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de Ree RH, de Jong LD, Hazebroek EJ, Somford MP. Optimal timing of hip and knee arthroplasty after bariatric surgery: A systematic review. J Clin Orthop Trauma 2024; 52:102423. [PMID: 38766387 PMCID: PMC11096744 DOI: 10.1016/j.jcot.2024.102423] [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: 11/10/2023] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 05/22/2024] Open
Abstract
Background Obesity is a risk factor for the development of osteoarthritis and contributes to the increasing demand for total joint arthroplasty (TJA). Because a lower preoperative weight decreases the risk of complications after TJA, and because bariatric surgery (BS) can reduce weight and comorbidity burden, orthopedic surgeons often recommend BS prior to TJA in patients with obesity. However, the optimal timing of TJA after BS in terms of complications, revisions and dislocations is unknown. Methods PubMed, Embase and Cochrane CENTRAL databases were systematically searched for any type of study reporting rates of complications, revisions and dislocations in patients who had TJA after BS. The included studies' quality was assessed using the Newcastle-Ottawa Scale. Results Out of the 16 studies eligible for review, eight registry-based retrospective studies of high to moderate quality compared different time periods between BS and TJA and overall their results suggest little differences in complication rates. The remaining eight retrospective studies evaluated only one time period and had moderate to poor quality. Overall, there were no clear differences in outcomes after TJA for the different time frames between BS and TJA. Conclusion The results of this systematic review suggest that there is limited and insufficient high-quality evidence to determine the optimal timing of TJA after BS in terms of the rates of complications, revisions and dislocations. Given this lack of evidence, timing of TJA after BS will have to be decided by weighing the individual patients' risk factors against the expected benefits of TJA.
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Affiliation(s)
- Roy H.G.M. de Ree
- Department of Orthopaedics, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
| | - Lex D. de Jong
- Department of Orthopaedics, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
| | - Eric J. Hazebroek
- Department of Bariatric Surgery, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
| | - Matthijs P. Somford
- Department of Orthopaedics, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, the Netherlands
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Kebeh M, Dlott CC, Kurek D, Morris JC, Wiznia DH. Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series. Orthop Nurs 2024; 43:75-83. [PMID: 38546679 PMCID: PMC10987043 DOI: 10.1097/nor.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.
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Affiliation(s)
- Martha Kebeh
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Chloe C. Dlott
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Donna Kurek
- National Association of Orthopaedic Nurses and Movement is Life, Chicago, IL, USA
- OrthoVirginia, Chesterfield, VA, USA
| | - Jensa C. Morris
- Hospital Medicine Service, Yale New Haven Hospital, New Haven, CT, USA
- Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Blankstein M, Browne JA, Sonn KA, Ashkenazi I, Schwarzkopf R. Go Big or Go Home: Obesity and Total Joint Arthroplasty. J Arthroplasty 2023; 38:1928-1937. [PMID: 37451512 DOI: 10.1016/j.arth.2023.07.001] [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: 12/03/2022] [Revised: 06/17/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
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.
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Affiliation(s)
- Michael Blankstein
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT, USA
| | - James A Browne
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kevin A Sonn
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Itay Ashkenazi
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York, USA
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Phillips JLH, Ennis HE, Jennings JM, Dennis DA. Screening and Management of Malnutrition in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:319-325. [PMID: 36812414 DOI: 10.5435/jaaos-d-22-01035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
Malnutrition is an increasingly prevalent problem in patients undergoing total joint arthroplasty (TJA). Increased risks associated with TJA in the setting of malnourishment have been well documented. Standardized scoring systems in addition to laboratory parameters such as albumin, prealbumin, transferrin, and total lymphocyte count have been developed to identify and evaluate malnourished patients. Despite an abundance of recent literature, there is no consensus on the best approach for screening TJA patients from a nutritional standpoint. Although there are a variety of treatment options, including nutritional supplements, nonsurgical weight loss therapies, bariatric surgery, and the involvement of dieticians and nutritionists, the effect of these interventions on TJA outcomes has not been well characterized. This overview of the most current literature aims to provide a clinical framework for approaching nutrition status in arthroplasty patients. A comprehensive understanding of the tools available for managing malnourishment will facilitate improved arthroplasty care.
