The purpose of this population-based study was to determine the association between morbid obesity and 10-year mortality and complications in patients undergoing primary THA. A cohort study of 22,251 patients, aged 45–74 years old, treated with primary THA between 2002 and 2007 for osteoarthritis, was conducted using Ontario administrative healthcare databases. Patients were followed for 10 years. Risk ratios (RRs) of mortality, reoperation, revision, and dislocation in patients with body mass index (BMI) > 45 kg/m2(morbidly obese patients) compared with BMI ≤45 kg/m2 (non-morbidly obese) were estimated. 3.3% of the cohort (726) was morbidly obese. Morbidly obese patients were younger (mean age 60.6 vs. 63.3, P-value < 0 .001) and more likely to be female (63.9% vs. 52.2%, P-value < 0 .001), compared with non-morbidly obese patients. Morbid obesity was associated with higher 10-year risk of death (RR 1.38, 95% CI 1.18, 1.62). Risks of revision (RR 1.43, 95% CI 0.96, 2.13) and dislocation (RR 2.38, 95% CI 1.38, 4.10) were higher in morbidly obese men, compared with non-morbidly obese men, there were no associations between obesity and revision or dislocation in women. Risk of reoperation was higher in morbidly obese women, compared to non-morbidly obese women (RR 1.60, 95% CI 1.05, 2.40), there was no association between obesity and reoperation in men. Morbidly obese patients undergoing primary THA are at higher risks of long-term mortality and complications. There were differences in complication risk by sex. Results should inform evidence-based perioperative counseling of morbidly obese patients considering THA

In the USA, 34.9% of adults are currently obese (BMI > 30). Growth in total knee arthroplasty (TKA) is outpacing growth in total hip arthroplasty (THA) largely due to a differential utilization of TKA in overweight patients in the USA. In a recent study, 54.5% of patients reporting to arthroplasty clinics in the USA were obese. From 2006–2010, 61.2% of primary unilateral TKA patients in the USA ACS-NSQIP database were obese. Arthroplasty surgeons are directly affected by the obesity epidemic and need to understand how to safely offer a range of peri-operative care for these patients in order to insure good clinical outcomes.

Pre-operative care for the obese patient involves nutritional counseling, weight loss methods, consideration for bariatric surgery, physical therapy, metabolic workup, and diagnosis and management of frequent comorbid conditions (OSA, DM2, HTN, HLD). Obese patients must also be counseled on their increased risk of complications following TKA.

In the operating room, several steps can be taken to insure success when performing TKA on obese patients. We recommend performing TKA without the use of a tourniquet in order to prevent fat necrosis and increased pain. The incision is made in 90 degrees of knee flexion, atypically midline proximally and curved distally to the midpoint between the tubercle and the medial edge of the tibia. Care is used to minimise the creation of dead space, and the approach to the knee is an extensile medial parapatellar incision. Closure is in multiple layers. The use of negative pressure dressing following surgery can minimise the early wound drainage that is frequently seen after TKA in obese patients.

Post-operative care of the obese patient following TKA involves several unique considerations. Chronic pain and obesity are frequent comorbid conditions and post-operative pain control regimens need to be tailored. Although the physical therapy regimen does not differ in obese patients, obese patients are more likely to be discharged to a rehabilitation facility.

Obese patients have a higher rate of all complications compared to healthy weight. All infection and deep infection increased in obese patients in large meta-analysis. Patients with BMI > 35 are 6.7 times more likely to develop infection after TKA. Patients with BMI > 40 have a 3.35 times higher rate of revision for deep infection than those with BMI < 35. The odds ratio for major complications increases dramatically beyond BMI > 45.

Although there are a few studies that have demonstrated worse clinical outcome in obese patients following TKA, most studies show no difference in clinical outcomes at short- or long-term follow-up. The arthroplasty surgeon must optimise the obese patient prior to surgery, use intra-operative techniques to maximise success, and anticipate potential problems in the post-operative course in order to achieve success with TKA in obese patients.

