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Marinier MC, Ogunsola AS, Elkins JM. Body Composition Changes in the Immediate Peri-operative Period Following Total Joint Arthroplasty. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2022; 13:39-44. [PMID: 36196241 PMCID: PMC9487908 DOI: 10.2478/joeb-2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Bioimpedance analysis (BIA) is a readily available tool to assess body composition in a clinical setting. BIA has received little attention in orthopaedics and namely joint arthroplasty. This study aims to quantify changes in body composition in the immediate peri-operative period following total joint arthroplasty. METHODS Adults scheduled for elective total joint arthroplasty were recruited to participate. Patients underwent BIA scans in the immediate peri-operative period: pre-operative on their day of surgery, post-operative day 0, and post-operative day 1. RESULTS 67 patients were enrolled to undergo BIA scans. Mean age was 62.64 ± 10.28 years old, and 49.2% were females. The all-supine cohort exhibited a 0.36 ± 0.61 kg increase in dry lean mass (p < 0.001) and 1.30 ± 2.14 kg increase in lean body mass on postoperative day 0 (p < 0.001). Patients received to 1.16 ± 0.58 kg of fluid mass, on average. CONCLUSION BIA is a rapid, portable tool that allows for body composition analysis of an inpatient surgical population. This study demonstrated that BIA can detect net fluid changes and may approximate implant mass following total joint arthroplasty. This may aid surgeons in interpreting post-operative body composition changes.
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Affiliation(s)
- Michael C. Marinier
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IAUSA
| | - Ayobami S. Ogunsola
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IAUSA
| | - Jacob M. Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IAUSA
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Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients. J Arthroplasty 2020; 35:2646-2651. [PMID: 32418743 DOI: 10.1016/j.arth.2020.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to determine whether the high risk of surgical complications within 1 year of total hip arthroplasty (THA) is due to associated comorbidities or morbid obesity alone as measured by body mass index (BMI ≥ 40 kg/m2). METHODS Population-based retrospective cohort study was conducted of all adults in Ontario undergoing primary THA for osteoarthritis (2012-2018). All patients were followed for 1 year. Outcomes were compared among matched groups (hypertension, diabetes, chronic obstructive pulmonary disease, frailty, congestive heart failure, coronary artery disease, asthma, and Charlson score). Primary outcome measure was major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, and revision surgery). RESULTS A total of 3683 patients with morbid obesity were matched and had a significantly greater risk of major complications within 1-year (132 [3.6%] vs 54 [1.5%]; hazard ratio [HR] 2.54, 95% confidence interval [CI]; 1.98-3.25). This included greater risk for deep infection requiring surgery (100 [2.8%] vs 26 [0.7%]; HR 3.85, 95% CI; 2.70-45.48) and revision arthroplasty (86 [2.4%] vs 34 [0.9%]; HR 2.61, 95% CI; 1.92-3.55). Operative time was also longer with a median 116 (99-138) vs 102 (87-121) minutes. There were no significant differences in hospital stay, cost of acute care episode, or medical complications. CONCLUSION Patients' large body habitus seems to contribute to the increased risk of surgical complications within 1-year of THA. Future research is needed to identify ways of mitigating surgical complications such as centralizing care for this complex group of patients in specialist centers.
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Tsymbal E, Ayala S, Singh A, Applegate RL, Fleming NW. Study of early warning for desaturation provided by Oxygen Reserve Index in obese patients. J Clin Monit Comput 2020; 35:749-756. [PMID: 32424516 PMCID: PMC8286939 DOI: 10.1007/s10877-020-00531-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/13/2020] [Indexed: 12/19/2022]
Abstract
Acute hemoglobin desaturation can reflect rapidly decreasing PaO2. Pulse oximetry saturation (SpO2) facilitates hypoxia detection but may not significantly decrease until PaO2 < 80 mmHg. The Oxygen Reserve Index (ORI) is a unitless index that correlates with moderately hyperoxic PaO2. This study evaluated whether ORI provides added arterial desaturation warning in obese patients. This IRB approved, prospective, observational study obtained written informed consent from Obese (body mass index (BMI) kg m-2; 30 < BMI < 40) and Normal BMI (19 < BMI < 25) adult patients scheduled for elective surgery requiring general endotracheal anesthesia. Standard monitors and an ORI sensor were placed. Patient's lungs were pre-oxygenated with 100% FiO2. After ORI plateaued, general anesthesia was induced, and endotracheal intubation accomplished using a videolaryngoscope. Patients remained apneic until SpO2reached 94%. ORI and SpO2 were recorded continuously. Added warning time was defined as the difference between the time to SpO2 94% from ORI alarm start or from SpO2 97%. Data are reported as median; 95% confidence interval. Complete data were collected in 36 Obese and 36 Normal BMI patients. ORI warning time was always longer than SpO2 warning time. Added warning time provided by ORI was 46.5 (36.0-59.0) seconds in Obese and 87.0 (77.0-109.0) seconds in Normal BMI patients, and was shorter in Obese than Normal BMI patients difference 54.0 (38.0-74.0) seconds (p < 0.0001). ORI provided what was felt to be clinically significant added warning time of arterial desaturation compared to SpO2. This added time might allow earlier calls for help, assistance from other providers, or modifications of airway management.Trial registration ClinicalTrials.gov NCT03021551.
