What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications?

Is Preoperative Weight Reduction in Patients Who Have Body Mass Index ≥ 40 Associated With Lower Complication Rates After Primary Total Hip Arthroplasty?

BACKGROUND

Given the heightened risk of postoperative complications associated with obesity, delaying total hip arthroplasty (THA) in patients who have a body mass index (BMI) > 40 to maximize preoperative weight loss has been advocated by professional societies and orthopaedic surgeons. While the benefits of this strategy are not well-understood, previous studies have suggested that a 5% reduction in weight or BMI may be associated with reduced complications after THA.

METHODS

We identified 613 patients who underwent primary THA in a single institution during a 7-year period and who had a BMI >40 recorded from 9 to 12 months prior to surgery. Subjects were stratified into 3 cohorts based on whether their baseline BMI decreased by >5% (147 patients, 24%), was unchanged ( ± 5%) (336 patients, 55%), or increased by >5% (130 patients, 21%) on the day of surgery. The frequency of 90-days Hip Society and Centers for Medicare & Medicaid Services complications was compared between these cohorts. There were significant baseline differences between the cohorts with respect to baseline American Society of Anesthesiologists class (P < .001) and hemoglobin A1C (P = .011), which were accounted for in a multivariate regression analysis.

RESULTS

In univariate analysis, there was a lower incidence of readmission (P = .025) and total complications (P = .005) in the increased BMI cohort. The overall complication rate was 18.4% in the decreased BMI cohort, 17.6% in the unchanged cohort, and 6.2% in the increased cohort. However, multivariable regression analysis controlling for potential confounders did not find that preoperative change in BMI was associated with differences in 90-days complications between cohorts (P > .05).

CONCLUSIONS

Patients who have a BMI >40 and achieved a clinically significant (>5%) BMI reduction prior to THA did not have a lower risk of 90-days complications or readmissions. Thus, delaying THA in these patients to encourage weight loss may result in restricting access to a beneficial surgery without an appreciable safety benefit.

Body Mass Index Does Not Drive the Risk for Early Postoperative Instability After Total Hip Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Instability remains the leading cause of revision following total hip arthroplasty (THA). The objective of the present investigation was to determine whether an elevated body mass index (BMI) is associated with an increased risk of instability after primary THA.

METHODS

An administrative claims database was queried for patients undergoing elective, primary THA for osteoarthritis between 2010 and 2022. Patients who underwent THA for a femoral neck fracture were excluded. Patients who had an elevated BMI were grouped into the following cohorts: 25 to 29.9 (n = 2,313), 30 to 34.9 (n = 2,230), 35 to 39.9 (n = 1,852), 40 to 44.9 (n = 1,450), 45 to 49.9 (n = 752), and 50 to 59.9 (n = 334). Patients were matched 1:1 based on age, sex, and Elixhauser Comorbidity Index, as well as a history of spinal fusion, neurodegenerative disorders, and alcohol abuse, to controls with a normal BMI (20 to 24.9). A multivariate logistic regression controlling for age, sex, Elixhauser Comorbidity Index, and additional risk factors for dislocation was used to evaluate dislocation rates at 30 days, 90 days, 6 months, 1 year, and 2 years. Rates of revision for instability were similarly compared at 1 year and 2 years postoperatively.

RESULTS

No significant differences in dislocation rate were observed between control patients and each of the evaluated BMI classes at all evaluated postoperative intervals (all P values > .05). Similarly, the risk of revision for instability was comparable between the normal weight cohort and each evaluated BMI class at 1 year and 2 years postoperatively (all P values > .05).

CONCLUSIONS

Controlling for comorbidities and known risk factors for instability, the present analysis demonstrated no difference in rates of dislocation or revision for instability between normal-weight patients and those in higher BMI classes.

Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years

BACKGROUND

To make an informed decision about total hip arthroplasty (THA), surgeons and patients need to understand the absolute and relative risks of periprosthetic joint infection (PJI). We sought to evaluate the long-term risk of PJI following primary THA stratified by body mass index (BMI) and PJI-related risk factors.