Background

Tranexamic acid (TXA) is a lysine analog that has been shown to reduce intra-operative blood loss in total joint replacements. Effect of TXA in morbid obese patients has not been established. The aim of this study was to evaluate the effect of TXA on change of haematocrit (HCT) and packed RBC (PRBC) blood transfusion rate in our institution, especially in morbid obese patients.

Introduction

Perioperative optimization efforts have improved outcomes following primary total knee arthroplasty (TKA). However, morbidly obese patients continue to have increased rates of complications. The purpose of this study was to assess if rates of early complications after TKA have similarly improved for both morbidly obese and non-morbidly obese patients.

Spinal surgery in obese and morbidly obese patients can be challenging to the operating surgeon. One of the major problems is obtaining a good surgical access. We have used the synframe retractor system in patients undergoing spinal fusion and have found it especially useful in obese and morbidly obese patients. This study reports our experience.

Seventy-seven consecutive obese and morbidly obese patients that underwent spinal decompression and fusion were reviewed. Patient selection was based on BMI values. Those with a BMI of more than thirty were included in the study. There were thirty-eight females and twenty-five males with an age of twenty-one to eighty-one years. Patient charts were used to acquire information regarding age,weight,height,gender,time in surgery, procedure start and end time,and departure. Postoperative complications and length of hospital stay were also recorded. Anesthesia notes were used to determine ASA scores,number of preoperative morbidities,and intraoperative blood loss. The synframe was used on all the patients. It is a retractor system which consists of a ring placed around the surgical site. It is fixed to both sides of the operating table with arms. Using retractor blades, the ring allows 360 degree access to the surgical exposure from any side.

The set up tme for obese patients was 59.8 minutes and 73.5 minutes for morbidly obese patients. The surgical time and blood loss was only marginally higher in these two groups than in normal weighted patients. The average postoperative length of hospitalisation was 5.8 days. The surgical incision length averaged 7.8 cms for single level and 11.5 for two level fusions. 44% patients suffered a complication. These included cage migration due to a fall, wound infection, dural leak,pulmonary embolism, deep vein thrombosis etc. No significant weight loss was recorded following the surgery.

Obese patients are a surgical challenge due to the comorbidities and difficulty in positioning and gaining good surgical access. The use of synframe retractor system improves surgical access, thereby reducing surgical time and blood loss. The surgical incision length was also comparable to normal weighted patients using this system. No significant weight loss was recorded following surgery. The high complication rate can be attributed to the associated comorbidities.

Aim

To compare the results of total knee replacement in a consecutive series of morbidly obese patients (body mass index (BMI) > 40 kg/m²) with a matched group of non-obese (BMI< 30 kg/m²) patients.

Recent studies suggest the use of computer navigation during TKA can reduce intraoperative blood loss. The purpose of this study was to assess if navigation affected blood loss after TKA in the morbidly obese patient (BMI> 40).

Total body blood loss was calculated from body weight, height and haemotocrit change, using a model which accurately assess true blood loss.

The computer navigated group comprised of 60 patients, 30 with BMI > 40 and 30 with BMI< 30. The matched conventional knee arthroplasty group consisted of 62 consecutive patients, 31 with BMI> 40 and 31 with BMI< 30 The groups were matched for age, gender, diagnosis and operative technique.

Following TKA, the mean total loss was 1014mls (521-1942, SD 312) in the computer assisted group and 1287mls (687-2356, SD 330) in the conventional group. This difference was statistically different (p< 0.001). The mean calculated loss of haemoglobin was 19 g/dl in the navigated group versus 25 g/dl in the conventional group; this was also significant at p< 0.01. The mean total loss was 1105mls in patients with a BMI> 40 in the navigated group compared to 1300mls in the conventional group (p< 0.01). A significant correlation was found between total blood loss and BMI (r=0.2, p< 0.05).

This study confirms a highly significant reduction in total body blood loss and calculated Hb loss between computer assisted and conventional TKA in obese patients. Therefore navigation-assisted TKA could present an effective and safe method for reducing blood loss and preventing blood transfusion in obese patients undergoing TKA.

