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LaValva SM, Grubel J, Ong J, Chiu YF, Lyman S, Mandl LA, Cushner FD, Della Valle AG, Parks ML. Is Preoperative Weight Reduction in Patients Who Have Body Mass Index ≥ 40 Associated with Lower Complication Rates After Primary Total Hip Arthroplasty? J Arthroplasty 2024:S0883-5403(24)00615-6. [PMID: 38897262 DOI: 10.1016/j.arth.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION 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 pre-operative 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 9 to 12 months prior to surgery. Subjects were stratified into three 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-day Hip Society and Centers for Medicare & Medicaid Services (CMS) complications was compared between these cohorts. There were significant baseline differences between the cohorts with respect to baseline American Society of Anesthesiologists Class (P < 0.001) and hemoglobin A1C (P = 0.011), which were accounted for in a multivariate regression analysis. RESULTS In univariate analysis, there was a lower incidence of readmission (P = 0.025) and total complications (P = 0.005) 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-day complications between cohorts (P > 0.05). CONCLUSION 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-day 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.
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Affiliation(s)
- Scott M LaValva
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Jacqueline Grubel
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Justin Ong
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yu-Fen Chiu
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Stephen Lyman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Lisa A Mandl
- Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Fred D Cushner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alejandro Gonzalez Della Valle
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Michael L Parks
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Tidd JL, Huffman N, Oyem PC, Pasqualini I, Hadad MJ, Klika AK, Deren ME, Piuzzi NS. Preoperative and Postoperative Weight Change has Minimal Influence on Health Care Utilization and Patient-Reported Outcomes Following Total Knee Arthroplasty. J Knee Surg 2024; 37:545-554. [PMID: 38113913 DOI: 10.1055/a-2232-7657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
As obesity becomes more prevalent, more patients are at risk of lower extremity osteoarthritis and subsequent total knee arthroplasty (TKA). This study aimed to test (1) the association of preoperative weight change with health care utilization and (2) the association of pre- and postoperative weight changes with failure to achieve satisfaction and minimal clinically important difference (MCID) in Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and function (KOOS-PS) 1 year after TKA. Prospectively collected monocentric data on patients who underwent primary TKA were retrospectively reviewed. Multivariable logistic regression assessed the influence of BMI and weight change on outcomes while controlling for confounding variables. Outcomes included prolonged length of stay (LOS >3 days), nonhome discharge, 90-day readmission rate, satisfaction, and achievement of MCID for KOOS-Pain and KOOS-PS. Preoperative weight change had no impact on prolonged LOS (gain, p = 0.173; loss, p = 0.599). Preoperative weight loss was associated with increased risk of nonhome discharge (odds ratio [OR]: 1.47, p = 0.003). There was also increased risk of 90-day readmission with preoperative weight gain (OR: 1.27, p = 0.047) and decreased risk with weight loss (OR: 0.73, p = 0.033). There was increased risk of nonhome discharge with obesity class II (OR: 1.6, p = 0.016) and III (OR: 2.21, p < 0.001). Weight change was not associated with failure to achieve satisfaction, MCID in KOOS-Pain, or MCID in KOOS-PS. Obesity class III patients had decreased risk of failure to reach MCID in KOOS-Pain (OR: 0.43, p = 0.005) and KOOS-PS (OR: 0.7, p = 0.007). Overall, pre- and postoperative weight change has little impact on the achievement of satisfaction and clinically relevant differences in pain and function at 1 year. However, preoperative weight gain was associated with a higher risk of 90-day readmissions after TKA. Furthermore, patients categorized in Class III obesity were at increased risk of nonhome discharge but experienced a greater likelihood of achieving MCID in KOOS-Pain and KOOS-PS. Our results raise awareness of the dangers of using weight changes and BMI alone as a measure of TKA eligibility.