METHODS

We identified 21,550 primary THAs performed from 2000 to 2021 at a single institution. Patients were stratified as having 0, 1, or ≥ 2 PJI risk factors (diabetes, chronic kidney disease, nonprimary osteoarthritis, immunosuppression, or active smoking) and into BMI categories. The 15-year cumulative risk of PJI was evaluated by BMI and PJI risk factors.

RESULTS

For the entire cohort, the 15-year absolute risk of PJI was 2%. For patients who did not have PJI risk factors, the absolute risk of PJI at 15 years was 1% in normal weight, 2% in class III obesity, and 4% in class IV obesity. Patients who had class III and IV obesity had a 3-times and 9-times higher relative risk of PJI, respectively (P = .03, P < .001). Among patients who had ≥ 2 PJI risk factors, the absolute risk of PJI at 15 years was 2% in normal weight, 4% in class III obesity, and 18% in class IV obesity.

CONCLUSIONS

Healthy patients who had class III and IV obesity had a 3-times and 9-times increased risk of PJI at 15 years relative to normal weight patients. However, the absolute risk of PJI at 15 years was 2 and 4%, respectively. Given emerging data questioning whether BMI modification decreases PJI risk, surgeons and patients must consider both a 3-times to 9-times increased relative risk of PJI and a 2 to 4% absolute risk of PJI at 15 years for healthy patients who had a BMI ≥ 40.

LEVEL OF EVIDENCE

IV.

Racial and Ethnic Minority Patients Have Increased Complication Risks When Undergoing Surgery While Not Meeting Clinical Guidelines

BACKGROUND

Clinical guidelines for performing total joint arthroplasty (TJA) have not been uniformly adopted in practice because research has suggested that they may foster inequities in surgical access, potentially disadvantaging minority sociodemographic groups. The aim of this study was to assess whether undergoing TJA without meeting clinical guidelines affects complication risk and leads to disparities in postoperative outcomes.

METHODS

This retrospective cohort study evaluated the records of 11,611 adult patients who underwent primary TJA from January 1, 2010, to December 31, 2020, at an academic hospital network. Based on self-reported race and ethnicity, 89.5% of patients were White, 3.5% were Black, 2.9% were Hispanic, 1.3% were Asian, and 2.8% were classified as other. Patients met institutional guidelines for undergoing TJA if they had a hemoglobin A1c of <8.0% and a body mass index of <40 kg/m 2 and were not currently smoking. A logistic regression model was utilized to identify factors associated with complications, and a mixed-effects model was utilized to identify factors associated with not meeting guidelines for undergoing TJA.

RESULTS

During the study period, 11% (1,274) of the 11,611 adults who underwent primary TJA did not meet clinical guidelines. Compared with the group who met guidelines, the group who did not had higher proportions of Black patients (3.2% versus 6.0%; p < 0.001) and Hispanic patients (2.7% versus 4.6%; p < 0.001). An increased risk of not meeting guidelines at the time of surgery was demonstrated among Black patients (odds ratio [OR], 1.60 [95% confidence interval (CI), 1.22 to 2.10]; p = 0.001) and patients insured by Medicaid (OR, 1.75 [95% CI, 1.26 to 2.44]; p = 0.001) or Medicare (OR, 1.22 [95% CI, 1.06 to 1.41]; p = 0.007). Patients who did not meet guidelines had a higher risk of reoperation than those who met guidelines (7.7% [98] versus 5.9% [615]; p = 0.017), including a higher risk of infection-related reoperation (3.1% [40] versus 1.4% [147]; p < 0.001).

