Pre‑Operative Optimisation: How GPs Can Help Improve Surgical Outcomes

When a patient is referred for joint replacement or fracture surgery, the path to a successful outcome often begins long before they arrive in Dr Khoo’s theatre. In my experience as an orthopaedic surgeon, well-prepared patients tend to have faster recoveries, fewer complications, and a smoother post‑operative course. That preparation is frequently the GP’s doing—coordinating and optimising health before surgery.

Here’s how GPs can make a real difference by optimising key comorbidities before surgical referral.

1. Diabetes Management

Why it matters:

High blood glucose impairs wound healing and increases infection risk. Anaesthetic complications can also spike in poor glycaemic control.

Practical GP steps:

• Aim for HbA1c <7.5%—or individualised targets depending on patient age and comorbidity.
• Adjust medications: Review insulin, metformin, and consider endocrinologist referral if control remains unstable.
• Screen for complications: Check renal function, neuropathy, retinopathy.
• Lifestyle support: Encourage low‑GI diets, consistent meal timing, and physical activity.

2. Hypertension (HTN)

Why control matters:

Uncontrolled blood pressure increases the risk of intra‑operative bleeding and post‑operative cardiac events.

GP checklist:

• Target BP <140/90 mmHg (or lower if other risk factors present).
• Medication review: Assess ACE inhibitors, ARBs, calcium-channel blockers, diuretics; ensure dosing is optimised.
• Use home or ambulatory BP monitoring for accuracy.
• Educate: Reinforce salt reduction, healthy diet, weight loss, and exercise.

3. Body Mass Index (BMI)

The link:

Obesity amplifies wound complications, prosthesis issues, and extends recovery time.

GP involvement:

• Aim for modest weight loss (5‑10%) pre‑operatively—it noticeably reduces surgical risk.
• Tailored plans: Collaborate with a dietitian or referral to weight‑management programmes or bariatric services if BMI ≥35 kg/m².
• Support physical activity: Low‑impact options like swimming, cycling, or hydrotherapy are excellent for joint pain.

4. Smoking Cessation

The evidence speaks:

Smoking delays wound healing, increases pulmonary complications, and prolongs recovery.

GP-driven action:

• Advocate quit times of at least 4 weeks before surgery—ideally longer for maximal benefit.
• Offer supports: Nicotine replacement therapy, varenicline, bupropion, and behavioural counselling.
• Regular follow‑ups: Monitor progress and reinforce motivation.

5. Cardiac Clearance

Why it’s critical:

Underlying cardiac disease can lead to peri‑operative myocardial infarction, arrhythmias, or stroke.

GP pathway:

• Screen risk factors: Diabetes, HTN, smoking history.
• Use tools: Apply calculators like the Revised Cardiac Risk Index (Lee index) to guide decisions.
• Arrange investigations as needed: ECGs, stress tests, or echocardiograms, especially for moderate-to-high-risk patients.
• Refer to cardiology if LVEF is reduced or if ischaemic heart disease is suspected.

Bringing It All Together: A Practical Workflow

Initial Assessment at GP Visit

– GP flags upcoming surgical referral.

– Orders HbA1c, BP logs, BMI calculation, ECG.

Optimisation Plan

– Sets targets for glycaemic control, BP management, weight loss, smoking cessation.

– Coordinates with allied health as needed (dietitian, psychologist, physiotherapist, cardiologist).

Ongoing Reviews

– Regular monthly follow-ups to monitor progress.

– Adjust medications, reinforce lifestyle changes, address barriers.

Pre‑Referral Summary

– Create a brief but comprehensive letter to Dr Khoo, noting:

• Latest HbA1c & trend

• BP readings & medication adjustments

• BMI and weight trajectory

• Smoking status & support undertaken

• Cardiac clearance status

– This allows the surgical team to build on your work and proceed confidently.

GP involvement in pre‑operative optimisation is pivotal. By proactively managing diabetes, hypertension, BMI, smoking status, and cardiac risk, you’re significantly enhancing patient safety and outcomes. A collaborative approach improves efficiency in Dr Khoo’s care pathway—and most importantly, it benefits the patient.

Dr Khoo’s tip:

“Patients who come into surgery optimised and ready are the ones who walk out sooner, with fewer problems.”

Frequently Asked Questions (FAQs)

1. What if my patient’s optimisation is incomplete but they are experiencing significant pain or disability?

In such cases, it’s still appropriate to refer. Include a note about ongoing optimisation efforts in the referral. Dr Khoo can assess urgency and recommend a timeline based on both surgical need and medical risk.

2. Should I delay referral until my patient quits smoking or loses weight?

Not necessarily. Starting the referral allows parallel planning—Dr Khoo can assess suitability while your patient begins lifestyle changes. It's often more efficient to run both tracks simultaneously.

3. How do I handle patients with multiple comorbidities and unclear surgical fitness?

Consider involving a multidisciplinary team—geriatricians, endocrinologists, cardiologists—especially if the patient is frail or has a high ASA (American Society of Anesthesiologists) classification. A pre‑referral case conference or shared care approach can help.

4. Is it worth optimising in patients over 75 years old?

Yes—age alone shouldn’t preclude surgery or optimisation. In fact, older patients often benefit the most from improved blood pressure, glucose control, and smoking cessation, reducing anaesthetic and recovery risks.

5. How far in advance should optimisation begin before surgery?

Ideally, 4–8 weeks before planned surgery. However, even short-term interventions—like a 2-week smoking cessation or rapid HbA1c improvement—can improve surgical safety.