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Heifner JJ, Pannu TS, Gomez O, Sakalian PA, Corces A. Body Mass Index is Not an Appropriate Proxy for the Condition of Peri-Incisional Adiposity in Primary Total Joint Arthroplasty Patients. J Arthroplasty 2024:S0883-5403(24)00843-X. [PMID: 39178972 DOI: 10.1016/j.arth.2024.08.020] [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: 04/01/2024] [Revised: 08/11/2024] [Accepted: 08/14/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons (AAOS) defined the acceptable threshold for elective safe surgery as a body mass index (BMI) under 40 due to the increased risk of complications. A consequence of this recommendation has been a hard cutoff based on BMI, which restricts access to care for an increasingly large and diverse population. There is an improved understanding that excess adipose tissue confers additional risk for postoperative complications, including infection, through mechanical and physiologic mechanisms. But it is unclear if BMI is an accurate indicator of adiposity in total joint arthroplasty (TJA) patients and, thus, whether BMI is capturing clinically relevant information in obese patients. Our objective was to determine the relationship between peri-incisional adiposity (PIA) and BMI in a consecutive series of diverse primary TJA patients. METHODS A consecutive series of patients indicated for primary TJA were preoperatively evaluated. For each patient, the following variables were collected: BMI, and measures of peri-incisional adiposity (PIA) on radiographs and ultrasounds. RESULTS In THA patients (N = 99), Pearson's correlation coefficient (r) = 0.436, which indicates a moderate correlation between BMI and adiposity. In TKA patients (N = 271), r = 0.395 for femoral PIA (FPIA) and r = 0.249 for tibial PIA (TPIA), which indicates a weak correlation between BMI and adiposity measured on radiography. In TKA patients, r = 0.560 for FPIA and r = 0.544 for TPIA, which indicates a moderate correlation between BMI and adiposity measured on ultrasound. CONCLUSION Quantification of obesity has become common practice in the preoperative evaluation of primary TJA patients. The intent is to determine the magnitude of adipose tissue, which is one of the main drivers of postoperative complications in obesity. The BMI is ubiquitously used as a proxy for obesity due to its simplicity of attainment and calculation. We report that BMI has a weak to moderate association with peri-incisional adiposity in this population. These findings indicate that BMI may not accurately represent the condition of peri-incisional adipose tissue and, thus, is not capturing the relevant obesity data for preoperative risk stratification in primary total joint arthroplasty patients.
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Affiliation(s)
- John J Heifner
- Miami Orthopaedic Research Foundation, Miami, Florida, USA.
| | - Tejbir S Pannu
- Larkin Hospital Department of Orthopedic Surgery, Miami, Florida, USA
| | - Osmanny Gomez
- Larkin Hospital Department of Orthopedic Surgery, Miami, Florida, USA
| | - Philip A Sakalian
- Larkin Hospital Department of Orthopedic Surgery, Miami, Florida, USA
| | - Arturo Corces
- Larkin Hospital Department of Orthopedic Surgery, Miami, Florida, USA
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Revelt N, Sleiman A, Kurcz B, George E, Kleinsmith R, Feibel B, Thuppal S, Delfino K, Allan DG. Acute Surgical Site Complications in Direct Anterior Total Hip Arthroplasty: Impact of Local Subcutaneous Tissue Depth and Body Mass Index. Arthroplast Today 2024; 28:101465. [PMID: 39100419 PMCID: PMC11295467 DOI: 10.1016/j.artd.2024.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 04/27/2024] [Accepted: 06/09/2024] [Indexed: 08/06/2024] Open
Abstract
Background Body mass index (BMI) is an imperfect measure of patients' adiposity and operative risk. Radiographic and direct subcutaneous measurements have been utilized in attempts to more accurately characterize the risk of postoperative complications, including surgical site infection. This study aims to evaluate whether direct tissue depth measurement is a more accurate predictor of skin complication following direct anterior total hip arthroplasty (THA). Methods A retrospective chart review of patients who underwent elective THA between April 30, 2020, and January 31, 2023, was performed. Baseline demographics, antibiotics, anticoagulation, and intraoperatively measured tissue depths at proximal, middle, and distal portions of the incision were recorded. Patient follow-up was reviewed to assess the development of skin complication in the acute postoperative period. Results Data were collected from 280 patients who underwent THA via direct anterior approach by a single surgeon. The mean age was 66.0 years, and 52.1% were female. A total of 18/280 (6.4%) patients developed an abrasion (5/18) or superficial surgical site infection (13/18) within the first 60 days postoperatively. Patients who developed skin complications had a significantly higher BMI (33.7 kg/m2 vs 29.9 kg/m2; P = .0021). Patients with a BMI >30 kg/m2 had more than 5 times increased odds of developing a superficial skin complication in the acute 60-day postoperative period compared to those with a BMI <30 kg/m2 (Odds ratio = 5.318, P = .0059). None of the measured tissue depths, nor their average together, were shown to be significant predictors of skin complications. Conclusions This study showed that BMI is a significant predictor of acute skin complications in direct anterior THA patients. No other significant predictors were found to be associated with increased risk, including proximal, middle, and distal tissue depths.
