he says. "But patients 60 and older
should, in addition to standard lab-work, be reviewed by their
internist to check on the condition of the kidneys, lungs and heart."
But even patients without perfect health can be eligible. Ms. White
says ASA 2 patients — those with controlled systemic diseases — can
be good candidates, depending on how well they manage their condi-
tions.
Consider diabetic patients. Dr. Caillouette notes that he'll perform
outpatient arthroplasty on diabetic patients as long as their hemoglo-
bin A1c levels are below 7%, which means their blood sugar is ade-
quately controlled. Even if the patient's diabetes is controlled, you still
want to schedule surgery early in the day so they aren't NPO for a
long time and at risk of getting dangerously low blood sugar. "I do my
total joints in the morning, so it usually doesn't present as much of a
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