Patient Obesity: A Growing Concern of Successful Total Knee Arthroplasty

Management of the Bariatric Patient. What Are the Implications of Obesity and Total Joint Arthroplasty: The Orthopedic Surgeon's Perspective?

BACKGROUND

Obesity in the United States has reached epidemic proportions. It is associated with multiple higher rates of osteoarthritis of the hip and knee and thus an increasing need for total hip and knee arthroplasty. The demand for total joint arthroplasty among obese patients has increased and outpaces that of a non-obese cohort. The complications associated with obese patients undergoing hip or knee replacement is well defined in the literature.

METHODS

Many practices have set restriction on body mass index (BMI) prior to elective total join arthroplasty. We review the implications of these BMI cutoffs as it is related to access to care for morbidly obese patients in need of hip and knee arthroplasty.

RESULTS

Of the 289 patients who presented with BMI >40, only 19% of patients underwent total hip or knee arthroplasty at a minimum of 2 years of follow-up.

CONCLUSION

This symposium discusses the implications of withholding surgery in the morbidly obese and sets the stage for the development of more collaborative work to ensure optimal care and optimal outcome for the morbidly obese.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Obesity and total joint arthroplasty: a literature based review

The prevalence of obesity in the population is unlikely to decline, and is likely to contribute to the increasing demand for hip or knee arthroplasty. Conflicting data exist on the risk and benefits of total joint arthroplasty in obese patients. The purpose of this manuscript is to define and identify areas of concern for obese patients undergoing total joint arthroplasty. A workgroup of total joint arthroplasty surgeons from the American Association of Hip and Knee Surgeons (AAHKS) was tasked with identifying key questions regarding obesity and total joint arthroplasty. The workgroup evaluated the available literature and sought to create a review regarding obesity and total joint arthroplasty to complement and guide the surgeon-patient discussion in addition to identifying areas of future research.