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De Mauro D, Balato G, Festa E, Di Cristo A, Marasco L, Loffredo G, Di Lauro P, Di Gennaro D, Maccauro G, Rosa D. Role of bariatric surgery in reducing periprosthetic joint infections in total knee arthroplasty. A systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:248. [PMID: 38561717 PMCID: PMC10983737 DOI: 10.1186/s12891-024-07288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Obesity represents an epidemic of rising numbers worldwide year after year. In the Orthopedic field, obesity is one of the major causes leading to osteoarthritis needing Total Joint Arthroplasty (TJA). Still, contextually, it represents one of the most significant risk factors for joint replacement complications and failures. So, bariatric Surgery (BS) is becoming a valuable option for weight control and mitigating obesity-related risk factors. This review of the literature and meta-analysis aims to evaluate periprosthetic joint infections (PJI) and surgical site infections (SSI) rates in patients who underwent TKA after BS compared to obese patients without BS. METHODS Systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines up to October 2023. We included longitudinal studies comparing obese patients who underwent total knee arthroplasty after bariatric surgery (study group) and obese patients who underwent TKA (control group). The surgical site infection and Periprosthetic joint infection rate were compared among groups using a meta-analytical approach. RESULTS The online database and references investigation identified one hundred and twenty-five studies. PJI rate differed significantly among groups, (z = -21.8928, p < 0.0001), with a lower risk in the BS group (z = -10.3114, p < 0.0001), for SSI, instead, not statistically significance were recorded (z = -0.6784, p = 0.4975). CONCLUSIONS The current Literature suggests that Bariatric Surgery can reduce infectious complications in TKA, leading to better outcomes and less related costs treating of knee osteoarthritis in obese patients.
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Affiliation(s)
- D De Mauro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy.
- Department of Orthopedics and Geriatric Sciences, Catholic University of the Sacred Heart, Rome, Italy.
- Department of Orthopedics and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - G Balato
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - E Festa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy.
| | - A Di Cristo
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - L Marasco
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - G Loffredo
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - P Di Lauro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - D Di Gennaro
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
| | - G Maccauro
- Department of Orthopedics and Geriatric Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Orthopedics and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - D Rosa
- Department of Public Health, Orthopedic Unit, "Federico II" University, Via Sergio Pansini, 5, Naples, 80130, Italy
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Weiner TR, El-Najjar DB, Herndon CL, Wyles CC, Cooper HJ. How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature. Orthop Rev (Pavia) 2024; 16:92287. [PMID: 38283138 PMCID: PMC10821814 DOI: 10.52965/001c.92287] [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: 07/18/2023] [Accepted: 10/17/2023] [Indexed: 01/30/2024] Open
Abstract
While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.
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Affiliation(s)
| | | | | | | | - H John Cooper
- Orthopedic Surgery Columbia University Medical Center
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Wilson CD, Lundquist KF, Baruch NH, Gaddipati R, Hammonds KAP, Allen BC. Clinical Pathways of Patients Denied Total Knee Arthroplasty Due to an Institutional BMI Cutoff. J Knee Surg 2022; 35:1364-1369. [PMID: 33607678 DOI: 10.1055/s-0041-1723969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Out of concern for the increased risk of complications with morbid obesity, institutional body mass index (BMI) cutoffs for total knee arthroplasty (TKA) have become commonplace. We sought to answer the questions: what percentage of morbidly obese patients with knee osteoarthritis who present to an arthroplasty clinic will, within 2 years, undergo TKA at (1) a BMI less than 40 kg/m2 or (2) at a BMI greater than 40 kg/m2? Of those who do not undergo surgery, (3) what percentage lose enough weight to become TKA-eligible, and (4) what percentage do not? We performed an observational study of 288 patients, of which 256 had complete follow-up. Institutional electronic medical record review and patient follow-up by telephone were conducted to determine which patients underwent surgery, and at what BMI. For those that did not undergo TKA, BMI was examined to see if the patient ever lost enough weight to become TKA eligible. Twelve of 256 patients (4.7%) underwent TKA at a BMI less than 40 kg/m2, 64 patients (25%) underwent TKA at a BMI greater than 40 kg/m2, and 7 patients (2.7%) underwent surgery at an outside hospital. The average BMI at the time of surgery was 42.3 kg/m2. Thirty-seven of 256 patients (14.4%) lost enough weight to become TKA-eligible within 2 years of the initial visit but did not undergo surgery, while 136 patients (53.1%) neither underwent TKA nor became eligible. Strict enforcement of a BMI cutoff for TKA is variable among surgeons. In the absence of weight loss protocols, 19.1% of morbidly obese patients may be expected to reach the sub-40 kg/m2 BMI milestone.