CONCLUSIONS

We found that patients who underwent TJA despite not meeting institutional preoperative criteria had a higher risk of postoperative complications. These patients were more likely to be from racial and ethnic minority groups, to have a lower socioeconomic status, and to have Medicare or Medicaid insurance. These findings underscore the need for surgery-related shared decision-making that is informed by evidence-based guidelines in order to reduce complication burden.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Athlete-Specific Considerations of Cartilage Injuries

Cartilage injuries can present in a diverse setting of anatomic locations, with varying severity, and can impact athletes of all ages and competition levels. Moreover, the timing of when an injury presents introduces an additional dimension to treatment decision-making. Frequently, the level of competition, in conjunction with career trajectory and short-term and long-term athlete goals, will dictate whether a temporary or definitive treatment strategy is ideal. Although indicating the correct therapeutic regimen may prove challenging, understanding the athlete-specific considerations can be essential to meeting the goals of the athlete and other stakeholders involved in the athlete's career. The purpose of this review is to comprehensively present the deliberations a treating physician must consider in managing cartilage injuries within a spectrum of athletic levels ranging from youth to professional levels, with a secondary focus on the presentation of temporizing treatment strategies and associated outcomes.

Glucagon-Like Peptide Receptor-1 Agonists Used for Medically-Supervised Weight Loss in Patients With Hip and Knee Osteoarthritis: Critical Considerations for the Arthroplasty Surgeon

Patients with morbid obesity and concomitant hip or knee osteoarthritis represent a challenging patient demographic to treat as these patients often present earlier in life, have more severe symptoms, and have worse surgical outcomes following total hip and total knee arthroplasty. Previously, bariatric and metabolic surgeries represented one of the few weight loss interventions that morbidly obese patients could undergo prior to total joint arthroplasty. However, data regarding the reduction in complications with preoperative bariatric surgery remain mixed. Glucagon-like peptide receptor-1 (GLP-1) agonists have emerged as an effective treatment option for obesity in patients with and without diabetes mellitus. Furthermore, recent data suggest these medications may serve as potential anti-inflammatory and disease-modifying agents for numerous chronic conditions, including osteoarthritis. This review will discuss the GLP-1 agonists and GLP-1/glucose-dependent insulinotropic polypeptide dual agonists currently available, along with GLP-1/glucose-dependent insulinotropic polypeptide/glucagon triple agonists presently being developed to address the obesity epidemic. Furthermore, this review will address the potential problem of GLP-1-related delayed gastric emptying and its impact on the timing of elective total joint arthroplasty. The review aims to provide arthroplasty surgeons with a primer for implementing this class of medication in their current and future practice, including perioperative instructions and perioperative safety considerations when treating patients taking these medications.

Increasing Body Mass Index Not Associated With Worse Patient-Reported Outcomes After Primary THA or TKA

INTRODUCTION

As the US obesity epidemic continues to grow, so too does comorbid hip and knee arthritis. Strict body mass index (BMI) cutoffs for total hip and knee arthroplasty (THA and TKA) in the morbidly obese have been proposed and remain controversial, although current American Academy of Orthopaedic Surgeons guidelines recommend a BMI of less than 40 m/kg2 before surgery. This study sought to compare patient-reported outcomes and 30-day complication, readmission, and revision surgery rates after THA or TKA between morbidly obese patients and nonmorbidly obese control subjects.

METHODS

All patients undergoing primary THA and TKA at our institution from May 2020 to July 2022 were identified. Patient demographics, surgical time, length of stay and 30-day readmission, revision surgery, and complication rates were prospectively collected. Preoperative and postoperative Hip and Knee Society (Hip Osteoarthritis Outcome Score [HOOS] and Knee Osteoarthritis Outcome Score [KOOS]) were collected. Patients were stratified by BMI as ideal weight (20 to 24.9), overweight (25 to 29.9), class I obese (30 to 34.9), class II obese (35 to 39.9), and morbidly obese (>40 m/kg2).

RESULTS

A total of 1,423 patients were included for final analysis. No difference was observed in 30-day unplanned return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Morbidly obese patients undergoing THA had lower preoperative HOOS (49.5 versus 54.5, P = 0.004); however, there was no difference in postoperative HOOS or KOOS at 12 months across all cohorts.

