Perioperative Care

Multidisciplinary perioperative optimization for spine surgery, focusing on ERAS protocols, frailty management, and prevention of postoperative delirium.

Overview

A structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty is informed by consensus-derived risk factors, perioperative interventions, and important outcomes [1]. Understanding preoperative risk factors can improve perioperative risk stratification and help minimize adverse outcomes [2]. High-risk patients should be medically optimized and closely monitored through the perioperative period [3]. Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria [16], while optimized fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications [20]. Implementation of an evidence-based perioperative protocol for elective spine surgery is associated with reduced length of stay and 90-day complications [39].

Prolonged procedures may be an indicator of perioperative complications, an inexperienced surgical team, less than optimal standardization programs, or patients' comorbid conditions [4]. Patients undergoing primary shoulder arthroplasty with a history of previous stroke have higher rates of mortality and perioperative complications [11]. A specific BMI threshold cannot be recommended as a screening tool for postoperative complications; rather, BMI should be incorporated as a component of the comprehensive preoperative clinical assessment [17]. Evaluating multimodal analgesic strategies is essential for understanding their benefits and limitations to develop individualized perioperative analgesic plans [40]. There is not enough evidence to provide definitive recommendations for perioperative management of anticoagulation in orthopaedic surgery [7]. It is crucial to meticulously evaluate the indications for percutaneous interlaminar endoscopic lumbar discectomy due to potential risks associated with spinal anesthesia [15].

Anatomy & Pathophysiology

Orthopaedic surgeons must recognize the pathophysiology and associated risks of spine surgery in the prone position to initiate preventive measures and ensure predictable treatment options [61]. Comprehensive physical examination requires inspection, palpation, range of motion testing, and neurologic evaluation to identify spinal pathology, nonspinal conditions, and signs of symptom magnification [82]. Preoperative planning for accurate pedicle screw selection and insertion in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [112]. Greater caution is required during the insertion of L5 and S1 percutaneous pedicle screws due to their more angulated pedicles, anatomical variations in their vertebral bodies, and the morphology of the spinal canal at this location [100].

Positioning and Alignment: The anatomical-pelvic-plane positioner serves as a simple, minimally invasive, and cost-effective means of reducing sagittal tilt in total hip arthroplasty in the lateral decubitus position [91]. Measurement of thoracic kyphosis with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6° [111]. Variations in the positioning of components in staged bilateral total hip arthroplasty were not associated with differences in patient-reported outcome measures, indicating that patients can tolerate these differences [114].

Risk Stratification and Outcomes: Composite measures of disease severity and surgery invasiveness may allow development of risk-adjusted predictive models for adverse events in spine surgery [95]. Longer instrumented segments and the development of complications contribute to worse clinical and radiographic outcomes in patients of eighty years of age and older undergoing instrumented lumbar surgery [92]. Patients with spinopelvic stiffness have higher rates of spinopelvic stiffness, which may be the mechanism by which pelvic incidence relates to total hip arthroplasty instability risk [94]. Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care after posterior spinal fusion for adolescent idiopathic scoliosis, with a threshold value of 74.5° [110]. Change in Cobb angle is an independent risk factor for minor perioperative complications after long fusion in the treatment of adult non-degenerative scoliosis [113]. Both change in Cobb angle and spinal osteotomy are independent risk factors for major perioperative complications after long fusion in the treatment of adult non-degenerative scoliosis [113].

Interventions and Technical Considerations: Staged halo-pelvic traction could mitigate the severity of spine deformity, minimize the need for invasive three-column osteotomies, and reduce the risk of complications for correction surgery [97]. Percutaneous surgical treatment of thoracolumbar fracture in ankylosing spondylitis can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods [98]. Biportal endoscopic transforaminal lumbar interbody fusion with large cage is a straightforward, safe, and minimally invasive method for inserting large cages in the treatment of lumbar instability [106]. Systems-based prevention methods are effective in identifying the proper patient, procedure, and region of the spinal column but cannot be relied on to establish the correct vertebral level during the operation [107]. Risk factors for nerve injury after total hip arthroplasty include possibly modifiable factors such as lumbar spine disease, smoking, and time of surgical scheduling [105].

Classification

Multidisciplinary Protocol: A structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty is informed by consensus-derived risk factors, perioperative interventions, and important outcomes [1]. Preoperative risk factors can improve perioperative risk stratification to help minimize adverse outcomes [2]. Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care [6].

ASA Classification: Preoperative assessment utilizes the American Society of Anesthesiologists (ASA) classification system [32]. ASA class significantly increases the risk of postoperative adverse events and hospital readmission within 30 days of open reduction and internal fixation for ankle fractures [54]. However, the American Society of Anesthesiologists grade does not reliably identify patients at risk for postoperative blood transfusion [52].

Frailty and Nutritional Tools: The modified five-item frailty index and nutritional status tools help stratify risk and determine ideal candidates for surgery in patients undergoing lumbar spinal fusion [71].

Transfusion and Hematologic Risk: Strata based on preoperative hemoglobin values can assist surgeons in stratifying patients' transfusion and complication risk after primary total knee arthroplasty [65]. The OARA score reliably identifies patients at risk for postoperative blood transfusion [52]. Preoperative medical risk stratification can identify patients at high risk of postoperative venous thromboembolic complications following primary shoulder arthroplasty [64]. Perioperative management was altered by preoperative hematologic genetic evaluation results, which appeared to limit the incidence of thrombotic events in a high-risk group [69].

Diabetes Management: Perioperative guidelines for the ten main diabetic drug classes have been summarized for patients undergoing elective total joint arthroplasty [68].

Other Considerations: Perioperative care should be organized differently for women and men [13]. There is not enough evidence to provide definitive recommendations for perioperative management of anticoagulation in orthopaedic surgery [7]. Various medical comorbidities significantly increase the risk of postoperative adverse events and hospital readmission within 30 days of open reduction and internal fixation for ankle fractures [54]. Clinical protocol, complications, patient age, ASA classification, neurological comorbidities, operative time, ward, intraoperative blood loss, and surgeon are factors contributing to a prolonged length of hospital stay following total knee arthroplasty [46]. A scoring system using classic statistics and machine learning provides a platform for stratifying patients undergoing anterior cervical discectomy and fusion into an inpatient or outpatient surgical setting [53].