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Affiliation(s)
- Nicolas Revelt
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Anthony Sleiman
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Brian Kurcz
- Cincinnati Sports Medicine & Orthopaedic Center, Cincinnati, OH
- Mercy Health, Cincinnati, OH, USA
| | - Edgar George
- Southern Illinois University School of Medicine, Springfield, IL
| | | | - Benjamin Feibel
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Sowmyanarayanan Thuppal
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Kristin Delfino
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - D. Gordon Allan
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
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Parikh S, Pannu TS, Davis T, Gomez O, Corces A. Local Soft-Tissue Thickness vs. Body Mass Index as Predictors of Complications After Total Knee or Hip Arthroplasty: A Literature Review. JBJS Rev 2023; 11:01874474-202311000-00009. [PMID: 38016004 DOI: 10.2106/jbjs.rvw.22.00128] [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: 11/30/2023]
Abstract
» Body mass index (BMI) is a nonspecific measure of general fat composition that demonstrates little conclusive or definitive association with surgical site complications after total knee and total hip arthroplasty.» Quantifying soft-tissue thickness (STT) around the joint of interest has shown positive correlations with complications and is arguably a better predictor than BMI.» In this literature review, 14 articles (7 discussing hips and 7 discussing knees) discussing the association of STT, BMI, and surgical site complications after total hip and knee arthroplasty were scrutinized and summarized to present relevant information necessary to compare STT with BMI.» Five of the 7 studies involving hips and 4 of the 7 studies involving knees show a positive relationship between STT and outcomes including complications and infection, with some claiming STT as a stronger predictor of surgery site problems than BMI.» Since many variables, such as STT measurement technique, surgical outcomes, sample sizes, and surgical approach, varied between the studies, definitive inferences are difficult to make and future studies of bigger sample size and higher power should focus on the described measurement techniques.
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Affiliation(s)
- Sarthak Parikh
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
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Heifner JJ, Fox YM, Sakalian PA, Corces A. The use of local adiposity as a proxy for obesity in primary total hip arthroplasty: A systematic review. J Orthop 2023; 38:79-84. [PMID: 37025554 PMCID: PMC10070364 DOI: 10.1016/j.jor.2023.03.012] [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: 03/14/2023] [Revised: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023] Open
Abstract
Introduction Preoperative optimization of obese patients is a critical component of risk stratification in primary total hip arthroplasty (THA). Body mass index is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. The use of adiposity as a proxy for obesity is an emerging concept. Local adiposity provides insight into the magnitude of peri-incisional tissue and has demonstrated an association with postoperative complications. Our objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty. Methods In keeping with the PRISMA guidelines, a database search of PubMed was conducted for articles which reported on the relationship between quantified measures of adiposity at the hip and rates of complication following primary THA. Methodological quality was assessed using GRADE and risk of bias using ROBINS-I. Results A total of six articles (N = 2931) met the inclusion criteria. Local adiposity at the hip was measured on anteroposterior radiograph in four articles and was measured intraoperatively in two. Across four of the six articles, adiposity was significantly associated with postoperative complications including prosthesis failure and infection. Conclusion The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in preoperative THA risk stratification. The current findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA.