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Affiliation(s)
- Joshua L Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Nickelas Huffman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Precious C Oyem
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | | | - Matthew J Hadad
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Matthew E Deren
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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LaValva SM, Grubel J, Ong J, Chiu YF, Lyman S, Mandl LA, Cushner FD, Gonzalez Della Valle A, Parks ML. Substantial Weight Loss May Not Improve Early Outcomes of Total Knee Arthroplasty in the Morbidly Obese. J Arthroplasty 2024:S0883-5403(24)00327-9. [PMID: 38670174 DOI: 10.1016/j.arth.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Body mass index (BMI) cutoffs for morbidly obese patients otherwise indicated for total knee arthroplasty (TKA) have been widely proposed and implemented, though they remain controversial. Previous studies suggested that a 5% reduction in BMI may be associated with fewer postoperative complications. Thus, the purpose of this study was to determine whether a substantial reduction in preoperative BMI in morbidly obese patients improved 90-day outcomes after TKA. METHODS There were 1,270 patients who underwent primary TKA at a single institution and had a BMI > 40 recorded during the year prior to surgery. Patients were stratified into three cohorts based on whether their BMI within 3 months to 1 year preoperatively had decreased by ≥ 5% (228 patients [18%]); increased by ≥ 5% (310 [24%]); or remained unchanged (within 5%) (732 [58%]) on the day of surgery. There were several baseline differences between the cohorts with respect to medical comorbidities. The rate of 90-day complications and six-week patient-reported outcome measures were compared via univariate and multivariable analyses. RESULTS On univariate analysis, individual and total complication rates were similar between the cohorts (P > .05). On multivariable logistic regression, the risk of complications was similar in patients who had decreased versus unchanged BMI (OR [odds ratio] 1.0; P = .898). However, there was a higher risk of complications in the increased BMI cohort compared to those patients who had an unchanged BMI (OR 1.5; P = .039). The six-week patient-reported outcome measures were similar between the cohorts. CONCLUSIONS Patients who have a BMI > 40 who achieved a meaningful reduction in BMI prior to TKA did not have a lower rate of 90-day complications than those whose BMI remained unchanged. Furthermore, considering that nearly one in four patients experienced a significant increase in BMI while awaiting surgery, postponing TKA may actually be detrimental.
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Affiliation(s)
- Scott M LaValva
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jacqueline Grubel
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Justin Ong
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Stephen Lyman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Lisa A Mandl
- Division of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Fred D Cushner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | | | - Michael L Parks
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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4
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Lachance AD, Steika R, Lutton J, Chessa F. Total Joint Arthroplasty in Patients Who Are Obese or Morbidly Obese: An Ethical Analysis. J Bone Joint Surg Am 2024; 106:659-664. [PMID: 38377222 DOI: 10.2106/jbjs.23.00617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Andrew D Lachance
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Roman Steika
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Jeffrey Lutton
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Frank Chessa
- Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
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Carender CN, Fruth KM, Lewallen DG, Berry DJ, Abdel MP, Bedard NA. Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years. J Arthroplasty 2024:S0883-5403(24)00249-3. [PMID: 38521248 DOI: 10.1016/j.arth.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
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.
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Affiliation(s)
| | - Kristin M Fruth
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Magruder ML, Jacofsky D, Springer B, Scuderi GR, Hameed D, Mont MA. Semaglutide and Other GLP-1 Agonists: A Boon for the Arthroplasty Industry? J Arthroplasty 2024; 39:277-282. [PMID: 38182322 DOI: 10.1016/j.arth.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024] Open
Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | | | - Bryan Springer
- OrthoCarolina - Hip & Knee Center and Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | - Giles R Scuderi
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Orthopaedic Institute, New York, New York
| | - Daniel Hameed
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Chan PYW, Mika AP, Martin JR, Wilson JM. Glucagon-like Peptide-1 Agonists: What the Orthopaedic Surgeon Needs to Know. JBJS Rev 2024; 12:01874474-202401000-00003. [PMID: 38181103 DOI: 10.2106/jbjs.rvw.23.00167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
» 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.
