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The best possible preparation for a new hip or knee joint is prehabilitation, the "pre-recovery" that takes place weeks before the surgery through education, health checks, and training. Stephan Kirschner, MD, president of the German Arthroplasty Society (AE), explained what good prehabilitation should look like and the benefits it can bring at the online press conference for the 25th AE Congress.

Every operation puts a strain on the body, and the fitter the patient is, the easier they find it to overcome these strains. Being fit for an operation is crucial. "Since the majority of our prosthetic operations are planned procedures, the time before the operation can be used to get into shape," said Kirschner, who directs the orthopedics clinic at the ViDia Clinics in Karlsruhe, Germany.

For the perioperative care phase, the classic problems after operations such as pain, nausea, vomiting, and gastrointestinal atony are successfully addressed under the term "fast track." To improve patient care, the period before the surgical procedure is being brought into focus. This is because physical performance and function are key predictors of the complication rate and rehabilitation after surgery. It is therefore important to prepare the patients in a targeted manner. Studies reported that individually tailored prehabilitation can improve the success of the operation, even for severely ill patients.

Alcohol and Smoking

Kirschner reminded clinicians that patients should attend their scheduled health screenings and checkups and make the results of their examinations available. This is particularly applicable for the medication regimen, which should list all of the drugs being taken.

The number of prescribed medications increases almost exponentially with age and correlates with an adverse postoperative course. In terms of preparation before surgery, particular attention should be paid to potentially inadequate medications; the Fit-fOr-The-Aged list is a good guide for this point. As a general rule, nonessential medications should be discontinued, and anticholinergic medications and benzodiazepines should not be administered.

The patient, too, can contribute to a favorable course of the operation by following a healthier lifestyle. Even lifestyle changes made 4-6 weeks before the scheduled procedure can have significant effects, said Kirschner.

In the run-up to the operation, the consumption of large amounts of alcohol should be avoided. For men, a risky consumption of alcohol is classed as anything above a daily intake of 0.5-0.6 L of beer or 0.3 L of wine. For women, risky consumption starts at just half of these amounts. The risk for postoperative complications can be almost halved in these patients if they abstain from alcohol for several weeks (relative risk, 0.62).

There is also a two to five times higher risk for postoperative complications for smokers, particularly with regard to infections. Stopping smoking for just 6 weeks before surgery is enough to decrease the risk by a relevant degree (approximately 50%). "This is not such a big effort — and the patient is the one who benefits the most from the positive effect," said Kirschner.

Physical Activity

"Sitting is the new smoking. Physical inactivity, lots of sitting, is not good for us," said Kirschner. Patients who are physically active on a regular basis are generally back on their feet a lot faster after the surgery. To maintain individual health, the World Health Organization recommends 150 minutes of physical activity a week. "This does not mean playing an extreme amount of sport for 2 hours once a week but is instead more about moving multiple times throughout the day." Very inactive patients may be able to significantly increase their physical performance for an operation by going for walks or riding their bicycle.

Simple breath training, in which you focus on breathing deeply, strengthens the inspiratory musculature, and a sufficient amount of time to exhale can improve pulmonary capacity and bring considerable positive effects.

Crucial risk factors that can be controlled in the short term are anemia, malnutrition and sarcopenia, severe obesity, a vitamin D deficiency, and previously untreated chronic diseases, such as kidney failure. For most of these risks, simple measures, such as an iron infusion after diagnosing anemia, can bring about rapid relief and greatly improve the patient's preoperative condition.

Sarcopenia

At the same time, proper collaboration between the primary care physician and surgeon is highly beneficial. Patients who are physically inactive, malnourished, and lacking muscle strength should be looked after. Sarcopenia is especially prevalent in elderly patients. These patients have a three to four times higher risk for relevant complications after tumor operations. If the patient has only a mild case of sarcopenia, then an intervention with increased protein and calorie intake, combined with strength training, can improve their physical fitness considerably in less than 12 weeks.

Patients with sarcopenia require a longer period to improve their condition. In some cases, it can be sensible to postpone their operation. The joint effort from patient and physician during prehabilitation reduces the perioperative risks and facilitates a rapid return to the desired activities, emphasized Kirschner. "At our clinic, we ask the patients to prepare for the procedure."

In principle, prescribing preventive measures such as muscle training and strength building, which were financed by the German health insurance funds, is also an option. Kirschner also referred to the equivalent options at sports clubs and adult education centers. "I think that we have to make it clear to patients where they can get this support." Essentially, there is cofinancing, and "the patient is not left alone with all of this."

This article was translated from the Medscape German edition.