Clinical Presentation

Optimizing perioperative care for hip and knee arthroplasty requires a structured, multidisciplinary protocol grounded in consensus-derived risk factors, interventions, and outcomes [1]. A systematic understanding of preoperative risk factors enables improved risk stratification to minimize adverse events [2]. High-risk patients necessitate medical optimization and close monitoring throughout the perioperative period [3]. Evaluation and management of medical comorbidities during this window can reduce surgical morbidity and mortality [26].

Prolonged surgical duration may signal perioperative complications, an inexperienced team, suboptimal standardization, or significant patient comorbidities [4]. Specific patient histories significantly alter risk profiles; those with prior stroke undergoing primary shoulder arthroplasty face higher mortality and complication rates [11]. Similarly, patients with chronic opioid use present challenges even with modern multimodal pain protocols [12], while mental health and substance use disorders directly influence perioperative opioid demand in upper extremity trauma [30]. These factors should guide surgeons to anticipate opioid needs and identify candidates for pain management collaboration [30]. Perioperative care strategies must also be organized differently for women and men [13].

Preoperative screening is critical for specific conditions. Depression is frequently underdiagnosed, warranting preoperative screening and appropriate perioperative management [23]. Clinical tools exist to screen, diagnose, and plan for orthopaedic patients with alcohol misuse [28]. Patients with obstructive sleep apnea do not exhibit higher rates of significant or major complications provided they undergo appropriate screening, monitoring, and management [31]. Understanding the influence of preoperative diagnosis on reverse total shoulder arthroplasty outcomes assists in risk stratification and expectation management [24].

Postoperative assessment requires vigilance for specific red flags and complications. Postoperative hypotension following acute hip fracture surgery predicts 30-day mortality [10]; clinicians must promptly identify this to individualize care through preventative measures or closer monitoring [10]. For spinal surgery, a systematic approach is required for adult patients with late or chronic complications, involving assessment, differential diagnosis, and familiarity with surgical approaches [5]. Differentiating Guillain-Barré Syndrome from other postoperative spinal complications relies on the timing of symptoms, imaging results, and the development of atypical features [14]. Infection workups are indicated only for patients with a temperature ≥39.0°C, those febrile for multiple days, or whose fever occurs on postoperative day 4 or later [25].

Discharge planning and metabolic monitoring are integral to the presentation of recovery. Early discharge within the first 2 days postoperatively appears feasible for risk-stratified patients without compromising care [6]. Nearly 98% of patients presenting to the emergency department for postoperative pain after outpatient hand surgery are subsequently discharged home [27]. The authors advocate for systematic preoperative and postoperative serum electrolyte analysis as part of perioperative management [29].

Investigations

Plain radiography: Routine postoperative radiography after primary total shoulder arthroplasty does not appear to add clinical utility up to a year postoperatively [55]. Current radiographic protocols in total hip arthroplasty require reassessment to determine if the benefits of frequent radiographs outweigh the risks to vital organs [70].

MRI: Metal suppression magnetic resonance imaging techniques provide a comprehensive overview of different metal artifacts in orthopaedic and spine surgery, including factors affecting their magnitude and recent technological advances [73]. Pediatric patients with neuromuscular conditions often have nonorthopaedic implants that require specific management before MRI scans or surgical procedures to ensure patient safety and device integrity [86].

CT: Preoperative CT evaluation of peri-hip muscles can be a useful predictor of postoperative walking outcomes in patients with femoral neck fracture [75]. Diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery include the utility of Hounsfield unit measurements on CT scans for identifying osteoporosis and predicting complications [84]. Postoperative routine CT scans in asymptomatic patients following pedicle screw placement in thoracolumbar fractures have no consequences drawn from them, requiring critical discussion of their use [48].

Other Considerations: A structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty should be informed by consensus-derived risk factors, perioperative interventions, and important outcomes [1]. A systematic approach to treatment for adult patients with late or chronic complications after spinal surgery requires patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches [5]. The timing of symptoms, imaging results, and the development of atypical symptoms can help distinguish Guillain-Barré Syndrome from other postoperative spinal complications [14]. Combined use of multimodality intraoperative neurophysiologic monitoring techniques is useful during complex spinal surgery because these modalities provide important complementary information to the surgery team [74]. A proper understanding of cardiac diagnoses before surgical intervention provides insight into potential risks for spine fusion patients and shows benefit in minimizing perioperative complications [77]. Awake percutaneous fixation for unstable fractures of the spine in high-risk patients is safe and feasible, requiring a dedicated team including an anesthesiologist and radiologist [78]. Pre-operative urodynamic assessment has poor predictive value for developing post-operative urinary retention, making its utility questionable [83]. A prior traumatic brain injury diagnosis is a potential risk factor for increased surgical and medical complications following total hip arthroplasty [85]. A thorough understanding of complications associated with anterior lumbar surgery aids in prevention, recognition, and management of these rare problems [87]. Current guidelines provide necessary information for clinicians diagnosing and treating periprosthetic joint infection, though further studies are needed to evaluate the role of specific metrics in clinical practice [88]. Surgeons should look further before the acute preoperative period regarding opioid claims prior to elective total joint arthroplasty to assess the risk of prolonged postoperative opioid claims [89]. Serious neurological complications can occur with percutaneous vertebroplasty unless careful attention is paid to technical details, including the use of appropriate imaging and cement consistency [90].

Treatment

Non-Operative

Conservative management for low back and pelvic girdle pain in pregnancy ranges from pharmacologic measures to surgical treatment, often requiring a collaborative plan between orthopaedic surgeons and obstetricians [51]. Clinicians should carefully weigh risk factors when considering surgical and non-surgical approaches for patients at higher risk of inferior surgical outcomes in knee arthroscopic procedures [76].

Operative

Indications: Surgical interventions, particularly total hip arthroplasty, are the primary modality of treatment for osteonecrosis of the femoral head, with limited use of other surgical and nonsurgical management [72]. A structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty is informed by consensus-derived risk factors, perioperative interventions, and important outcomes [1]. Preoperative risk factor understanding can improve perioperative risk stratification and help minimize adverse outcomes in total shoulder arthroplasty [2]. High-risk patients undergoing spine surgery should be medically optimized and closely monitored through the perioperative period [3]. A systematic approach to treatment for adult patients with late or chronic complications after spinal surgery involves patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches [5]. There is currently not enough evidence to provide definitive recommendations for perioperative management of anticoagulation in orthopaedic surgery [7]. A specific BMI threshold cannot be recommended as a screening tool for postoperative complications in primary total knee or total hip arthroplasty; BMI should instead be incorporated as a component of comprehensive preoperative clinical assessment [17].