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Affiliation(s)
- Ekaterina Tsymbal
- Department of Anesthesiology and Pain Medicine, University of California Davis, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
| | - Sebastian Ayala
- Department of Anesthesiology and Pain Medicine, University of California Davis, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
| | - Amrik Singh
- Department of Anesthesiology and Pain Medicine, University of California Davis, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
| | - Richard L Applegate
- Department of Anesthesiology and Pain Medicine, University of California Davis, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA.
| | - Neal W Fleming
- Department of Anesthesiology and Pain Medicine, University of California Davis, 4150 V Street, PSSB Suite 1200, Sacramento, CA, 95817, USA
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Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention, Treatment Decisions, and Treatment Outcomes. J Arthroplasty 2020; 35:39-44. [PMID: 31530460 DOI: 10.1016/j.arth.2019.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The United States is in an obesity epidemic. Obesity has multiple common comorbid conditions, including lower extremity arthritis. We sought to examine the course of treatment for a population with body mass index (BMI) ≥40 kg/m2 and osteoarthritis (OA) of the hip or knee. We investigated decision criteria that influenced arthroplasty surgeons to recommend nonoperative management vs total joint arthroplasty (TJA). For those patients who ultimately received TJA, we compared outcomes in this population to those with BMI <40 kg/m2. METHODS This study retrospectively reviewed 158 new patients with BMI ≥40 kg/m2 and moderate/severe OA of the hip or knee. Demographics, comorbidity profiles, and weight loss were compared between groups that underwent TJA and those that did not. The arthroplasty database was used to identify patients who underwent TJA during 2016-2018 (N = 1473). Comorbidities, readmissions, surgical site infections, and overall complications were compared between those with BMI ≥40 kg/m2 and BMI <40 kg/m2. RESULTS About 51.3% of new patients with BMI ≥40 kg/m2 and moderate/severe OA did not return for a second clinic visit. Of those who did return, 42.9% eventually underwent surgery. BMI was higher in single visit patients vs those with multiple visits (49.5 vs 46.3 kg/m2, P < .001), no difference in those scheduled on an "as-needed" basis vs a specific return date (P = .18), and did not change significantly during the 2-year follow-up (P = .41). Patients who underwent TJA had a lower mean BMI at presentation than their nonoperative counterparts (44.5 vs 47.6 kg/m2, P < .01) and demonstrated significant weight loss prior to surgery (44.5 vs 42.6 kg/m2, P < .05). When comparing patients with BMI ≥40 kg/m2 vs BMI <40 kg/m2, overall complications were not higher in the BMI ≥40 kg/m2 group, although surgical site infections were higher in those undergoing total hip arthroplasty with BMI ≥40 kg/m2 (0.3% vs 3.1%, P < .05). CONCLUSION A majority of patients with BMI ≥40 kg/m2 and moderate/advanced OA will be lost to orthopedic follow-up. A relatively lower BMI indicates a greater chance of retention in care, and ultimately surgery, but does not influence surgeons' recommendations to continue orthopedic management. Patients who persist in seeking treatment, lose significant weight, and exhaust nonoperative alternatives may be suitable for TJA despite a BMI ≥40 kg/m2, with an overall complication rate of 4.3%. However, only 9% of patients at 2-year follow-up achieved BMI <40 kg/m2 and only 20% of surgeries were performed on patients who had achieved this proposed cutoff.
