Arthroplasty Pre-Op Selection Protocol

Provider reference · candidacy questionnaire, outpatient (ASC) & inpatient criteria

Staff Resources · From Dr. Allred · Transcribed from the printed sheet · 3 sections

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If you have questions about a protocol or a specific patient, call the clinic where the surgery was performed.

After hours & emergency numbers → Weekdays, business hours.

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Screen every arthroplasty candidate with the questionnaire below. Patients who meet the Outpatient (ASC) criteria may have same-day/ambulatory surgery; those who do not, but meet the Inpatient criteria, are scheduled as inpatients. Inpatient thresholds are intentionally more permissive (older age, higher BMI/HbA1c, ASA III) because these patients are admitted and monitored.

1 · Candidacy Risk-Assessment Questionnaire

Must meet all of the following:

  • Unilateral, uncomplicated, primary knee or hip arthroplasty
  • ASA I or II; optimized ASA III acceptable with anesthesia review
  • Preoperative body mass index < 36 kg/m²
  • Age < 75 years at time of surgery (patients ≥ 75 are candidates for the inpatient pathway)
  • No active liver disease or active kidney disease (preoperative GFR > 60)
  • Well-controlled diabetes with HbA1c < 7 — insulin-dependent diabetics acceptable if optimized
  • Albumin ≥ 3.5 g/dL
  • No uncorrected moderate-to-severe peripheral vascular disease
  • No intra-articular injection into the surgical joint within the last 3 months
  • Assistance available at home 24 hrs/day for at least the first 3 days
  • No poorly controlled or severe cardiac disease
  • No chronic opioid use or history of opioid addiction
  • No home oxygen
  • No history of uncorrected urinary retention or difficult catheterization
  • No history of significant opiate-related nausea (exception: nausea with one opioid but tolerates another)

Recommendations (not hard stops)

  • No DVT, PE, TIA/stroke, MI, or other thromboembolic event within the last year
  • Non-smoker
  • Drinks fewer than 14 alcoholic beverages per week

Additional screening questions

  • History of metal allergy?
  • Taking Ozempic or another GLP-1? (hold per current perioperative guidance for aspiration risk)

Reference: Knee Surg Sports Traumatol Arthrosc. 2017 Sep;25(9):2668–2675. doi:10.1007/s00167-016-4140-z. PMID: 27106923.

2 · Outpatient (ASC) Criteria

All must be met for same-day / ambulatory-surgery-center arthroplasty:

  • Unilateral, uncomplicated, primary hip or knee arthroplasty
  • ASA I or II; optimized ASA III acceptable with anesthesiologist approval on chart review
  • Preoperative body mass index < 36 kg/m²
  • Age < 75 years at time of surgery
  • Preoperative hemoglobin > 12 g/dL
  • No seizure disorder, active liver disease, or active kidney disease (GFR > 60)
  • Well-controlled diabetes with HbA1c < 7 — insulin-dependent diabetics acceptable if optimized
  • Fewer than 14 alcoholic beverages per week
  • No cardiopulmonary disease that would require inpatient monitoring after surgery
  • No MI or stroke within the past 6 months. A remote, resolved, well-controlled event (e.g., a single prior DVT/PE, or MI/TIA/stroke > 6 months ago with good functional capacity) may proceed with cardiology/hematology clearance and risk-adjusted VTE prophylaxis
  • Preoperative ambulatory status does not require a walker or wheelchair
  • No chronic preoperative opioid use or history of opioid addiction
  • No significant opiate-related nausea (exception as above)
  • No contraindication to IV or oral NSAIDs
  • Biologic/immunomodulatory medications (e.g., rheumatoid arthritis) managed case-by-case, held perioperatively per current guidelines
  • Assistance available at home 24 hrs/day for at least the first 3 days after discharge
  • No uncorrected moderate-to-severe PVD
  • No other condition or circumstance that would preclude rapid discharge from the ASC

3 · Inpatient Criteria

All must be met for the inpatient pathway (intentionally more permissive than the ASC pathway — patients are admitted and monitored):

  • Unilateral, uncomplicated, primary knee or hip arthroplasty
  • ASA I–III (optimized); higher acuity acceptable with anesthesia review
  • Preoperative body mass index < 40 kg/m²
  • No strict upper age limit — older patients are appropriate here, individualized to overall health
  • Preoperative hemoglobin > 12 g/dL
  • No active liver disease or active kidney disease (preoperative GFR > 60)
  • Well-controlled diabetes with HbA1c < 7.5
  • Albumin ≥ 3.5 g/dL
  • No uncorrected moderate-to-severe PVD
  • No intra-articular injection into the surgical joint within the last 3 months
  • Assistance available at home 24 hrs/day for at least the first 3 days, or appropriate for skilled-nursing-facility (SNF) discharge

Recommendations (not hard stops)

  • No chronic preoperative opioid use or history of opioid addiction
  • No MI or stroke within the past 6 months; a remote, resolved, well-controlled event may proceed with cardiology/hematology clearance and risk-adjusted VTE prophylaxis
  • Fewer than 14 alcoholic beverages per week
Questions about this sheet? Call the clinic where the surgery was performed. I'm happy to talk through the plan. Numbers are at the top of this page, and every after-hours line is on the emergency numbers page.