Surgical Approach / Technique: Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria in total joint selection [16]. A one-day surgery protocol is safe and effective in unicompartmental knee arthroplasty, reducing length of stay from 3 to 1 day without significantly impacting clinical and functional outcomes at 1 year of follow-up [9]. Success in outpatient total knee arthroplasty requires a multidisciplinary approach including extensive preoperative patient education, optimum pain control, and early mobilization [42].

Pain Management: Multimodal analgesia is recommended for early postoperative pain control in shoulder surgery to optimize patient outcomes and reduce opioid consumption [34]. Multimodal anesthesia can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications compared to traditional general anesthesia with epidural and patient-controlled opioid analgesia in total knee arthroplasty [35]. Strategies to reduce opioid consumption via multimodal medications, regional anesthesia, and enhanced recovery after surgery protocols have led to markedly improved pain scores and patient satisfaction, decreased lengths of stay, and decreased pain-related readmissions and complications in total hip and knee arthroplasties [38]. A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures [59]. Level I evidence supports the routine perioperative use of NSAIDs to improve pain control and reduce opioid consumption in spine surgery, while selective COX-2 inhibitors or short-term, low-dose nonselective COX inhibitors do not appear to affect spinal fusion rates [79]. Patients with a history of chronic opioid use continue to present a challenge for pain management even with modern multimodal pain protocols in total knee arthroplasty [12]. Perioperative use of pregabalin does not reduce postoperative opioid requirements, improve early postoperative pain scores, or improve functional outcomes at 6 months in total knee arthroplasty [43]. Testosterone, growth hormone, and vitamin D supplementation are not routinely indicated for orthopaedic surgery patients, and testosterone replacement therapy is not recommended for routine use in perioperative management [33].

Adjuncts: The routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas, and the absence of a drain does not lead to a significant change in the incidence of wound infection [80].

Setting of Care: An integrated management bundle improved 1-year overall survival and had positive effects on perioperative outcomes in super elderly patients aged 90 and over with hip fracture [8]. Different perioperative care procedures have a positive impact on in-hospital recovery of patients undergoing primary total knee arthroplasty [18]. Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications [20]. Safe and effective sedation for hand surgery in adults can be achieved if care is given to thoroughly evaluating the patient preoperatively, selecting the appropriate patient and procedure, carefully titrating sedative agents to effect, and closely observing airway and breathing [36]. It is crucial to meticulously evaluate indications for percutaneous interlaminar endoscopic lumbar discectomy due to potential risks associated with local anesthesia [15].

Complications

General Perioperative Risk: Optimising care involves consensus-derived risk factors and interventions to inform multidisciplinary protocols [1]. Preoperative risk stratification is critical for minimizing adverse outcomes in total shoulder arthroplasty [2] and requires detailed histories for medically complicated elderly patients undergoing total knee and hip arthroplasty [58]. High-risk spine surgery patients must be medically optimized and closely monitored [3]. Prolonged procedures may indicate complications, inexperienced teams, suboptimal standardization, or patient comorbidities in total hip and knee arthroplasty [4]. Perioperative COVID-19 nearly doubled the background postoperative mortality risk following orthopaedic and trauma surgery [47].

Infection (PJI): Short-term, 30-day surgical site infections occur in approximately 1% of patients undergoing total joint arthroplasty [50]. Preoperative opioid use is associated with higher readmission and revision rates in total knee and total hip arthroplasty [21], as well as an increased risk of complications in total joint arthroplasty [45]. Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of adverse effects and complications in hip arthroscopy [44].

Cardiac and Thromboembolic Events: An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty [49]. Perioperative stroke patients experienced severe outcomes, with previous stroke history and hyperlipidemia identified as associated risk factors in spinal surgery [67].

Wound and Soft Tissue Complications: Patients with a history of solid organ transplant undergoing shoulder arthroplasty remain a unique population due to vulnerability to minor complications and increased inpatient resource utilization [56]. Numerous perioperative complications and predisposing risk factors were identified in surgical treatment for degenerative adult de novo scoliosis, raising awareness in preoperative selection [66].

Other Considerations: An integrated management bundle improved 1-year overall survival and perioperative outcomes in super elderly patients aged 90 and over with hip fracture [8]. A one-day surgery protocol is safe and effective in unicompartmental knee arthroplasty, reducing length of stay from 3 to 1 day without significantly impacting clinical and functional outcomes [9]. Longer follow-up is needed to determine the durability and long-term outcomes of surgeries for displaced femoral neck fractures in workers' compensation patients aged 45-65 years [19]. The rate of surgical complications and related hospital admissions following shoulder arthroplasty remained meaningful during the entire year after surgery, suggesting a postoperative follow-up period longer than the traditional 90 days may be warranted [22]. Patients undergoing total joint arthroplasty after lung transplantation should be informed of inherent risks related to postoperative complications and survival rates, though such risks do not appear to be further increased than other transplant cohorts undergoing arthroplasty [57]. Preoperative opioid use is associated with inferior patient-reported outcomes, increased opioid consumption after surgery, an increased risk for chronic opioid use, and an increased risk of complications in total joint arthroplasty [45].

Recovery

Light activity (weeks): Early discharge within the first 2 days postoperatively appears feasible for risk-stratified patients without compromising care [6]. In a well-defined fast-track protocol, reducing the length of stay from 3 to 1 day did not significantly impact clinical and functional outcomes [9]. Time to discharge was significantly improved in the recent period compared to the historical period for both total hip arthroplasty and subacromial decompression groups [96].

Full activity (months): Pre-emptive use of cyclooxyenase-2 inhibitors improves analgesia and functional recovery in the first postoperative week but does not improve long-term knee function [41]. Operative time is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction [81]. Surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors [101].

Complete recovery / outcome plateau (months): No or mild pain and good functional abilities at 4 months are associated with high HRQOL and patient satisfaction at 4- and 12-month follow-up [63]. The rate of surgical complications and related hospital admissions remained meaningful during the entire year after shoulder arthroplasty, suggesting that a postoperative follow-up period longer than the traditional 90 days may be warranted [22]. Long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing unicompartmental knee arthroplasty [62].

