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There should be multidisciplinary input for the preoperative assessment of high risk patients such as patients with cognitive disorders, chronic kidney disease, diabetes mellitus and ischaemic heart disease.^50,65 The anaesthetist should be involved in preoperative optimisation and prehabilitation plans.^60,62

In patients aged over 65, frailty screening using an appropriate validated screening tool should be performed and documented early in the preassessment pathway. A screening tool used in combination with direct questioning should also be adopted to help identify patients with cognitive impairment and therefore increased risk of delirium.⁶⁶

Patients should be screened for chronic pain and opioid use in the preoperative period. Preoptimisation should ensure optimal management of preoperative pain, psychological preparation, education, and expectation management.^49,67

A perioperative management plan should be formulated for all patients and should include multimodal analgesia and intrathecal opioid sparing analgesic techniques.⁶⁸ Multimodal analgesic techniques should aim to provide optimal pain relief whilst minimising side effects such as sedation, postoperative nausea, and vomiting, and hypotension which might compromise early rehabilitation and recovery.^47,48,67

There should be an enhanced recovery after surgery programme for suitable patients undergoing elective orthopaedic surgery as it improves early mobilisation, reduces length of stay, postoperative complications and mortality.⁶⁹

Elective patients with major comorbidities or those undergoing complex or prolonged surgery should be scheduled earlier in the day, to allow time for postoperative stabilisation.

Elective orthopaedic operating lists should be separated from trauma lists, to allow efficiency, ensure safety, prevent cancellations and enable a flexible response for emergencies.

Hospitals should consider providing specific regional anaesthesia lists and using dedicated areas for performing peripheral nerve blocks.⁷⁰

Elective orthopaedic units performing major inpatient surgery should have 24/7 access to all support services including acute pain services and critical care.

Primary and revision arthroplasty surgery, together with trauma surgery involving bone implants or internal fixation should be carried out in an operating theatre with multiple air changes per hour (e.g., laminar flow).