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Affiliation(s)
- John J. Heifner
- Miami Orthopaedic Research Foundation, Coral Gables, FL, USA
| | - Yitzak M. Fox
- Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, FL, USA
| | - Philip A. Sakalian
- Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, FL, USA
| | - Arturo Corces
- Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, FL, USA
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Intermuscular Fat, But Not Subcutaneous Fat, Correlated With Major Complications After Primary Total Hip Arthroplasty. Acad Radiol 2022:S1076-6332(22)00505-0. [DOI: 10.1016/j.acra.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/22/2022]
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Crookes PF, Cassidy RS, Machowicz A, Hill JC, McCaffrey J, Turner G, Beverland D. Should isolated morbid obesity influence the decision to operate in hip and knee arthroplasty? Bone Jt Open 2021; 2:515-521. [PMID: 34247491 PMCID: PMC8325969 DOI: 10.1302/2633-1462.27.bjo-2021-0062.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS We studied the outcomes of hip and knee arthroplasties in a high-volume arthroplasty centre to determine if patients with morbid obesity (BMI ≥ 40 kg/m2) had unacceptably worse outcomes as compared to those with BMI < 40 kg/m2. METHODS In a two-year period, 4,711 patients had either total hip arthroplasty (THA; n = 2,370), total knee arthroplasty (TKA; n = 2,109), or unicompartmental knee arthroplasty (UKA; n = 232). Of these patients, 392 (8.3%) had morbid obesity. We compared duration of operation, anaesthetic time, length of stay (LOS), LOS > three days, out of hours attendance, emergency department attendance, readmission to hospital, return to theatre, and venous thromboembolism up to 90 days. Readmission for wound infection was recorded to one year. Oxford scores were recorded preoperatively and at one year postoperatively. RESULTS On average, the morbidly obese had longer operating times (63 vs 58 minutes), longer anaesthetic times (31 vs 28 minutes), increased LOS (3.7 vs 3.5 days), and significantly more readmissions for wound infection (1.0% vs 0.3%). There were no statistically significant differences in either suspected or confirmed venous thromboembolism. Improvement in Oxford scores were equivalent. CONCLUSION Although morbidly obese patients had less favourable outcomes, we do not feel that the magnitude of difference is clinically significant when applied to an individual, particularly when improvement in Oxford scores were unrelated to BMI. Cite this article: Bone Jt Open 2021;2(7):515-521.
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Affiliation(s)
- Peter F Crookes
- Outcomes Unit, Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - Roslyn S Cassidy
- Outcomes Unit, Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | | | - Janet C Hill
- Outcomes Unit, Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
| | - John McCaffrey
- Department of Anaesthetics, Musgrave Park Hospital, Belfast, UK
| | - Gillian Turner
- Department of Anaesthetics, Musgrave Park Hospital, Belfast, UK
| | - David Beverland
- Outcomes Unit, Primary Joint Unit, Musgrave Park Hospital, Belfast, UK
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Rey Fernández L, Angles Crespo F, Miguela Álvarez SM, Bernaus-Johnson MC, Bartra Ylla A, Font-Vizcarra L. Soft-tissue thickness radiographic measurement: a marker to evaluate acute periprosthetic joint infection risk in total hip replacement. J Bone Jt Infect 2021; 6:211-217. [PMID: 34159045 PMCID: PMC8209611 DOI: 10.5194/jbji-6-211-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/02/2021] [Indexed: 12/04/2022] Open
Abstract
The objective of our study was to evaluate the association between acute
periprosthetic joint infection (APJI) and radiographic measurement of soft-tissue thickness in elective total hip replacement surgery. A case-control study was conducted to compare the soft-tissue thickness
radiographic measurement (SRM) at the hip in patients diagnosed with APJI
based on Tsukayama et al. (2003) criteria after total hip replacement with patients
that were not infected, at a single institution from 2013 to 2019. To
minimize selection bias, each case was matched with two controls using the
following methodology: patients of the same sex, with an age variation of
± 5 years, and nearest in surgery date to the cases were selected. All
postoperative radiographs were performed in the first 24 h after total hip arthroplasty (THA)
surgery as it is protocolized in our institution. Soft-tissue thickness
radiographic measurement was defined as the distance from the tip of the
greater trochanter to the skin following a perpendicular line to the femoral
diaphysis in postoperative anteroposterior hip radiographs. In total, 78 patients were included (26 cases and 52 controls). The SRM median of the cases
was 76.19 mm (SD: 26.518) and 53.5 mm (SD: 20.47) in controls. A multivariate
logistic regression model showed an independent association between APJI and
SRM (odds ratio (OR) = 1.033, 95 % confidence interval (CI) 1.007–1.059, p=0.012). Patients with an SRM
greater than 60 mm had a 7-fold increase in the odds of APJI
(OR = 7.295, 95 % CI = 2.364–22.511, p<0.001). The results of our study suggest an association between large SRM at the hip
and the risk of APJI in patients with primary total hip arthroplasty. SRM
may be a helpful and easy tool for evaluating the risk of APJI before
elective primary total hip replacement surgery.
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Affiliation(s)
- Laura Rey Fernández
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Francesc Angles Crespo
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitari Mútua Terrassa, Barcelona, Spain.,Department of Surgery, Universitat de Barcelona, Barcelona, Spain
| | | | | | - Agustí Bartra Ylla
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitari Mútua Terrassa, Barcelona, Spain
| | - Lluís Font-Vizcarra
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitari Mútua Terrassa, Barcelona, Spain
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