Rehabilitation protocol: High-risk patients should be medically optimized and closely monitored through the perioperative period [3]. Clinicians should promptly identify patients with postoperative hypotension to allow for improved individualization of care through preventative measures or closer monitoring [10]. Patients with stage 3 hypertension with evidence of end-organ damage should be delayed if the case is elective, allowing medical optimization prior to surgery [104]. The time-dependent approach to intervention escalation provides clear clinical decision-making criteria and suggests that early identification and systematic management of wound complications are critical determinants of successful outcomes [99].

Functional milestones: Different perioperative care procedures have a positive impact on in-hospital recovery of patients undergoing primary total knee arthroplasty [18]. The integrated management bundle improved 1-year overall survival and played positive effects in improving perioperative outcomes in super elderly patients aged 90 and over with hip fracture [8]. Patients with long-term opioid use prior to total hip and total knee arthroplasty have an increased risk of poor outcomes and increased postoperative health-care utilization [21].

Other Considerations: Prolonged procedures may be an indicator of perioperative complications, inexperienced surgical team, less than optimal standardization programs, or patients' comorbid conditions [4]. Postoperative hypotension following acute hip fracture surgery is a predictor of 30-day mortality [10]. Evaluating operative time as a cause of adverse events is difficult due to potential unmeasured confounders and lack of orthopedic-specific outcome data [93]. Operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling [81]. The peak period for readmission occurs from 10 to 40 days after surgery for thoracic spinal stenosis, suggesting the need for close follow-up during this interval [102].

