Chronic concern over an acute-phase reactant: a teachable moment.

A59-year-oldmanwith a history of shoulder and knee pain presented to our clinic reporting 6 years of left osteoarthritic hippain.Hispainhadbeenprogressive, and at the timeofpresentation,he required theuseofacane for support. The results of radiologic studies showed a loss of joint space with thinning of the upper aspect of the lefthip jointwithbone-on-boneappearanceandsubchondral cyst formation.The femoralheadarticular contour showed flattening and severe atrophy on x-ray. He had no history of prior joint replacement or cardiovascular disease. He was referred to the orthopedic surgery clinic, where he was deemed an appropriate candidate and scheduled for total hip arthroplasty. The operation was subsequently canceled when preoperative screening laboratory test results revealed an elevatedserumC-reactiveprotein (CRP) level of 11.6mg/L (to convert to nanomoles per liter, multiply by 9.524). Despite the fact that the patient felt well and therewas no evident disease process to explain this abnormality, repeatedCRPstudieswereobtained subsequently, and all resultswere in excessof the specifiedpresurgical criterionof less than2.9mg/L.Meanwhile, thepatienthas reluctantly begun taking hydrocodone/acetaminophen and etodolac for pain control. His surgery has not been rescheduled. C-reactiveprotein isanacute-phasereactantthatcan bedetectedearly inadiseaseprocessbeforeothersymptoms begin to appear. It is often used to monitor disease activity or detect an inflammatory process becauseof its rapiddeclinewithresolutionof inflammation.1 AnelevatedserumCRPconcentration isnot specific and can be seen with trauma, infection, inflammation, tissue infarction, or malignant neoplasm.2 Specific concerns regarding CRP levels preoperatively may stem in part from studies showing a correlation between increasedpreoperativeCRP levelsandpostoperativecomplications among patients undergoing esophagectomy for squamous cell carcinoma and adenocarcinoma.3 However, this correlation was unrelated to infection and confounded by other variables.3 Studies regarding increased CRP levels in patients undergoing cardiac surgery have shown this elevation to be a risk factor for postoperative infection. Unfortunately, there are no data to suggest that use of this measurement in patient management has influenced the rate of infection or other surgical complications.4 Use of a CRP level criterion prior to elective orthopedic surgical procedures may be a result of concerns that this could indicate a chronic inflammatory state or subclinical infection that may compromise the outcome of prosthetic placement. However, in the absence of other systemic indicators or comorbidities, this concern is poorly founded. Although CRP levels are sometimes measured as part ofpreoperativeevaluation for elective surgery, this practice is not supportedbyexisting evidenceor guidelines. In a review of the preoperative testing literature forhealthypatientsundergoingnoncardiacelective surgerybetween2001and2011, Johanssonet al5 found insufficient evidence to support CRP screening for these asymptomaticpatients.Nationaland internationalguidelines, such as those of the United Kingdom National Institute forHealthandCareExcellence6and theAmerican Society of Anesthesiologists,7 do not recommend routineCRPscreening in asymptomatic patients undergoing elective surgery. Cancellation of this patient’s procedure due to an isolated elevation in his CRP level is not only unjustified on thebasis of current recommendationsbut a causeof harm.Ourpatient continues toexperiencepainand limitedmobility associatedwithhis impairment.Hehasbegunanarcoticpainmanagement regimen,whichhehad been previously avoiding. The focus of hismedical care seems to have veered off course as a result of this unnecessary “routine” test—from improving his quality of life to following the graph of his CRP levels.