Computer navigated total knee arthroplasty (TKA) has several proposed benefits including reduced post operative blood loss. We compared the total blood volume loss in a cohort of morbidly obese (BMI> 40) patients undergoing computer navigated (n=30) or standard intramedullary techniques (n=30) with a cohort of matched patients with a BMI< 30 also undergoing navigated (n=31) or standard TKA (n=31). Total body blood loss was calculated from body weight, height and haemotocrit change, using a model which accurately assesses true blood loss as was maximum allowable blood loss. The groups were matched for age, gender, diagnosis and operative technique.

The mean true blood volume loss was significantly (p< 0.001) less in the computer assisted group (1014±312mls) compared to the conventional group (1287±330mls). Patients with a BMI > 40 and a computer navigated procedure (1105 ±321mls) had a significantly lower (p< 0.001) blood volume loss compared to those who underwent a conventional TKA (1399±330mls). There was no significant difference in the transfusion rate or those reaching the maximum allowable blood loss between groups.

This study confirms a significant reduction in total body blood loss between computer assisted and conventional TKA in morbidly obese patients. However computer navigation did not affect the transfusion rate or those reaching the transfusion trigger in the morbidly obese group. Therefore computer navigation may reduce blood loss in the morbidly obese patient but this may not be clinically relevant to transfusion requirements as previously suggested.

Introduction

The purpose of this study is to estimate the cost-effectiveness of performing total hip arthroplasty (THA) versus nonoperative management (NM) in non-obese (BMI 18.5–24.9), overweight (25–29.9), obese (30–34.9), severely-obese (35–39.9), morbidly-obese (40–49.9), and super-obese (50+) patients.

Aims. There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients. Methods. Morbidly obese patients (n = 86), with BMI ≥ 40 kg/m. 2. who underwent DAA THA at our institution between September 2010 and December 2017, were matched to 172 patients with BMI < 30 kg/m. 2. Data regarding demographics, set-up and operating time, blood loss, radiological assessment, Harris Hip Score (HHS), International Hip Outcome Tool (12-items), reoperation rate, and complications at two years postoperatively were retrospectively analyzed. Results. No significant differences in blood loss, intra- and postoperative complications, or implant position were observed between the two groups. Superficial wound infection rate was higher in the obese group (8.1%) compared to the nonobese group (1.2%) (p = 0.007) and relative risk of reoperation was 2.59 (95% confidence interval 0.68 to 9.91). One periprosthetic joint infection was reported in the obese group. Set-up time in the operating table and mean operating time were higher in morbidly obese patients. Functional outcomes and patient-related outcome measurements were superior in the obese group (mean increase of HHS was 52.19 (SD 5.95) vs 45.1 (SD 4.42); p < 0.001), and mean increase of International Hip Outcome Tool (12-items) was 56.8 (SD 8.88) versus 55.2 (SD 5.85); p = 0.041). Conclusion. Our results suggest that THA in morbidly obese patients can be safely and effectively performed via the DAA by experienced surgeons. Cite this article: Bone Jt Open 2022;3(1):4–11

Literature has suggested that obese (BMI >30) and morbidly obese (BMI > 35) patients should not be offered surgery as a day case due to increases in complication and readmission rates. At Torbay hospital, patients are routinely offered day case surgery, in a specialist day case unit, regardless of BMI. This is done with minimal complications and enables a higher throughput of patients and at least 75% of surgical procedures to be performed as a day case, as per NHS guidelines.

We present 12 year data of day case knee arthroscopy surgery performed at Torbay hospital. Over 12 years, 3421 knee arthroscopies were performed. 649 were performed on obese patients and 222 on morbidly obese patients. No anaesthetic complications were observed in any of the obese patient groups and readmissions rates (up to 28 days) were 0.8% in the morbidly obese group and 0.9% in the Obese group, compared to 0.9% for patients with BMI <30.

Our data shows that day case surgery can be performed on all patients regardless of BMI and patient obesity. We believe that other units should offer surgery to obese and morbidly obese patients to allow increased efficiency and achievement of NHS day case guidelines.

Purpose: To determine the extent to which, a medically monitored rapid weight-loss program will improve pain, psychological status and functional abilities for morbidly obese women with knee osteoarthritis.

