Editor's Spotlight/Take 5: What are the Risk Factors for Cerebrovascular Accidents After Elective Orthopaedic Surgery?

Abstract

A visiting professor once asked an audience of residents why patients come to the doctor’s office. ‘‘To get a diagnosis?’’ one answered. The professor shook his head. ‘‘To learn about treatment options?’’ offered another. Thumbs down again. More guesses, more noes. ‘‘Patients come to physicians’ offices because we can see the future,’’ pronounced the visiting instructor. That physician—whose opinions and contributions I continue to respect, though he has since retired—was a tumor surgeon. This fact no doubt colored his perspective; certainly patients with cancer are appropriately concerned about prognostic information. And certainly he offered his punch line at least in part for effect. Many factors cause patients to seek care, and all of the residents’ suggestions were reasonable. Although at the time I found his answer thought-provoking, I now am struck by how ineffective we actually are at seeing the future on behalf of our patients. While we can predict with some accuracy whether a patient undergoing elective orthopaedic surgery will experience a cardiac complication [5, 8], we have few other good tools of this sort. Yet so many complications and failures can occur after major surgery: Infection, nerve injury, cerebrovascular accident (CVA), pulmonary embolism, and simple (but important) dissatisfaction, to name a few. Groups continue to develop predictive models [4, 10], and risk calculators like those by Lee et al. [6, 7, 11] and the National Surgical Quality Improvement Program (NSQIP) [1, 2] are publicly available, but these calculators generally have not been validated by others, and where they have been, their performance has been imperfect [3]. If we were to create a ratio with fear plus harm in the numerator and our ability to predict it in the denominator, I imagine that few complications would score higher than CVA. Postoperative strokes can be devastating or fatal, yet we are so ineffective at predicting them. In fact, CVA does not even appear on the NSQIP’s Surgical Risk Calculator [1, 2]. For this reason, we are fortunate to have the analysis in this month’s Clinical Orthopaedics and Related Research by Alpesh A. Patel’s team at the Feinberg School of Medicine at Northwestern University. Note from the Editor-In-Chief: In ‘‘Editor’s Spotlight,’’ one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present ‘‘Take Five,’’ in which the editor goes behind the discovery with a oneon-one interview with an author of the article featured in ‘‘Editor’s Spotlight.’’ The author certifies that he, or any members of his immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This comment refers to the article available at: DOI: 10.1007/s11999-015-4496-2. S. S. Leopold MD (&) Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19013, USA e-mail: sleopold@clinorthop.org Editor’s Spotlight/Take 5 Published online: 4 January 2016 The Association of Bone and Joint Surgeons1 2015