Key Evidence

• [L5] The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. (10.1186/s12891-018-2062-2)
• [L3] A better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes. (10.1016/j.jseint.2022.06.006)
• [L3] High-risk patients should be medically optimized and closely monitored through the perioperative period. (10.5435/jaaos-d-17-00650)
• [L3] Prolonged procedures may be an indicator of perioperative complications, inexperienced surgical team, less than optimal standardization programs, or patients' comorbid conditions. (10.1016/j.arth.2008.01.220)
• [L5] A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery, involving patient assessment, differential diagnosis formulation, and familiarity with different surgical approaches. (10.5435/jaaos-d-16-00530)
• [L3] Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care. (10.2106/jbjs.15.01109)
• [L5] Currently, there is not enough evidence to provide definitive recommendations for perioperative management of anticoagulation in orthopaedic surgery. (10.2106/jbjs.rvw.n.00105)
• [L3] The integrated management bundle improved 1-year overall survival and played positive effects in improving perioperative outcomes. (10.1186/s12891-022-05720-z)
• [L2] The one-day surgery protocol is safe and effective, and reducing the length of stay from 3 to 1 day in a well-defined fast-track protocol did not significantly impact clinical and functional outcomes. (10.1002/ksa.12350)
• [L2] Clinicians should promptly identify patients with postoperative hypotension to allow for improved individualization of care through preventative measures or closer monitoring. (10.1302/0301-620x.106b2.bjj-2023-0692.r2)
• [L3] This information should be considered to counsel patients and surgeons to optimize care and help mitigate risks associated with the perioperative period. (10.1016/j.jse.2022.10.014)
• [L2] This patient population continues to present a challenge even with modern multimodal pain protocols. (10.1016/j.arth.2016.01.037)
• [L3] Perioperative care should be organized differently for women and men. (10.1186/s12891-023-06788-x)
• [L5] The timing of symptoms, imaging results, and the development of atypical symptoms can help distinguish this rare possibility from other postoperative spinal complications. (10.5435/jaaos-d-16-00572)
• [L3] However, it is crucial to meticulously evaluate the indications due to potential risks associated with this form of anesthesia. (10.1186/s12891-024-07898-w)
• [L3] Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria. (10.1016/j.arth.2025.05.054)
• [L4] We cannot recommend a specific BMI threshold to utilize as a screening for postoperative complications but rather emphasize incorporating BMI as a component of the comprehensive preoperative clinical assessment. (10.1016/j.arth.2024.10.040)
• [L3] This study highlights the positive impact of different perioperative care procedures on in-hospital recovery of patients undergoing primary TKA. (10.1302/0301-620x.106b6.bjj-2023-0819.r2)
• [L3] Longer follow-up will help determine the durability and long-term outcomes of these surgeries. (10.1016/j.arth.2020.06.003)
• [L3] The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. (10.1002/ksa.12122)
• [L4] This study illustrates the increased risk of poor outcomes and increased postoperative health-care utilization for patients with long-term opioid use prior to THA and TKA. (10.2106/jbjs.17.01414)
• [L3] The finding that the rate of surgical complications and related hospital admissions remained meaningful during the entire year after surgery suggests that a postoperative follow-up period longer than the traditional 90 days may be warranted. (10.1016/j.jses.2017.10.002)
• [L3] Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. (10.1302/0301-620x.98b6.37208)
• [L4] Understanding the influence of preoperative diagnosis on rTSA outcomes can assist clinicians with preoperative risk stratification as well as managing patient expectations. (10.1016/j.jseint.2025.06.002)
• [L5] Evaluation and management of medical comorbidities in the perioperative period can help improve surgical morbidity and mortality. (10.5435/00124635-200804000-00005)
• [L3] Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home. (10.5435/jaaos-d-19-00527)
• [L5] The article comprehensively reviews clinical tools for screening, diagnosis, preoperative planning, and postoperative management of orthopaedic patients who misuse alcohol, aiming to provide practical information to assist surgeons in managing this prevalent spectrum of disease. (10.5435/jaaos-d-17-00708)
• [L3] The authors advocate for systematic preoperative and postoperative serum electrolyte analysis as part of perioperative management. (10.1186/s12891-022-05451-1)
• [L4] These findings can guide surgeons to anticipate expected perioperative opioid demand and identify patients who may benefit from collaboration with pain management specialists. (10.1016/j.jse.2020.06.024)
• [L5] TRT is not recommended for routine use in the perioperative management of orthopaedic surgery patients. (10.1016/j.arthro.2025.01.033)
• [L5] Multimodal analgesia is recommended for early postoperative pain control to optimize patient outcomes and reduce opioid consumption. (10.1016/j.jse.2020.04.049)
• [L5] Multimodal anesthesia can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications compared to traditional general anesthesia with epidural and patient-controlled opioid analgesia. (10.5435/jaaos-d-14-00259)
• [L5] Safe and effective sedation can be achieved if care is given to thoroughly evaluating the patient preoperatively, selecting the appropriate patient and procedure, carefully titrating sedative agents to effect, and closely observing airway and breathing. (10.1016/j.jhsa.2011.01.038)
• [L5] Strategies to reduce opioid consumption via multimodal medications, regional anesthesia, and enhanced recovery after surgery protocols have led to markedly improved pain scores and patient satisfaction, decreased lengths of stay, and decreased pain-related readmissions and complications. (10.1016/j.arth.2017.06.035)
• [L3] Length of stay and 90-day complications for elective spine surgery improved after implementation of an evidence-based perioperative protocol. (10.5435/jaaos-d-17-00274)
• [L2] Evaluating these strategies is essential for understanding their benefits and limitations to develop individualized perioperative analgesic plans. (10.1186/s13018-024-05324-4)
• [L2] While they improve analgesia and functional recovery in the first postoperative week, they do not improve long-term knee function. (10.1186/s42836-019-0015-3)
• [L4] Success requires a multidisciplinary approach including extensive preoperative patient education, optimum pain control, and early mobilization. (10.1016/j.arth.2018.09.042)
• [L2] This study showed no reduction in postoperative opioid requirements, or improvement in early postoperative pain scores or functional outcomes at 6 months, with perioperative use of pregabalin. (10.1007/s00167-019-05385-7)
• [L3] Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of several adverse effects/complications. (10.1016/j.arthro.2018.03.016)
• [L1] Preoperative opioid use is associated with inferior patient-reported outcomes, increased opioid consumption after surgery, an increased risk for chronic opioid use, and an increased risk of complications. (10.1016/j.arth.2020.05.034)
• [L4] Clinical protocol, complications, patient age, ASA classification, neurological comorbidities, operative time, ward, intraoperative blood loss, and surgeon were all factors contributing to a prolonged length of hospital stay. (10.1186/s12891-020-3042-x)
• [L3] Perioperative COVID-19 nearly doubled the background postoperative mortality risk following surgery. (10.1302/0301-620x.102b12.bjj-2020-1395.r2)
• [L3] No consequences were drawn from postoperative routine CT in asymptomatic patients, therefore its use has to be discussed critically. (10.1186/s12891-021-04860-y)
• [L3] An age of eighty years or more, a history of cardiac disease, and hypertension requiring medication are significant risk factors for developing postoperative cardiac complications following primary unilateral total knee arthroplasty and total hip arthroplasty. (10.2106/jbjs.n.00153)
• [L4] Management ranges from conservative and pharmacologic measures to surgical treatment, often requiring a collaborative plan between orthopaedic surgeons and obstetricians. (10.5435/jaaos-d-14-00248)
• [L3] The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. (10.1302/0301-620x.103b1.bjj-2019-1555.r3)
• [L3] Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting. (10.5435/jaaos-d-20-00894)
• [L3] ASA class and various medical comorbidities were found to significantly increase the risk of postoperative adverse events and hospital readmission. (10.1186/s13018-024-04895-6)
• [L4] Routine postoperative radiography after primary TSA does not appear to add clinical utility up to a year postoperatively. (10.1016/j.jse.2016.11.035)
• [L3] Patients with history of solid organ transplant undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization. (10.1016/j.jse.2018.02.064)
• [L4] Patients should be informed of inherent risks related to postoperative complications and survival rates, but such risks do not appear to be any further increased than other transplant cohorts undergoing arthroplasty. (10.1016/j.arth.2013.03.029)
• [L3] These results emphasize the need for detailed histories by health care professionals for medically complicated elderly patients preoperatively. (10.1016/j.arth.2012.05.005)