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Affiliation(s)
- Peter Y W Chan
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
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8
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Zink TM, Kent SE, Choudhary AN, Kavolus JJ. Nutrition in Surgery: An Orthopaedic Perspective. J Bone Joint Surg Am 2023; 105:1897-1906. [PMID: 37856576 DOI: 10.2106/jbjs.23.00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
➤ Malnutrition is common among subsets of patients undergoing orthopaedic surgery and is associated with an increased risk of postoperative complications.➤ Serum proteins, in particular, albumin, may be used in the evaluation of nutritional status.➤ Anthropometric measurements and surveys also play a role in the evaluation of nutritional status.➤ Increased energy and nutrient requirements due to surgical procedures necessitate increased caloric and protein intake in the perioperative period, which may be achieved through diet or supplementation.➤ Evidence supports the use of protein-calorie, amino acid, and immunonutrition supplements. Vitamin D supplementation is an area of further consideration.➤ Diet restriction, activity alterations, pharmacotherapy, and bariatric surgery are all safe, effective approaches to weight loss, although the optimal timing and magnitude of preoperative weight loss require further investigation.
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Affiliation(s)
- Thomas M Zink
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Suzanne E Kent
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | | | - Joseph J Kavolus
- Tufts University School of Medicine, Boston, Massachusetts
- Newton-Wellesley Orthopedic Associates, Newton, Massachusetts
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Rechenmacher AJ, Yancy WS, Bolognesi MP, Jiranek WA, Seyler TM, Horn ME. Does Preoperative Weight Loss Within 6 Months or 1 Year Change the Risk of Adverse Outcomes in Total Knee Arthroplasty by Initial Body Mass Index Classification? J Arthroplasty 2023; 38:2517-2522.e2. [PMID: 37331436 DOI: 10.1016/j.arth.2023.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND High body mass index (BMI) is associated with adverse outcomes after total knee arthroplasty (TKA). Thus, many patients are advised to lose weight before TKA. This study examined how weight loss before TKA is associated with adverse outcomes depending on patients' initial BMI. METHODS This was a retrospective study of 2,110 primary TKAs at a single academic center. Data on preoperative BMIs, demographics, comorbidities, and incidences of revision or prosthetic joint infection (PJI) were obtained. Multivariable logistic regressions segmented by patients' initial (1-year preoperative) BMI classifications were performed to determine if a > 5% BMI decrease from 1 year or 6 months preoperatively predicted PJI and revision controlling for patient age, race, sex, and Elixhauser comorbidity index. RESULTS Preoperative weight loss did not predict adverse outcomes for patients who had Obesity Class II or III. 6-month weight loss had greater odds of adverse outcomes than 1-year weight loss and most significantly predicted the occurrence of 1-year PJI (adjusted odds ratio: 6.55, P < .001) for patients who had Obesity Class 1 or lower. CONCLUSION This study does not show a statistically significant effect to patients who had Obesity Class II and III losing weight preoperatively with respect to PJI or revision. For patients who have Obesity Class I or lower pursuing TKA, future research should consider potential risks associated with weight loss. Further study is needed to determine if weight loss can be implemented as a safe and effective risk reduction strategy for specific BMI classes of TKA patients.
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Affiliation(s)
| | - William S Yancy
- Department of Medicine, Duke University School of Medicine, Duke Diet & Fitness Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maggie E Horn
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; Department of Population Health Sciences, Duke University, Durham, North Carolina
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Pavlovic N, Harris IA, Boland R, Brady B, Genel F, Naylor J. 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. ARTHROPLASTY 2023; 5:48. [PMID: 37777817 PMCID: PMC10544191 DOI: 10.1186/s42836-023-00203-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/25/2023] [Indexed: 10/02/2023] Open
Abstract
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.
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Affiliation(s)
- Natalie Pavlovic
- South Western Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, 2170, Australia.
- Fairfield Hospital, South Western Sydney Local Health District, Sydney, NSW, 2176, Australia.