DISCUSSION

No difference was observed in 30-day return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Despite a lower preoperative HOOS, there was no difference in 12-month HOOS or KOOS when stratified by BMI. These findings suggest that such patients may achieve similar benefit from arthroplasty as their ideal weight counterparts.

Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study

INTRODUCTION

Optimizing operating room (OR) scheduling accuracy is important for OR efficiency, meeting patient expectations, and maximizing value for health systems. However, limited data exist on factors influencing the precision of Total Hip Arthroplasty (THA) OR scheduling. This study aims to identify the factors influencing the accuracy of OR scheduling for THA.

METHODS

A retrospective review of 6,072 THA (5,579 primary THA and 493 revision THA) performed between January 2020 and May 2023 at an urban, academic institution was conducted. We collected baseline patient characteristics, surgeon years of experience, and compared actual wheels in to wheels out (WIWO) OR time against scheduled OR time. Significant scheduling inaccuracies were defined as actual OR times deviating by at least 15% from scheduled OR times. Logistic regression analyses were employed to assess the impact of patient, surgeon, and intraoperative factors on OR scheduling accuracy.

RESULTS

Using adjusted odds ratios, primary THA patients who had a lower BMI and surgeons who had less than 10 years of experience were associated with overestimation of OR time. Whereas, higher BMI, younger age, general anesthesia, non-primary osteoarthritis indications, and afternoon procedure start times were linked to underestimation of OR time. For revision THA, lower BMI and fewer components revised correlated with overestimated OR time. Men, higher BMI, more components revised, septic indication for surgery, and morning procedure start times were associated with underestimation of OR time.

CONCLUSION

This study highlights several critical patient, surgeon, and intraoperative factors influencing OR scheduling accuracy for THA. OR scheduling models should consider these factors to enhance OR efficiency.

Preoperative weight loss before total hip arthroplasty negatively impacts postoperative outcomes

BACKGROUND

Obesity adversely impacts outcomes of total hip arthroplasty (THA), leading surgeons to impose body mass index cutoffs for patient eligibility and encourage preoperative weight loss. This study aimed to determine if preoperative weight loss impacts outcomes of THA in the general patient population and if it mitigates poor outcomes in obese patients.

METHODS

Patients who underwent THA from 2013-2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by weight loss of >10% of body weight over the preceding 6 months. We used multivariable linear and logistic regression models, adjusted for age, sex, race/ethnicity, and comorbidities, to examine the effect of significant preoperative weight loss on 30-day outcomes after THA in the general and obese patient populations.

RESULTS

In the overall population, patients who lost significant weight preoperatively had significantly increased length of stay, were more likely to have a non-home discharge, return to the operating room, or be readmitted, and were more likely to experience numerous medical complications. In the obese population, patients who lost significant weight preoperatively had significantly increased length of stay and were more likely to require a transfusion or experience any medical complication.

DISCUSSION

Rapid significant preoperative weight loss is not associated with improved postoperative outcomes after THA in the obese population and is associated with worse outcomes in the general population. Arthroplasty surgeons should balance these risks with the risks of obesity when advising patients about preoperative weight loss prior to THA.

LEVEL OF EVIDENCE

III.

The weight of complications: high and low BMI have disparate modes of failure in total hip arthroplasty

BACKGROUND

Body mass index (BMI) has been shown to influence risk for revision total hip arthroplasty (rTHA), but few studies have specifically examined which causes of rTHA are most likely in different BMI classes. We hypothesized that patients in different BMI classes would undergo rTHA for disparate reasons.

METHODS

Ninety-eight thousand six hundred seventy patients undergoing rTHA over 2006-2020 were identified in the National Inpatient Sample. Patients were classified as underweight, normal-weight, overweight/obese, or morbidly obese. Multivariable logistic regression was used to analyze the impact of BMI on rTHA for periprosthetic joint infection (PJI), dislocation, periprosthetic fracture (PPF), aseptic loosening, or mechanical complications. Analyses were adjusted for age, sex, race/ethnicity, socioeconomic status, insurance, geographic region, and comorbidities.