• [L4] A multimodal, nonopioid pain protocol was found to be effective in managing postoperative pain following common orthopedic sports procedures. (10.1016/j.arthro.2020.04.018)
• [L5] Orthopaedic surgeons should be aware of pathophysiology and related risks associated with spine surgery in the prone position, and initiate preventive measures and predictable treatment options. (10.5435/00124635-200703000-00005)
• [L3] This study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders. (10.1016/j.arth.2024.02.021)
• [L2] No or mild pain and good functional abilities at 4 months are associated with high HRQOL and patient satisfaction at 4- and 12-month follow-up. (10.1007/s00167-012-1919-4)
• [L3] Preoperative medical risk stratification can potentially identify patients at high risk of postoperative VTE. (10.1016/j.jse.2020.09.030)
• [L3] These strata can assist surgeons in stratifying patients' transfusion and complication risk based on their preoperative hemoglobin value. (10.5435/jaaos-d-23-01241)
• [L3] The study identified numerous perioperative complications and multiple possible predisposing risk factors, raising awareness in preoperative patient selection and preparation. (10.1186/s12891-017-1925-2)
• [L3] Perioperative stroke patients experienced a heavy financial burden and severe outcomes, with previous stroke history and hyperlipidemia identified as associated risk factors. (10.1186/s12891-022-05591-4)
• [L4] Based on this literature review, the authors provided a summation of the perioperative guidelines for the ten main diabetic drug classes. (10.1016/j.arth.2025.10.054)
• [L5] Current radiographic protocols should be reassessed to determine if the benefits of frequent radiographs outweigh the newly demonstrated risks. (10.5435/jaaos-d-16-00713)
• [L3] These tools help stratify risk and determine ideal candidates for surgery. (10.1302/0301-620x.102b12.bjj-2020-0874.r1)
• [L3] Surgical interventions, particularly THA, are the primary modality of treatment, with limited use of other surgical and nonsurgical management. (10.1016/j.arth.2025.06.002)
• [L5] This review provides a comprehensive overview of different metal artifacts in orthopaedic MRI and factors affecting their magnitude, discussing commonly applied techniques and recent technological advances to facilitate better-informed diagnostic decisions. (10.5435/jaaos-d-24-01057)
• [L5] Combined use of multimodality monitoring techniques is useful during complex spinal surgery because these modalities provide important complementary information to the surgery team. (10.5435/00124635-200802000-00001)
• [L3] Preoperative CT evaluation of these muscles can be a useful predictor of postoperative walking outcomes. (10.1186/s12891-025-08668-y)
• [L3] For patients who are at higher risk of inferior surgical outcomes, clinicians should carefully weigh risk factors when considering surgical and non-surgical approaches. (10.1007/s00167-022-06919-2)
• [L3] Before surgical intervention, a proper understanding of cardiac diagnoses could give insight into the potential risks for each patient based on their heart condition and preventive measures showing benefit in minimizing perioperative complications after elective spine fusion. (10.5435/jaaos-d-21-00850)
• [L4] Awake fixation in extreme cases is safe and feasible; a dedicated team including an anesthesiologist and radiologist is needed to treat these cases safely and quickly. (10.5435/jaaos-d-21-00959)
• [L1] Level I evidence supports the routine perioperative use of NSAIDs to improve pain control and reduce opioid consumption, while selective COX-2 inhibitors or short-term, low-dose nonselective COX inhibitors do not appear to affect spinal fusion rates. (10.5435/jaaos-d-16-00049)
• [L1] The routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas, and the absence of a drain does not lead to a significant change in the incidence of wound infection. (10.1302/0301-620x.98b7.37190)
• [L3] Operative time may be a useful perioperative variable for post-operative risk stratification and patient counseling. (10.1007/s00167-019-05622-z)
• [L3] The utility of obtaining these measurements pre-operatively is questionable. (10.1016/j.arth.2021.01.056)
• [L5] This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery, highlighting new anabolic pharmacologic options and the utility of Hounsfield unit measurements on CT scans for identifying osteoporosis and predicting complications. (10.5435/jaaos-d-24-00311)
• [L3] Our findings highlight a prior TBI diagnosis as a potential risk factor for increased surgical and medical complications following a THA. (10.1016/j.arth.2025.08.025)
• [L5] Pediatric patients with neuromuscular conditions often have nonorthopaedic implants that require specific management before MRI scans or surgical procedures to ensure patient safety and device integrity. (10.5435/jaaos-d-22-00634)
• [L4] A thorough understanding of the complications associated with anterior lumbar surgery will aid in prevention, recognition, and management of these rare problems. (10.5435/00124635-201105000-00002)
• [L4] Further studies are needed to evaluate the role of these metrics in clinical practice, whereas the current guidelines provide necessary information for clinicians diagnosing and treating PJI. (10.5435/jaaos-d-20-00438)
• [L3] Surgeons should look further before the acute preoperative period. (10.5435/jaaos-d-20-01184)
• [L5] The case demonstrates that serious neurological complications can occur with vertebroplasty unless careful attention is paid to technical details, including the use of appropriate imaging and cement consistency. (10.2106/00004623-200107000-00014)
• [L4] The device holds promise as a simple, minimally invasive, and cost-effective means of reducing sagittal tilt. (10.1016/j.arth.2016.11.048)
• [L4] Longer instrumented segments and development of complications contributed to worse clinical and radiographic outcomes. (10.1186/s12891-016-1239-9)
• [L5] Evaluating operative time as a cause of adverse events is difficult due to potential unmeasured confounders and lack of orthopedic-specific outcome data; additional research is needed to better clarify the causality of observed associations. (10.1016/j.arth.2018.04.029)
• [L3] Patients with SSD had higher rates of spinopelvic stiffness, which may be the mechanism by which PI relates to THA instability risk, but further clinical studies are required. (10.1302/0301-620x.104b3.bjj-2021-0894.r1)
• [L4] Composite measures of disease severity and surgery invasiveness may allow development of risk-adjusted predictive models for adverse events in spine surgery. (10.1186/1471-2474-7-53)
• [L3] HPT could mitigate the severity of spine deformity, minimize the need for invasive three-column osteotomies, and reduce the risk of complications for correction surgery. (10.1186/s13018-025-05739-7)
• [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
• [L2] The time-dependent approach to intervention escalation provides clear clinical decision-making criteria and suggests that early identification and systematic management of wound complications are critical determinants of successful outcomes. (10.1002/ksa.70077)
• [L3] Greater caution must be taken during the insertion of L5 and S1 percutaneous pedicle screws owing to their more angulated pedicles, the anatomical variations in their vertebral bodies and the morphology of the spinal canal at this location. (10.1302/0301-620x.97b8.35330)
• [L3] These data suggest that surgical duration should be considered for postoperative risk stratification, as well as patient counseling, and may be a surgeon-modifiable risk factor independent of patient risk factors. (10.1016/j.jse.2019.08.015)
• [L3] The peak period for readmission occurs from 10 to 40 days after surgery, suggesting the need for close follow-up during this interval. (10.1186/s12891-021-03975-6)
• [L5] Patients with stage 3 hypertension with evidence of end-organ damage should be delayed if the case is elective, allowing medical optimization prior to surgery. (10.1016/j.jhsa.2015.03.027)
• [L3] We found risk factors that are possibly modifiable factors such as lumbar spine disease, smoking, and time of surgical scheduling. (10.1016/j.arth.2018.09.008)
• [L4] The technique is a straightforward, safe, and minimally invasive method for inserting large cages in the treatment of lumbar instability. (10.1186/s13018-024-05018-x)
• [L4] Systems-based prevention methods are effective in identifying the proper patient, procedure, and region of the spinal column but cannot be relied on to establish the correct vertebral level during the operation. (10.5435/jaaos-21-05-312)
• [L3] Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care, and has a threshold value of 74.5°. (10.1302/0301-620x.106b7.bjj-2023-1334.r1)
• [L3] Measurement of TK with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6°. (10.1186/s12891-021-04786-5)
• [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
• [L3] Change in Cobb angle is an independent risk factor for minor perioperative complications, while both change in Cobb angle and spinal osteotomy are independent risk factors for major perioperative complications. (10.1186/s12891-021-04361-y)
• [L3] Variations in the positioning of the components was not associated with differences in PROMs, indicating that patients can tolerate these differences. (10.1302/0301-620x.107b5.bjj-2024-0880.r2)