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New York Arthroplasty Council (NYAC) Consensus on Reducing Risk in Total Joint Arthroplasty: Obesity. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Li Z, Liu D, Long G, Ke G, Xiao A, Tang P, Dong J. Association of tourniquet utilization with blood loss, rehabilitation, and complications in Chinese obese patients undergoing total knee arthroplasty: A retrospective study. Medicine (Baltimore) 2017; 96:e9030. [PMID: 29245293 PMCID: PMC5728908 DOI: 10.1097/md.0000000000009030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Obesity not only gives rise to more blood loss volume but also correlates with postoperative rehabilitation and complications in surgical patients. It is not clear at present whether tourniquet utilization is associated with blood loss, rehabilitation, and complications, and it is imperative to ascertain the tactics of utilizing tourniquet in obese patients undergoing total knee arthroplasty (TKA). The present study was designed to explore the association of tourniquet utilization with blood loss, rehabilitation, and complications, and ascertain the tactics of utilizing tourniquet in obese patients undergoing TKA.A total of 130 patients from January 2014 to December 2014 were categorized into tourniquet group (n = 94) and non-tourniquet group (n = 36) based on whether the tourniquet was utilized or not during operation. Recorded data were as follows: total blood loss volume, intraoperative blood loss volume, hidden blood loss volume, blood transfusion volume, drainage volume, difference between hemoglobin value before operation and that on the fifth day after operation (5d Hb D-value), thigh swelling rate and visual analogue scale (VAS) score of motion pain, and Knee Society Score (KSS) score.Mean age was 65.27 ± 7.43 (49-82) years, and 15 patients (11.5%) were men. No significant difference in total blood loss volume, drainage volume, blood transfusion volume, and 5d Hb D-value was noted between the 2 groups (P > .05 for all). Tourniquet group had significantly less intraoperative blood loss volume and significantly more hidden blood loss volume than the non-tourniquet group (P < .05 for all). Tourniquet group had significantly higher thigh swelling rate and VAS score of motion pain on the third day after operation, and significantly lower KSS function score in the third week after operation than non-tourniquet group (P < .05). No significant difference in KSS function score in the first year after operation was found between the 2 groups (P > .05). No difference in postoperative complications was observed between the groups (P > .05).The current study demonstrated that the tourniquet is not associated with reduced blood loss and increased postoperative complications in obese patients undergoing TKA. Step-down postoperative rehabilitation related to tourniquet is short-term rather than long-term in obese patients undergoing TKA.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/instrumentation
- Arthroplasty, Replacement, Knee/rehabilitation
- Blood Loss, Surgical/statistics & numerical data
- Blood Transfusion/statistics & numerical data
- China
- Drainage/statistics & numerical data
- Female
- Humans
- Male
- Middle Aged
- Obesity/complications
- Osteoarthritis, Knee/etiology
- Osteoarthritis, Knee/rehabilitation
- Osteoarthritis, Knee/surgery
- Postoperative Complications/etiology
- Postoperative Period
- Retrospective Studies
- Thigh/surgery
- Tourniquets/adverse effects
- Treatment Outcome
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Affiliation(s)
- Zhirui Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
- Department of Orthopedics, Chinese PLA General Hospital and Hainan Branch, Sanya
| | - Daohong Liu
- Department of Orthopaedics, the 309th hospital of PLA, Beijing
| | - Gong Long
- Department of Orthopedics, 252 Hospital of Chinese PLA, Baoding, Hebei, China
| | - Gong Ke
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
| | - An Xiao
- Department of Orthopedics, Chinese PLA General Hospital and Hainan Branch, Sanya
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
| | - Jiyuan Dong
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
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Otero-López A, Beaton-Comulada D. Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly. Phys Med Rehabil Clin N Am 2017; 28:795-810. [PMID: 29031344 DOI: 10.1016/j.pmr.2017.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.
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Affiliation(s)
- Antonio Otero-López
- Department of Orthopaedic Surgery, School of Medicine, University of Puerto Rico, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067, USA.
| | - David Beaton-Comulada
- Department of Orthopaedic Surgery, School of Medicine, University of Puerto Rico, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067, USA
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Ninh A, Kim S, Goldberg A. Perioperative Pain Management of a Patient Taking Naltrexone HCl/Bupropion HCl (Contrave): A Case Report. ACTA ACUST UNITED AC 2017; 9:224-226. [PMID: 28604472 DOI: 10.1213/xaa.0000000000000573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 42-year-old obese woman (body mass index = 30.2 kg/m) presented for urgent anterior cervical diskectomy and fusion. She had been taking oral naltrexone-bupropion extended-release (Contrave, Orexigen Therapeutics Inc, La Jolla, CA) for the past 6 months and continued using it until 12 hours preoperatively. Despite discontinuation of this medication, and employing an intraoperative and postoperative multimodal analgesia strategy, immediate pain control was inadequately achieved. Patients taking opioid antagonists who present for surgery pose unique challenges to the anesthesiologist and require extensive preoperative interdisciplinary discussions and planning for pain control throughout the perioperative period.
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Affiliation(s)
- Allen Ninh
- From the Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Springer BD, Carter JT, McLawhorn AS, Scharf K, Roslin M, Kallies KJ, Morton JM, Kothari SN. Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of the hip and knee: a review of the literature. Surg Obes Relat Dis 2017; 13:111-118. [DOI: 10.1016/j.soard.2016.09.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 12/14/2022]
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