The majority of orthopedic surgeries are considered “elective” because they are not being performed for life-threatening or limb-threatening problems. They are pre-planned and done on a non-emergent basis. These surgeries might be considered simple or low risk (like a knee arthroscopy or carpal tunnel surgery), or more major and higher risk (like joint replacement or spinal fusion). In general, you need to meet some health parameters in order to be considered a good candidate for elective surgery, especially if it is a major surgery. If you don’t meet those parameters, your surgeon might require you to postpone your surgery until you are “healthy enough” to proceed with surgery. This is not a punishment, but rather it is out of concern for you as a patient, as your surgeon wants you to have the best possible outcome from your procedure, with the lowest possible risk of complication. It is important to understand that there is no such thing as a “risk-free” surgery, no matter how minor the procedure is.
Some of the more common parameters considered when determining if a patient is healthy enough for a major surgery include, but are not limited to: blood pressure, lab values, body mass index, blood sugar/HgA1c, heart health, and lung function/smoking. If any of these parameters don’t meet criteria, surgery might need to be postponed until the problem is addressed. If the problem can’t be improved, then surgery might not be an option. Here is a list of some of the health problems, and a few of their respective associated risks, that need to be corrected before undergoing elective orthopedic surgery:
- Blood pressure greater than 180/110 mmHg (120/80 is normal): higher risk of heart attack or stroke during or soon after surgery.
- White blood cell count greater than 11,000/microliter (4,500-11,000 is normal): could indicate an infection somewhere, increasing risk for surgical infection.
- Hemoglobin less than 10 g/dL (normal for men is 13.2-16.6 and for women is 11.5-15): increased risk of needing blood transfusions, wound healing problems, and increased risk of death post operatively.
- Electrolytes such as potassium or sodium too high or too low (normal for potassium is 3.6-5.2 mmol/L and normal for sodium is 135-145 mEq/L): abnormal heart rhythms, muscle cramps, fatigue, or confusion.
- Albumin level less than 3.4 g/dL (3.4-5.4 is normal): significant risk for wound healing problems, prolonged hospitalization, and even death.
- Body Mass Index greater than 40 (18.5-24.9 is normal): significant increased risk of blood clots, infection, blood loss, and anesthetic complications, as well as increased risk of in-hospital death.
- Blood sugar greater than 200 mg/dL (90-110 is normal) or HgA1c greater than 8.0% (normal is below 5.7): significant increased risk for infection and wound healing problems.
- Heart disease: increased risk for stroke, heart attack, and death during or after surgery.
- Lung disease and/or being a smoker: risk for anesthesia complications, cardiovascular events (stroke, heart attack, etc.), delayed wound healing, wound infections, pneumonia, delayed bone healing, and death.
Your individual surgeon will have their own parameters that might slightly differ from those listed. This list is not complete, but reflects some of the more common health issues that need to be optimized prior to having elective orthopedic surgery. Anesthesiologists also have their own parameters that have to be met, though they are similar to those listed here. You don’t have to be perfectly healthy to have orthopedic surgery, but you do need to be “healthy enough.” Remember that your surgeon has your best interests at heart, and wants you to have a complication-free surgery and a full recovery. While they can’t eliminate all risks related to surgery, optimizing your health goes a long way to lowering your risk of complications.
Tulsa Bone & Joint is proud to employ the most female physicians of any orthopedic practice in the state of Oklahoma. March 8 is International Women’s Day — a day for celebrating women’s achievements and forging a gender equal world. We celebrate that our practice makes an effort to seek out quality physicians, and 6 out of 31 of those are women.
According to Modern Healthcare, orthopedics is the surgery specialty with the least number of women. Women make up just 6.5% of the active physicians in orthopedic surgery, according to a 2019 report from the American Academy of Orthopaedic Surgeons. At Tulsa Bone & Joint, women make up 15% of our surgeons and 19% of our physicians (surgical and non-surgical).
While the number of women in orthopedics is growing, change is occurring slowly, considering that more women than men are now enrolled in medical school. However, statistics show women are drawn to other specialties like obstetrics-gynecology and pediatrics. At Tulsa Bone & Joint, we make an effort to seek out qualified physicians — both female and male.
One of our surgeons, Dr. Marcy Word Clements (top left photo), was the first (and still only) female to complete the Oklahoma State University College of Osteopathic Medicine Orthopedic Residency program. She shares about her decision to practice orthopedics and the challenges she’s faced along the way since beginning the residency program in 1990:
“I knew I wanted to be an orthopedic surgeon when I was in junior high school. When I was a medical student, and I would tell people that I wanted to be an orthopedic surgeon, they would tend to be less than encouraging. I had a couple of practicing surgeons laugh at me when I told them my plans. I was told that I would have to work harder to prove my worth if I was going to get picked for an orthopedic residency position.
While I wasn’t treated any worse than any other resident during my training, I did have to endure sexist comments and passive aggressive behavior from other residents, attending physicians, nurses, and ancillary staff. It took some time to prove myself to everyone, but I think by the time I finished training, I had gained the respect of others to the point that I didn’t have to deal with that as much. I did (and still do) occasionally run up against a patient that didn’t/doesn’t want to see me because I am a woman, but I consider that their loss, not mine!
Times have definitely changed since 1990! When I started out, women made up only about 2% of orthopedic surgeons. That number has more than doubled and almost tripled! I would go to an orthopedic conference back then and maybe see one or two other women there. Now there are at least double digits! There still aren’t any lines in the women’s bathrooms at orthopedic conferences, though! ?.