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Affiliation(s)
- Jessica L H Phillips
- From the Colorado Joint Replacement (Phillips, Ennis, Jennings, and Dennis), the Department of Mechanical and Materials Engineering, University of Denver (Jennings and Dennis), the Department of Orthopaedics, University of Colorado School of Medicine (Dennis), Denver, CO, and the Department of Biomedical Engineering, University of Tennessee, Knoxville, TN (Dennis)
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Obesity Disparities. J Am Acad Orthop Surg 2022; 30:1028-1035. [PMID: 35171875 DOI: 10.5435/jaaos-d-21-00424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 12/24/2021] [Indexed: 02/01/2023] Open
Abstract
Thirty five percent of the American population is considered obese (body mass index [BMI] > 30). Obesity disproportionately affects African Americans, Hispanics, and women. Obesity is associated with postoperative complications, including wound complications, infections, and revision total joint arthroplasty (including total hip arthroplasty and total knee arthroplasty). Current BMI benchmarks (many institutions rely on a BMI of 40) selectively preclude patients from having surgery. Patients in these underserved populations can be optimized through the lens of shared decision making through the assessment of food security (eg, food deserts and food swamps), ability to afford healthy food, knowledge of social safety net and community resources to access healthy food, nutrition and weight loss referrals to programs that accept all forms of insurance, weight loss measurements as a percentage of body weight lost instead of BMI cutoffs, pharmacologic modalities, and bariatric surgery.
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Rankin KA, Gibson D, Schwarzkopf R, O’Connor MI, Wiznia DH. Operative Techniques to Reduce Hip and Knee Arthroplasty Complications in Morbidly Obese Patients. Arthroplast Today 2022; 17:120-125. [PMID: 36082285 PMCID: PMC9445224 DOI: 10.1016/j.artd.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/05/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Obesity, defined as a body mass index (BMI) >30, is associated with an increased likelihood of osteoarthritis and need for total joint arthroplasty (TJA). Unfortunately, the morbidly obese population has a higher risk of postoperative complications. For some surgeons, patient selection criteria for TJA includes BMI<40. The associated risks are recognized by The American Association of Hip And Knee Surgeons, and many surgeons follow these guidelines. Importantly, as obese patients have been demonstrated to have equal or greater gains in functional outcomes and quality of life metrics, it is important for obese patients to have access to TJA. Through a comprehensive literature review and structured interviews with leading surgeons in the field, we provide guidance for orthopedic surgeons treating patients with BMI>40 to minimize risks, including tailored preoperative, intraoperative, and postoperative considerations.
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Affiliation(s)
- Kelsey A. Rankin
- Yale School of Medicine, New Haven, CT, USA
- Corresponding author. Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA. Tel.: +1 617 285 4102.
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Wu HH, Samuel LT, Silvestre J, Acuña AJ, Nelson CL, Israelite CL, Kamath AF. The accuracy of patient-reported weight prior to total joint arthroplasty and arthroscopy of the lower extremity. Arch Orthop Trauma Surg 2022; 142:2381-2388. [PMID: 34331581 DOI: 10.1007/s00402-021-04095-5] [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: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight. METHODS Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors. RESULTS There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05). CONCLUSION Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.
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Affiliation(s)
- Hao-Hua Wu
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Jason Silvestre
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Craig L Israelite
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.