RESULTS

Compared to normal-weight patients, underweight patients were 131% more likely to have a revision due to dislocation and 63% more likely due to PPF. Overweight/obese patients were 19% less likely to have a revision due to dislocation and 10% more likely due to PJI. Cause for revision in morbidly obese patients was 4s1% less likely to be due to dislocation, 8% less likely due to mechanical complications, and 90% more likely due to PJI.

CONCLUSIONS

Overweight/obese and morbidly obese patients were more likely to undergo rTHA for PJI and less likely for mechanical reasons compared to normal weight patients. Underweight patients were more likely to undergo rTHA for dislocation or PPF. Understanding the differences in cause for rTHA among the BMI classes can aid in patient-specific optimization and management to reduce postoperative complications.

LEVEL OF EVIDENCE

III.

Short stem hip arthroplasty with the optimys prosthesis is a safe and effective option for obese patients: a mid-term follow-up multicenter study

INTRODUCTION

Short stems are a valuable option in young patients undergoing total hip arthroplasty (THA) because of their bone stock preserving properties facilitating revision hip arthroplasty. Although the effect of obesity on conventional THA is well studied, data about short stem THA in obese patients are lacking. Therefore, this study aimed to investigate the influence of obesity on complications, revisions, and outcome after short stem THA.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients undergoing short stem THA with the optimys prosthesis. Follow-up examinations were performed at specific intervals up to 7 years postoperatively. Operation characteristics, general and specific complications, revisions, VAS rest pain, VAS load pain, VAS patient satisfaction, and Harris Hip Score (HHS) were recorded and statistically compared between obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) patients.

RESULTS

Of the 224 patients included with a mean follow-up of 87.2 months (range 81.9-104.0), 69 were assigned to the OB group and 155 to the non-OB group. A minimally invasive approach was significantly less often selected in obese patients (p = 0.049), whereas operating time and length of hospital stay were not significantly different. The rate of general and specific complications did not significantly differ between both groups. Survival of the optimys prosthesis was 99.1% at 7-year follow-up and one patient per group had to undergo revision surgery. VAS rest pain, load pain, and satisfaction improved from preoperatively to postoperatively in both groups without a significant difference between both groups. While the HHS was improved from preoperatively to postoperatively, obese patients showed a significantly lower HHS at the 7-year follow-up (p = 0.01) but still exhibited an excellent scoring above the PASS threshold.

CONCLUSION

Short stem THA with the optimys prosthesis is a safe and effective option also in obese patients with an excellent clinical outcome and a low complication rate.

The Impact of Obesity on Total Hip Arthroplasty Outcomes When Performed by High-Volume Surgeons-A Propensity Matched Analysis From a High-Volume Urban Center

BACKGROUND

Previous data suggest that obesity does not impact surgical outcomes following total knee arthroplasty performed by high-volume (HV) surgeons. However, this effect has yet to be studied in total hip arthroplasty (THA) patients. This study aimed to evaluate the impact of patient obesity on THA outcomes when surgery is performed by HV surgeons.

METHODS

A retrospective analysis of patients who underwent primary, elective THA between January 2012 and December 2022 with a HV surgeon (top 25% of surgeons by number of annual primary THA) was performed. Patients were stratified by their body mass index (BMI) into 3 cohorts: BMI ≥ 40 (morbidly obese [MO]), 30 ≤ BMI < 40 (obese), and BMI < 30 (nonobese); and 1:1:1 propensity matched based on baseline characteristics. A total of 13,223 patients were evaluated, of which 669 patients were included in the final matched analysis (223 patients per group). The average number of annual THAs performed for HV surgeons was 171 cases.