| | - Ian A Harris
- South Western Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, 2170, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, NSW, 2170, Australia
- School of Clinical Medicine, UNSW Medicine and Health, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Robert Boland
- Fairfield Hospital, South Western Sydney Local Health District, Sydney, NSW, 2176, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Bernadette Brady
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, 2170, Australia
- School of Health Sciences, Western Sydney University, Sydney, NSW, 2560, Australia
| | - Furkan Genel
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, NSW, 2170, Australia
- Faculty of Medicine and Health, St George and Sutherland Clinical School, University of New South Wales, Sydney, NSW, 2217, Australia
| | - Justine Naylor
- South Western Sydney Clinical School, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, 2170, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, NSW, 2170, Australia
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11
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Abhari S, Rhea EB, Arrington DD, Smith LS, Yakkanti MR, Malkani AL. Is There a Difference in PROMs Between Morbidly Obese Patients and Nonobese Patients Following Primary Total Knee Arthroplasty? Arthroplast Today 2023; 22:101169. [PMID: 37521737 PMCID: PMC10374861 DOI: 10.1016/j.artd.2023.101169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 08/01/2023] Open
Abstract
Background Patient satisfaction and patient-reported outcome measures (PROMs) are important for patients, surgeons, and payers in the current healthcare climate. Morbidly obese patients (body mass index [BMI] >40) have demonstrated higher incidence of complications after total knee arthroplasty (TKA) and can have difficulty obtaining access for their surgical care. The purpose of this study was to evaluate PROMs and patient satisfaction in morbidly obese patients undergoing primary TKA. Methods A total of 75 patients with BMI >40 kg/m2 undergoing robotic-assisted TKA were retrospectively identified and matched 2:1 to a consecutive cohort of patients with BMI <35. The average BMI of the study cohort was 42.4 kg/m2 (39.5-51.3) compared to 28.6 kg/m2 (18.5-34.9) in the control group. Clinical outcomes, PROMs, and patient satisfaction were evaluated at a minimum 2-year follow-up. Results The patients of the BMI >40 cohort were less likely to be discharged home (P = .0076), had less active flexion at 2 years (P = .0046), and had worse knee scores at 2 years (0.0497). Despite this, the percentage of patients who were satisfied or very satisfied after surgery was similar between the groups (87.5% vs 91.2%, P = .1943). Conclusions Morbidly obese patients are less likely to be discharged directly to home and may have functional differences after primary TKA. However, morbidly obese patients have similar PROMs and are as satisfied as nonobese patients at 2 years. Morbidly obese patients with end-stage knee osteoarthritis should also be able to enjoy the benefits of primary TKA following medical and surgical optimization.
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Affiliation(s)
- Sarag Abhari
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
| | - Evan B. Rhea
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
| | | | | | | | - Arthur L. Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
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Sharma N, Al-Mouazzen L, Kuiper JH, Gallacher P, Barnett A. Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07391-2. [PMID: 37036473 DOI: 10.1007/s00167-023-07391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 03/10/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes. METHODS This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26 months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting. RESULTS A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30 kg/m2 (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30 kg/m2 (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found. CONCLUSION BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- N Sharma
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK.
- , 28 Buckingham Road, Penn, Wolverhampton, WV4-5TJ, UK.
| | - L Al-Mouazzen
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - J H Kuiper
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
- Keele University, Stoke-on-Trent, UK
| | - P Gallacher
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - A Barnett
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
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Khanzada MA, Awadelkarim OA, Abdel Rahman T, Ghandour A. Primary Total Knee Replacement: A Recipe for Dry Dressing. Cureus 2023; 15:e37820. [PMID: 37213992 PMCID: PMC10197911 DOI: 10.7759/cureus.37820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
OBJECTIVE To evaluate surgical outcomes using sets of techniques to achieve single dry dressing for two weeks post total knee replacement (TKR) at Dr. Sulaiman Al-Habib Hospital, Riyadh, Saudi Arabia. MATERIAL AND METHODS A prospective study comprised of 110 consecutive unilateral total knee replacements was conducted at the orthopedic department of Dr. Sulaiman Al-Habib Hospital, Suwaidi, Riyadh, KSA. Patients of both genders underwent knee replacement surgery due to primary knee osteoarthritis, Kellgren-Lawrence grades 3 and 4. Routine investigations and fitness evaluations of patients were carried out preoperatively. Preoperative minimal use of a tourniquet and release prior to arthrotomy closure; intravenous tranexamic acid, no drains; capsule infiltration with local anesthetics without adrenaline; tight closure with barbed sutures up to the skin in three layers; skin glue; Aquacel dressing; adductor canal block; and continuation of oral anticoagulant for four weeks. RESULTS A total of 110 cases were included, of which 81 (73.6%) were females and 29 (26.4%) were males. The mean age of the study population was 60.5+10.3 years (48 to 88 years). The mean BMI in our patients was 30.57+10.5 kg/m2. Most patients were morbidly obese 13 (30.95%). The mean preoperative Hb% was 13.07+1.6 g/dl, while the mean postoperative Hb% was 12.58+1.9 mg/dl with a p-value of 0.28, which was non-significant statistically. Only two patients needed a change of Aquacel wound dressing for ooze. None of our patients developed deep venous thrombosis (DVT) or an infection. CONCLUSION A sequential use of sets of techniques is observed to be associated with improved outcomes in terms of blood loss, wound infection, mobility, and patient satisfaction, leading to the ultimate end point of dry Aquacel wound dressing.