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Liu J, Zhong H, Poeran J, Sculco PK, Kim DH, Memtsoudis SG. Bariatric surgery and total knee/hip arthroplasty: an analysis of the impact of sequence and timing on outcomes. Reg Anesth Pain Med 2021; 46:941-945. [PMID: 34462345 DOI: 10.1136/rapm-2021-102967] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/17/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Patients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied. METHODS This cohort study extracted claims data on patients with an obesity diagnosis that received both bariatric surgery and TKA/THA surgery within 5 years of each other (Premier Healthcare database 2006-2019). Overall, 1894 patients received bariatric surgery before TKA or THA, while 1000 patients underwent TKA or THA before bariatric surgery. Main outcomes and measures include major complications (acute renal failure, acute myocardial infarction, other cardiovascular complications, sepsis/septic shock, pulmonary complications, pulmonary embolism, pneumonia, and central nervous system-related adverse events), postoperative intensive care unit utilization, ventilator utilization, 30-day readmission, 90-day readmission, 180-day readmission and total hospital length of stay after the second surgery. Regression models measured the association between the complications and sequence of TKA/THA and bariatric surgery. RESULTS Undergoing TKA/THA before bariatric surgery (compared with the reverse) was associated with higher odds of major complications (7.0% vs 1.9%; adjusted OR 4.8, 95% CI 3.1, 7.6, p<0.001). Similar patterns were also observed for intensive care unit admission, ventilator use postoperatively, 30-day, and 90-day readmissions. Patients who received a second surgery within 6 months of their first surgery exhibited worse outcomes, especially among the TKA/THA first patient cohort. Major complication incidences occurred at 20.5%, 12.5%, 5.1%, 5.0%, 5.8% and 8.5% with time between TKA/THA and bariatric surgery at <6 months, 6 months-1 year, 1-2, 2-3, 3-4 and 4-5 years, respectively. CONCLUSIONS Patients who require both bariatric surgery and TKA/THA should consider bariatric surgery before TKA/THA as it is associated with improved outcomes. Procedures should be staged beyond 6 months.
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Affiliation(s)
- Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Jashvant Poeran
- Depts of Population Health Science & Policy/Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter K Sculco
- Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - David H Kim
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA
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Statz JM, Odum SM, Johnson NR, Otero JE. Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous? Arthroplast Today 2021; 10:18-23. [PMID: 34277906 PMCID: PMC8267488 DOI: 10.1016/j.artd.2021.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/18/2022] Open
Abstract
Background There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA. Methods The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m2 and age of 72 years, and 60% of whom were female. Results We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m2, tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001). Conclusions Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient. Level of Evidence IV.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nicholas R Johnson
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Jesse E Otero
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA.,OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
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Ellis RT, Nettrour JF, Keeney JA. TKA is More Durable Than UKA for Morbidly Obese Patients: A Two-Year Minimum Follow-Up Study. J Arthroplasty 2021; 36:1933-1941. [PMID: 33483247 DOI: 10.1016/j.arth.2020.12.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) indications have expanded during the past two decades to include some morbidly obese patients (body mass index (BMI) > 40 kg/m2). Few published studies have compared UKA and total knee arthroplasty (TKA) in this unique patient subgroup with conflicting observations. METHODS We retrospectively compared 89 mobile bearing UKA (71 patients) and 201 TKA (175 patients) performed at a single institution with a minimum 2-year follow-up (mean 3.4 years). Demographic characteristics were similar for both patient cohorts. A detailed medical record review was performed to assess the frequency of component revision, revision indications, minor secondary procedures (components retained), and infections. RESULTS UKA was more frequently associated with clinical failure (29.2% vs 2.5%, P < .001) and component revision (15.7% vs 2.5%, P < .001), TKA was more frequently associated with extensor mechanism complications or knee manipulation (5.5% vs 0.0%, P = .02), and there was no difference in the infection rate (3.0% vs 2.2%, P = 1.0). CONCLUSION Early complications were lower following UKA but were outweighed by higher component revision rates for arthritis progression and implant failure. The study findings suggest that TKA provides a more predictable mid-term outcome for morbidly obese patients considering knee arthroplasty surgery.
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Affiliation(s)
- R Tyler Ellis
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - John F Nettrour
- Department of Orthopaedic Surgery, University of Pittsburgh, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - James A Keeney
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
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Value-based Healthcare: Improving Outcomes through Patient Activation and Risk Factor Modification. Clin Orthop Relat Res 2019; 477:2418-2420. [PMID: 31567580 PMCID: PMC6903833 DOI: 10.1097/corr.0000000000000985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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