Method: 34 women (age 40 to 65) with morbid obesity and severe osteoarthritis of the knee that presented to an orthopedic surgeon for total knee arthroplasty were offered enrollment into a medically supervised weight loss program prior to consideration of a total knee replacement. Twenty-six subjects chose to participate in the weight loss program. They were enrolled in the Dr. Bernstein diet program, (a low-calorie, low-fat diet) at no cost to them. We collected the following questionnaires at enrollment and every six weeks while they remained in the weight loss program: WOMAC, SF36, Self-Efficacy, Health Locus of control, Dieting beliefs scale, Body image state scale, and the Beck depression inventory as well as Functional tests, namely the Timed up and go (TUG) and 6 minute walk test (6MWT). Our hypothesis was that weight loss would be associated with dramatic improvements in pain, self-report quality of life measures, psychological variables, and measured functional abilities for those patients who were successful in the weight loss program.

Results: At enrollment the mean age was 58.5 years and mean BMI was 47.8.

Subjects were significantly disabled with WOMAC (total) scores of 48+/ − 7 and impaired function in both the 6 minute walk test 229+/ − 146 metres and the timed up-go test 5.9+/ − 11.

(table removed)

Subjects lost an average of 32 kilograms (range 14 to 50 kg) after six months of dieting.

Weight loss was associated with dramatic improvements in pain(p < .01), self-report quality of life measures (p < .01) and measured functional abilities (p < .01).

Successful weight loss was associated with patients’ self-report of no longer requiring TKA for their knee OA.

Initially 100% of subjects felt that they required surgery. This decreased to 9.5% after six months of weight loss.

Conclusion: A low-fat, low-calorie medically monitored weight loss program (Dr. Bernstein Diet Clinics Inc.) is effective for achieving significant weight loss in women with severe knee osteoarthritis and morbid obesity. Weight loss leads to significant improvements in pain and functional abilities and alleviates or delays the need for knee replacement surgery in the majority of middle-aged, morbidly obese women.

Purpose: The increasing trend of morbidly obese patients (BMI 40+) requiring joint replacement is becoming a growing concern in Total Hip Replacement (THR) surgery. The purpose of this study was to investigate the influence that BMI may have on implant longevity and clinical outcome using prospectively collected patient data. Method: A consecutive cohort of 2864 THR’s in 2488 patients with osteoarthritis and a minimum 2 years follow-up were evaluated. Patients were divided into appropriate BMI categories; Normal and Underweight (BMI< 25, n=650), Overweight (BMI 25–29.9, n=1069), Obese (BMI 30–39.9, n=981), and Morbidly Obese (BMI 40+, n=164). Pre-operative, latest, and change in clinical outcome scores (HSS, SF12, WOMAC) were analyzed using ANOVA and Kaplan-Meier (K-M) survivorship was determined. Categorical variables such as gender and survival status were analyzed using chi-squared. Results: Morbidly Obese patients requiring THR’s were significantly younger than all other BMI groups by 5.4±0.83 years (p< 0.0001). Gender was also significant to BMI grouping with more females being Morbidly Obese and Normal or Underweight (p< 0.0001). All pre-operative and latest HHS and WOMAC domain scores were lower for the Morbidly Obese, significantly in all preoperative score domains and latest HHS Function (p< 0.05). The change in clinical scores from pre-operative to latest was greatest in all domains for the Morbidly Obese group. K-M cumulative survival with implant revision as the endpoint at 10 years was not different between the BMI groups. Revision rates for infection for the Morbidly Obese, Obese, Overweight, and Normal were 1.3%, 0.65%, 0.3% and 0.69% respectively. Overall Revision rates for the Morbidly Obese, Obese, Overweight, and Normal were 6.7%, 5.4%, 6.9% and 5.7% respectively and were not found to be significant (p=0.496). Conclusion: The Morbidly Obese cohort undergoing THR had significantly lower preoperative and lower postoperative clinical outcome scores than all other BMI groups but demonstrated the most significant improvement. No difference was found in the K-M survivorship although revisions and revisions for infection were not equal between the groups