See Also

• Pain Management
• Surgical Interventions
• Surgical Complications

References

[1] Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2062-2

[2] Chronic steroid use and readmission following total shoulder arthroplasty. JSES International. 2022. DOI: 10.1016/j.jseint.2022.06.006

[3] Cardiac Complications Related to Spine Surgery: Timing, Risk Factors, and Clinical Effect. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00650

[4] Effect of Procedure Duration on Total Hip Arthroplasty and Total Knee Arthroplasty Survivorship in the United States Medicare Population. The Journal of Arthroplasty. 2008. DOI: 10.1016/j.arth.2008.01.220

[5] An Approach to Lumbar Revision Spine Surgery in Adults. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00530

[6] Hospital Discharge within 2 Days Following Total Hip or Knee Arthroplasty Does Not Increase Major-Complication and Readmission Rates. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.01109

[7] Recommendations for Perioperative Management of Patients on Existing Anticoagulation Therapy. JBJS Reviews. 2015. DOI: 10.2106/jbjs.rvw.n.00105

[8] Effect of integrated management bundle on 1-year overall survival outcomes and perioperative outcomes in super elderly patients aged 90 and over with hip fracture: non-concurrent cohort study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05720-z

[9] One‐day surgery is safe and effective in unicompartmental knee arthroplasty: A prospective comparative study at 1 year of follow‐up. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12350

[10] Postoperative hypotension following acute hip fracture surgery is a predictor of 30-day mortality. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b2.bjj-2023-0692.r2

[11] Higher rates of mortality and perioperative complications in patients undergoing primary shoulder arthroplasty and a history of previous stroke. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.10.014

[12] Is There a Benefit for Liposomal Bupivacaine Compared to a Traditional Periarticular Injection in Total Knee Arthroplasty Patients With a History of Chronic Opioid Use?. The Journal of Arthroplasty. 2016. DOI: 10.1016/j.arth.2016.01.037

[13] Same-gender differences in perioperative complications and transfusion management for lower limb arthroplasty. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06788-x

[14] Guillain-Barré Syndrome After Elective Spinal Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00572

[15] Comparison of spinal anesthesia and local anesthesia in percutaneous interlaminar endoscopic lumbar discectomy for L5/S1 disc herniation: a retrospective cohort study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07898-w

[16] Should We Expand Outpatient Total Joint Selection Criteria? Re-exploring Hard Stop Criteria. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.05.054

[17] Is There a Threshold Limit for Body Mass Index for Patients Undergoing Primary Total Knee or Total Hip Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.040

[18] A stepwise transformation: description and outcome of perioperative procedures in patients receiving a total knee arthroplasty. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b6.bjj-2023-0819.r2

[19] Displaced Femoral Neck Fractures in Workers’ Compensation Patients Aged 45-65 Years: Is It Best to Fix the Fracture or Replace the Joint?. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.06.003

[20] Optimised fast‐track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12122

[21] Preoperative Opioid Use Is Associated with Higher Readmission and Revision Rates in Total Knee and Total Hip Arthroplasty. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01414

[22] Shoulder arthroplasty in the US Medicare population: a 1-year evaluation of surgical complications, hospital admissions, and revision surgery. JSES Open Access. 2018. DOI: 10.1016/j.jses.2017.10.002

[23] The influence of a history of clinical depression on peri-operative outcomes in elective total shoulder arthroplasty. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b6.37208

[24] Influence of preoperative diagnosis on outcomes after reverse total shoulder arthroplasty: a systematic review. JSES International. 2025. DOI: 10.1016/j.jseint.2025.06.002

[25] Cost_and_Effectiveness_of_Postoperative_Fever_Workup_in_Hip_and_Knee_Arthroplast_S0883540310000409. n.d..

[26] Perioperative Medical Comorbidities in the Orthopaedic Patient. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200804000-00005

[27] Emergency Department Utilization After Outpatient Hand Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00527

[28] Perioperative Management of the Orthopaedic Patient and Alcohol Use, Abuse, and Withdrawal. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00708

[29] Variations in postoperative electrolyte concentrations and influential factors in hip arthroscopy. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05451-1

[30] Mental health and substance use affect perioperative opioid demand in upper extremity trauma surgery. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.024

[31] Prevalence_of_Obstructive_Sleep_Apnea_and_Management_in_Patient_Undergoing_Total_S0883540310000306. n.d..

[32] Chapter 6 Anesthesiology. 2019.

[33] Editorial Commentary: Testosterone, Growth Hormone, and Vitamin D Supplementation Is Not Routinely Indicated for Orthopaedic Surgery Patients. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.01.033

[34] Perioperative pain management for shoulder surgery: evolving techniques. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.049

[35] Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-14-00259

[36] Sedation for Hand Surgery in Adults. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.01.038

[38] Current Trends in Pain Management in Total Hip and Knee Arthroplasties. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.06.035

[39] Perioperative Protocol for Elective Spine Surgery Is Associated With Reduced Length of Stay and Complications. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00274

[40] Advances in perioperative pain management for total knee arthroplasty: a review of multimodal analgesic approaches. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05324-4

[41] Efficacy of pre-emptive use of cyclooxyenase-2 inhibitors for total knee arthroplasty: a mini-review. Arthroplasty. 2019. DOI: 10.1186/s42836-019-0015-3

[42] Outpatient Total Knee Arthroplasty—The New Reality and How Can It Be Achieved?. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.09.042

[43] Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05385-7

[44] Perioperative Opioid Analgesics and Hip Arthroscopy: Trends, Risk Factors for Prolonged Use, and Complications. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.03.016

[45] Opioids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. The Journal of Arthroplasty. 2020. DOI: 10.1016/j.arth.2020.05.034

[46] Perioperative predictors of prolonged length of hospital stay following total knee arthroplasty: a retrospective study from a single center in China. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3042-x

[47] IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV-2 infection after orthopaedic and trauma surgery. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b12.bjj-2020-1395.r2

[48] Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary?. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04860-y

[49] Postoperative Myocardial Infarction and Cardiac Arrest Following Primary Total Knee and Hip Arthroplasty: Rates, Risk Factors, and Time of Occurrence. The Journal of Bone and Joint Surgery-American Volume. 2014. DOI: 10.2106/jbjs.n.00153

[50] The_Incidence_of_and_Risk_Factors_for_30-Day_Surgical_Site_Infections_Following_S0883540315004763. n.d..