I do think it is now ‘easier’ for women to get into orthopedic residency positions now than it was 20-30 years ago. It’s more acceptable in general, and women are becoming the majority of medical students, so the applicant pool for orthopedic residencies is showing a shift as well.
It’s definitely exciting to see more women in orthopedic surgery. While I have always felt comfortable being the only female in a male-dominated field/group, I now have female colleagues with whom I can commiserate. While we don’t really see ourselves as being different than our male colleagues from a professional standpoint, there still is a bit of a ‘sisterhood’ feel with the presence of other women in our group and in the profession at large.
Even though I was frequently discouraged from pursuing orthopedic surgery, I never considered that being a woman would be an obstacle. People would even tell me as much, but I honestly just kept pursuing and pushing and simply doing what I needed to do to accomplish my goals. My dad was probably my biggest supporter and always encouraged me to work hard and set my goals high, and I had other people in my life who taught me ‘stick-to-it-tiveness.’
It never even entered my mind that I couldn’t be an orthopedic surgeon simply because I was a woman. In reality, discrimination could have derailed my professional pursuits, but God had other plans!”
Thank you for sharing your story, Dr. Clements, and for helping pave the way for other female orthopedists!
Physician photos (from left to right, top to bottom): Dr. Marcy Word Clements, Dr. Jessica Childe, Dr. Jennifer Peterson, Dr. Lindsay Cunningham, Dr. Britney Else, and Dr. Elizabeth Weldin.
If you have an orthopedic injury or disease that requires surgery, your overall health is a factor that helps determine how well you will recover from that injury or surgery. Certain health problems can negatively affect your outcome, including peripheral vascular disease, diabetes, osteoporosis, and obesity. Most of these health issues can improve with treatment. Since many orthopedic surgeries are non-emergent, I recommend that these health problems be addressed prior to any elective orthopedic surgery.
One of the most common health issues associated with orthopedic problems is obesity. Obesity is a medical diagnosis, and is defined as having a Body Mass Index (BMI) > 30.0. BMI is calculated as follows:
Obesity is frequently subdivided into categories:
- Class 1: BMI of 30 to < 35
- Class 2: BMI of 35 to < 40
- Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity.
Not only can obesity contribute to the development of degenerative arthritis and other orthopedic problems, it can also lead to significant complications during or after orthopedic surgery, such as joint replacement surgery. Complications could include anesthesia-related events, such as trouble establishing an IV or maintaining an open airway, or requiring large doses of medication to achieve adequate anesthesia. Surgical complications might include longer operative times, increased blood loss, surgical infection, blood clots in the legs that can travel to the lungs, and wound healing problems. These complications can be life or limb threatening, so decreasing the risk of having such a complication is of paramount importance.
If you are considering an orthopedic procedure such as joint replacement surgery, and you carry a diagnosis of obesity, your doctor might recommend or require weight loss prior to your procedure, especially if you have Class 3 obesity. Your doctor realizes that weight loss is not easy, but they also want to “first do no harm.” Your doctor wants to prevent complications as much as possible and ensure that you have a successful recovery. While it might be frustrating to have your surgery postponed until you are healthy enough, it is in your best interests to lower your risk of having a bad outcome by losing weight prior to your procedure.
Obesity is a multi-factorial disease, so there is no single right (or easy) way to lose weight. Some patients think that exercise is the key to losing weight, but there is a lot of truth to the saying, “You can’t out-exercise a bad diet.” Many people with orthopedic conditions have difficulty exercising anyway. If you are able to exercise, it’s best to do low-impact exercises such as using an elliptical machine, stationary bike, indoor rower, or doing water exercises. While exercise will help you burn calories, it is rarely effective as a weight loss method if not combined with dietary changes.
So, weight loss depends mostly on your diet. The best way to start losing weight is to make changes in your diet that can be sustained over a long period of time. Sometimes, it’s just a matter of eliminating sugary drinks like soda, or high calorie substances like alcohol or candy.
Some people have good results with specific diets like the Ketogenic Diet, Paleo Diet, Weight Watcher’s, or Jenny Craig. Others see success with physician-monitored weight loss or consulting a dietitian. Still others might require bariatric surgery if they are severely obese and have failed other methods. Perhaps the ”simplest” weight loss method is to keep a food log and count calories. There are several phone apps that can make this an easier task, such as MyNetDiary or MyFitnessPal. The key is to find something that you can live with over the “long haul” and that fits into your lifestyle. Rapid weight loss is not advisable, as it can result in loss of muscle mass or malnutrition, and the resulting weight loss is harder to maintain. A reasonable goal would be to lose 1-2 points a week. If you accomplish this, you will lose anywhere from 25 to 50 pounds in 6 months!
Patients who need orthopedic surgery, especially joint replacement surgery, often say they will lose weight after their surgery. However, studies show that very few patients with obesity are successful in losing weight after joint replacement.
Therefore, I advise you to establish a healthier lifestyle now, even before you need surgery. Losing weight and reducing your BMI will decrease your risk for complications and increase the likelihood of a successful surgical outcome. It also may decrease your pain to the point where surgery could be postponed or be avoided altogether. If you need help losing weight, discuss it with your primary care physician or surgeon, and they can assist you in finding the help you need.