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Affiliation(s)
- Charlie D Wilson
- Department of Orthopedic Surgery, Baylor Scott & White Health, Temple, Texas.,College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | | | - Nathan H Baruch
- College of Medicine, Texas A&M Health Science Center, Temple, Texas
| | | | | | - Bryce C Allen
- Department of Orthopedic Surgery, Baylor Scott & White Health, Temple, Texas.,College of Medicine, Texas A&M Health Science Center, Temple, Texas
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Seward MW, Chen AF. Obesity, preoperative weight loss, and telemedicine before total joint arthroplasty: a review. ARTHROPLASTY 2022; 4:2. [PMID: 35005434 PMCID: PMC8723914 DOI: 10.1186/s42836-021-00102-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/03/2021] [Indexed: 01/22/2023] Open
Abstract
The preoperative period prior to elective total joint arthroplasty (TJA) is a critical time for lifestyle interventions since a scheduled surgery may help motivate patients to lose weight. Weight loss may reduce complications associated with obesity following TJA and enable patients with severe obesity (body mass index [BMI] > 40 kg/m2) to become eligible for TJA, as many institutions use a 40 kg/m2 cut-off for offering surgery. A comprehensive review was conducted to (1) provide background on complications associated with obesity following TJA, (2) synthesize prior research on the success rate of patients losing weight after being denied TJA for severe obesity, (3) discuss bariatric surgery before TJA, and (4) propose mobile health telemedicine weight loss interventions as potential weight loss methods for patients preoperatively. It is well established that obesity increases complications associated with TJA. In total knee arthroplasty (TKA), obesity increases operative time, length of stay, and hospitalization costs as well as the risk of deep infection, revision, and component malpositioning. Obesity may have an even larger impact on complications associated with total hip arthroplasty (THA), including wound complications and deep infection. Obesity also increases the risk of hip dislocation, aseptic loosening, and venous thromboembolism after THA. Synthesis of the only two studies (n = 417), to our knowledge, that followed patients denied TJA for severe obesity demonstrated that only 7% successfully reduced their BMI below 40 kg/m2 via lifestyle modifications and ultimately underwent TJA. Unfortunately, bariatric surgery may only increase certain post-TKA complications including death, pneumonia, and implant failure, and there is limited research on preoperative weight loss via lifestyle modification. A review of short-term mobile health weight loss interventions that combined personalized counseling with self-monitoring via a smartphone app found about 5 kg of weight loss over 3-6 months. Patients with severe obesity have more weight to lose and may have additional motivation to do so before TJA, so weight loss results may differ by patient population. Research is needed to determine whether preoperative mobile health interventions can help patients become eligible for TJA and produce clinically significant weight loss sufficient to improve postoperative outcomes.
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Affiliation(s)
- Michael W Seward
- Mayo Clinic, Department of Orthopedic Surgery, 200 1st St SW, Rochester, MN 55905 USA
| | - Antonia F Chen
- Brigham and Women's Hospital, Department of Orthopaedic Surgery, 75 Francis Street, Boston, MA 02115 USA
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Seward MW, Briggs LG, Bain PA, Chen AF. Preoperative Nonsurgical Weight Loss Interventions Before Total Hip and Knee Arthroplasty: A Systematic Review. J Arthroplasty 2021; 36:3796-3806.e8. [PMID: 34247869 DOI: 10.1016/j.arth.2021.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND An upcoming total joint arthroplasty (TJA) may motivate patients with severe obesity (body mass index [BMI] > 40 kg/m2) to lose weight. Weight loss can optimize outcomes following TJA, and many surgeons use a 40 kg/m2 cut-off for undergoing TJA to reduce the risk of complications. However, few patients who are denied TJA for severe obesity successfully lose weight. This is the first systematic review of nonsurgical weight loss interventions before TJA. METHODS Five electronic databases were searched for articles on January 11, 2021. Studies that utilized preoperative nonsurgical weight loss interventions for patients with obesity (BMI ≥ 30 kg/m2) scheduled for or awaiting TJA of the hip or knee were included. Two reviewers independently screened articles, assessed methodological quality, and extracted data. RESULTS We retrieved 1943 unique records, of which 7 met inclusion criteria including 2 randomized clinical trials and 5 single-arm case series. Overall, weight loss ranged from 5.0 to 32.5 kg. Four interventions reduced BMI by 3 kg/m2 at 3-5 months, while 1 reduced BMI by 12.7 kg/m2. Other weight outcomes and those related to pain, function, complications, and adverse events were inconsistently reported. CONCLUSION Although larger trials are needed, particularly randomized controlled trials that measure preoperative weight loss in a control group, nutritional status, and postoperative complications, the available evidence indicates that short-term, nonsurgical, preoperative weight loss interventions before TJA produce both statistically significant weight loss and reduced BMI before surgery. It remains unknown if the amount of weight loss from these interventions is clinically significant and sufficient to improve outcomes after TJA.
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Affiliation(s)
- Michael W Seward
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Paul A Bain
- Countway Library, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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