[51] Low Back Pain and Pelvic Girdle Pain in Pregnancy. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00248

[52] Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b1.bjj-2019-1555.r3

[53] A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00894

[54] Readmission within 30-days of open reduction and internal fixation for ankle fractures: NSQIP analysis of 29,905 patients. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04895-6

[55] Utility of postoperative radiography in routine primary total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.11.035

[56] The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.02.064

[57] Outcomes of Primary Total Joint Arthroplasty After Lung Transplantation. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.03.029

[58] Validity of Patient-Reported Comorbidities Before Total Knee and Hip Arthroplasty in Patients Older Than 65 years. The Journal of Arthroplasty. 2012. DOI: 10.1016/j.arth.2012.05.005

[59] A Multimodal Protocol to Diminish Pain Following Common Orthopedic Sports Procedures: Can We Eliminate Postoperative Opioids?. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.04.018

[61] Ophthalmologic Complications Associated With Prone Positioning in Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200703000-00005

[62] Outcomes of Unicompartmental Knee Arthroplasty in Patients Receiving Long-Term Anticoagulation Therapy: A Propensity-Matched Cohort Study. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.02.021

[63] Patient‐reported outcome after fast‐track knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-1919-4

[64] Low-dose aspirin and the rate of symptomatic venous thromboembolic complications following primary shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.030

[65] Evaluating the Effect of Decreasing Preoperative Hemoglobin on Blood Transfusions, Major Complications, and Periprosthetic Joint Infection After Primary Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01241

[66] Perioperative complications after surgical treatment in degenerative adult de novo scoliosis. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-017-1925-2

[67] Perioperative stroke in patients undergoing spinal surgery: a retrospective cohort study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05591-4

[68] Perioperative Management of Diabetic Medications in Patients Undergoing Elective Total Joint Arthroplasty: A Review of Current Guidelines and Recommendations. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.10.054

[69] The_Role_of_Preoperative_Hematologic_Genetic_Evaluation_in_Arthroplasty_Patients_S0883540310000689. n.d..

[70] The Relative Effects of Manual Versus Automatic Exposure Control on Radiation Dose to Vital Organs in Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00713

[71] Predicting postoperative complications in patients undergoing lumbar spinal fusion by using the modified five-item frailty index and nutritional status. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b12.bjj-2020-0874.r1

[72] Epidemiology, Management, and Systematic Review of Surgical Trends for Patients Who Have Osteonecrosis of the Femoral Head. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.06.002

[73] Metal Suppression Magnetic Resonance Imaging Techniques in Orthopaedic and Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01057

[74] Intraoperative Neurophysiologic Monitoring During Spinal Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200802000-00001

[75] Preoperative computed tomography assessment of peri-hip muscles in patients with femoral neck fracture and its impact on postoperative walking function. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08668-y

[76] Demographics and surgery‐related complications lead to 30‐day readmission rates among knee arthroscopic procedures. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06919-2

[77] Assessment of Postoperative Outcomes of Spine Fusion Patients With History of Cardiac Disease. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00850

[78] Awake Percutaneous Fixation for Unstable Fractures of the Spine in High-risk Patients: A Retrospective Study. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00959

[79] The Role of Multimodal Analgesia in Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00049

[80] Wound drains in non-complex lumbar surgery. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b7.37190

[81] Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05622-z

[82] Chapter 12 Physical Examination of the Spine. 2019.

[83] Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.01.056

[84] Osteoporosis Evaluation and Management in Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00311

[85] Does Traumatic Brain Injury Increase Surgical and Medical Complications After Total Hip Arthroplasty?. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.025

[86] Perioperative Management of Nonorthopaedic Devices in the Pediatric Neuromuscular Patient Population. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00634

[87] Complications of Anterior Lumbar Surgery. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201105000-00002

[88] A Case Illustrating the Practical Application of the AAOS Clinical Practice Guideline: Diagnosis and Prevention of Periprosthetic Joint Infection. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00438

[89] Opioid Claims Prior to Elective Total Joint Arthroplasty and Risk of Prolonged Postoperative Opioid Claims. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-01184

[90] Major Neurological Complications Following Percutaneous Vertebroplasty with Polymethylmethacrylate. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200107000-00014

[91] Efficacy of the Anatomical-Pelvic-Plane Positioner in Total Hip Arthroplasty in the Lateral Decubitus Position. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.11.048

[92] Surgical outcomes after instrumented lumbar surgery in patients of eighty years of age and older. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1239-9

[93] Response to Letter to the Editor on “Impact of Operative Time on Adverse Events Following Primary Total Joint Arthroplasty”. The Journal of Arthroplasty. 2018. DOI: 10.1016/j.arth.2018.04.029

[94] Pelvic incidence significance relative to spinopelvic risk factors for total hip arthroplasty instability. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b3.bjj-2021-0894.r1

[95] Towards standardized measurement of adverse events in spine surgery: conceptual model and pilot evaluation. BMC Musculoskeletal Disorders. 2006. DOI: 10.1186/1471-2474-7-53

[96] The_Impact_of_Study_Period_on_Perioperative_Outcomes_Following_Hip_Arthroplasty_S0883540315000765. n.d..

[97] The effectiveness and safety of staged halo-pelvic traction combined with posterior spinal fusion in the treatment of severe rigid spine deformity: a prospective cohort study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05739-7

[98] Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03378-w

[99] Time‐dependent wound management protocol prevents periprosthetic joint infection in total knee arthroplasty with persistent drainage. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70077

[100] The accuracy and safety of fluoroscopically guided percutaneous pedicle screws in the lumbosacral junction and the lumbar spine. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b8.35330

[101] Is surgical duration associated with postoperative complications in primary shoulder arthroplasty?. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.08.015

[102] Unplanned hospital readmission after surgical treatment for thoracic spinal stenosis: incidence and causative factors. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-03975-6

[104] Perioperative Management of Hypertension in Hand Surgery Patients. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.03.027

[105] Risk Factors for Nerve Injury After Total Hip Arthroplasty: A Case-Control Study. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.09.008

[106] Biportal endoscopic transforaminal lumbar interbody fusion with large cage: a technique without additional spacer portal. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05018-x

[107] Wrong-site Spine Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/jaaos-21-05-312

[110] Predictive factors for critical care dependency after posterior spinal fusion for adolescent idiopathic scoliosis. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b7.bjj-2023-1334.r1

[111] Determining the validity and reliability of spinopelvic parameters through comparing standing whole spinal radiographs and upright computed tomography images. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04786-5

[112] Three-dimensional morphological analysis of the thoracic pedicle and related radiographic factors in adolescent idiopathic scoliosis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05799-4

[113] Factors and predictive model associated with perioperative complications after long fusion in the treatment of adult non-degenerative scoliosis. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04361-y

[114] Matching the other side at staged bilateral total hip arthroplasty. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b5.bjj-2024-0880.r2