RESULTS

The MO patients had significantly longer surgical times (P < .001) and hospital lengths of stay (P < .001). Rates of 90-day readmissions (P = .211) and all-cause, septic, and aseptic revisions at the latest follow-up (P = .268, P = .903, and P = .168, respectively) were comparable between groups. In a subanalysis for non-HV surgeons, MO patients had a significantly greater risk of revision (P = .021) and trended toward significantly greater readmissions (P = .056).

CONCLUSIONS

Clinical outcomes and complication rates after THA performed by a HV surgeon are similar regardless of patient obesity status. Patients who have MO may experience improved outcomes and reduced procedural risks if they are referred to HV surgeons.

LEVEL OF EVIDENCE

III.

Does Your Patient Need to Lose Weight? Weight Change Before and After Total Hip Arthroplasty Does Not Affect Health Care Utilization and Achievement of the Minimal Clinically Important Difference

BACKGROUND

Despite the potential negative impact of preoperative obesity on total hip arthroplasty (THA) outcomes, the association between preoperative and postoperative weight change and outcomes is much less understood. Therefore, this study aimed to determine the impact of preoperative and postoperative weight change and preoperative body mass index (BMI) on health care utilization, satisfaction, and achievement of minimal clinically important difference (MCID) for Hip Disability and Osteoarthritis Outcome Score Physical Function Short-Form (HOOS PS) and HOOS Pain.

METHODS

Patients who underwent primary elective unilateral THA between January 2016 and December 2019 were included (N = 2,868). Multivariable logistic regression assessed the association between BMI and preoperative and postoperative weight change on outcomes while controlling for demographic characteristics.

RESULTS

There was no association between preoperative weight change and prolonged length of stay (> 3 days), 90-day readmission, nonhome discharge, patient dissatisfaction at 1 year, or achievement of HOOS Pain or HOOS PS MCID. Postoperative weight loss was an independent risk factor for patient dissatisfaction at 1 year but was not associated with achievement of either HOOS Pain or HOOS PS MCID at 1-year postoperative. Preoperative obesity classes I to III were independent risk factors for nonhome discharge. Nevertheless, preoperative obesity class I and class II were associated with an increased probability of reaching HOOS Pain MCID. Preoperative BMI was not associated with an increased risk of patient dissatisfaction.

CONCLUSIONS

Preoperative weight change does not appear to influence health care utilization, satisfaction, or achievement of MCID in pain and function following THA. Postoperative weight loss may play a role as a risk factor for dissatisfaction following THA. Additionally, patients who had a higher baseline BMI may be more likely to see improvement in pain following THA. Therefore, when counseling obese patients for THA, surgeons must balance the risk of perioperative complications with the expectation of greater improvements in pain.

Glucagon-like Peptide-1 Agonists: What the Orthopaedic Surgeon Needs to Know

» Orthopaedic surgeons are increasingly likely to encounter patients with obesity and/or type 2 diabetes taking glucagon-like peptide-1 (GLP-1) agonists for weight loss.» GLP-1 agonists are an effective treatment for weight loss with semaglutide and tirzepatide being the most effective agents. Randomized controlled trials using these agents have reported weight loss up to 21 kg (46 lb).» The use of GLP-1 agonists preoperatively can improve glycemic control, which can potentially reduce the risk of postoperative complications. However, multiple cases of intraoperative aspiration/regurgitation have been reported, potentially related to the effect of GLP-1 agonists on gastric emptying.» While efficacious, GLP-1 agonists may not produce sufficient weight loss to achieve body mass index cutoffs for total joint arthroplasty depending on individual patient factors, including starting bodyweight. Multifactorial approaches to weight loss with focus on lifestyle modification in addition to GLP-1 agonists should be considered in such patients.» Although GLP-1 agonists are efficacious agents for weight loss, they may not be accessible or affordable for all patients. Each patient's unique circumstances should be considered when creating an ideal weight loss plan during optimization efforts.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Go Big or Go Home: Obesity and Total Joint Arthroplasty

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study

BACKGROUND

Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty.

METHODS

Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques.

RESULTS

From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery.

CONCLUSION

Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.