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Affiliation(s)
| | | | - Tarig Abdel Rahman
- Orthopedics/Anesthesiology, Dr. Sulaiman Al Habib Suwaidi Hospital, Riyadh, SAU
| | - Adel Ghandour
- Orthopedics, Dr. Sulaiman Al Habib Suwaidi Hospital, Riyadh, SAU
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Adrados M, Samuel LT, Locklear TM, Moskal JT. A Reduction in Body Mass Index From ≥ 40 to < 40 Lowers Emergency Department Visits, but May Increase All-Cause Readmissions After Primary Total Hip Arthroplasty: Conflicting 90-Day Outcomes at a Single Institution. J Arthroplasty 2023:S0883-5403(23)00275-9. [PMID: 36966887 DOI: 10.1016/j.arth.2023.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The American Association of Hip and Knee Surgeons tasked a 2013 workgroup to provide obesity-related recommendations in total joint arthroplasty. Morbidly obese patients (body mass index (BMI) ≥ 40) seeking hip arthroplasty were determined to be at increased perioperative risk, and surgeons were recommended to encourage these patients to reduce their BMI <40 presurgery. We report the effect of instituting a 2014 BMI <40 threshold on our primary total hip arthroplasties (THAs). METHODS We queried our institutional database to select all primary THAs from January 2010 to May 2020. There were 1,383 THAs that were pre-2014 and 3,273 THAs that were post-2014. The 90-day emergency department (ED) visits, readmissions, and returns to operating room (OR) were identified. Patients were propensity score weight-matched according to comorbidities, age, initial surgical consultation (consult) BMI, and sex. We conducted 3 comparisons: A) pre-2014 patients who had a consult and surgical BMI ≥40 against post-2014 patients who had a consult BMI ≥40 and surgical BMI <40; B) pre-2014 patients against post-2014 patients who had a consult and surgical BMI <40; and C) post-2014 patients who had a consult BMI ≥40 and surgical BMI <40 against post-2014 patients who had a consult BMI ≥40 and surgical BMI ≥40. RESULTS Post-2014 patients who had a consult BMI ≥ 40 and surgical BMI <40 had less ED visits (7.6 versus 14.1%, P = .0007), but similar readmissions (11.9 versus 6.3%, P = .22) and returns to OR (5.4 versus 1.6%, P = .09) compared to pre-2014 patients who had a consult BMI and surgical BMI ≥ 40. Post-2014 BMI <40 had less readmissions (5.9 versus 9.3%, P < .0001), and similar all-cause returns to OR and ED visits than patients pre-2014. Post-2014 patients who had a consult and surgical BMI ≥ 40 had lower readmissions (12.5 versus 12.8%, P = .05), and similar ED visits and returns to OR than consult BMI ≥ 40 and surgical BMI <40. CONCLUSION Patient optimization prior to total joint arthroplasty is critical. However, the BMI optimization that mitigates risk in primary total knee arthroplasty may not apply to primary THA. We observed a paradoxical increased readmission rate for patients who reduced their BMI before THA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Murillo Adrados
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Orthopaedic Surgery, Institute for Orthopaedics & Neurosciences, Carilion Clinic, Roanoke, Virginia
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Institute for Orthopaedics & Neurosciences, Carilion Clinic, Roanoke, Virginia
| | - Tonja M Locklear
- Health Analytics Research Team, Carilion Clinic, Roanoke, Virginia
| | - Joseph T Moskal
- Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Department of Orthopaedic Surgery, Institute for Orthopaedics & Neurosciences, Carilion Clinic, Roanoke, Virginia
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