Purpose: The growing trend of morbidly obese (BMI 40+) patients requiring a total joint replacement is becoming major concern in total knee Arthroplasty (TKA). The purpose of this study was to investigate the affects that BMI may have on implant longevity and clinical patient outcome using historical patient data. Method: A consecutive cohort of 3083 TKA’s in 2048 patients since 1995 (minimum 2 years follow-up) were evaluated. Pre-operative scores, latest scores, and change in clinical outcome scores (KSCRS, SF12, WOMAC) were analyzed using ANOVA and Kaplan-Meier (K-M) survivorship was determined. Results: K-M cumulative survival at 10 years by BMI group was 0.951±0.033 for Normal and Underweight (< 25, n=277), 0.944±0.024 for Overweight (25–29.9, n=915), 0.882±0.032 for Obese (30–39.9, n=1460) and 0.843±0.076 for Morbidly Obese (40+, n=352). Cumulative revision rates were 1.8% for Normal and Underweight, 1.9% for Overweight, 2.9% for Obese and 2.8% for Morbidly Obese. All pre-operative clinical scores were significantly different between the Morbidly Obese and all other BMI groups (p< 0.05), with the non-morbidly obese having higher scores in all cases. Significant difference was found in the change in WOMAC domain scores and the KSCRS knee score (p< 0.05) between the morbidly obese group and all other BMI groups, with the morbidly obese having the greatest improvement in all domains. Conclusion: The morbidly obese patient cohort (BMI > 40) undergoing TKA demonstrated the most significant improvement in clinical outcome scores; however also had the lowest cumulative 10 year survivorship. This risk/benefit information is important in pre-operative discussions with this challenging, and increasingly prevalent, patient population

Introduction and Aims: Morbid obesity (BMI> 40) has been shown to cause increased perioperative morbidity and poorer long-term implant survivorship following total knee arthroplasty (TKA). The aim of this study was to determine the impact of morbid obesity on patient-reported outcomes following TKA. Methods: Patients undergoing primary TKA were invited to complete questionnaires preoperatively and one year after surgery. Questionnaires include the WOMAC and SF-36 health status measures, demographics, self-reported comorbid medical conditions, height and weight. At follow-up, satisfaction with results of TKA is included. Patients were categorised by their preoperative BMI categories as ideal weight (20–25), overweight (> 25–30), obese (> 30–40) or morbidly obese (> 40). We used multivariate analysis to adjust for known significant correlates of WOMAC and SF-36, namely age, gender and comorbid medical conditions. Adjusted mean scores for each assessment were compared by BMI category. Results: A total of 769 patients were included in the study which included 27 morbidly obese, 280 obese, 314 overweight and 148 ideal weight patients. Morbidly obese patients when compared with non-obese patients had significantly worse preoperative WOMAC pain and function and a trend for worse SF36 scores (Vitality significantly worse, p=0.04). There was no significant difference between the BMI categories at one year for WOMAC or SF-36 scores (trend for the Physical Functioning score to be lower, p=0.052). Morbidly obese patients were all satisfied with pain relief after surgery but were less satisfied with functional results when compared to the non-obese groups. Discussion: This study shows that morbidly obese patients report significantly worse health status prior to TKA but their post-operative improvement is greater than the non-obese population. Although morbid obesity should not be an absolute contraindication to TKA, patients should be carefully selected balancing the risk of perioperative complications and earlier failure against the demonstrated marked improvement in quality of life

Aims. This study investigated the influence of body mass index (BMI) on the post-operative fall in the level of haemoglobin (Hb), length of hospital stay (LOS), 30-day re-admission rate, functional outcome and quality of life, two years after total knee arthroplasty (TKA). Patients and Methods. A total of 7733 patients who underwent unilateral primary TKA between 2001 and 2010 were included. The mean age was 67 years (30 to 90). There were 1421 males and 6312 females. The patients were categorised into three groups: BMI < 25.0 kg/m. 2. (normal); BMI between 25.0 and 39.9 kg/m. 2. (obese); and BMI ≥ 40.0 kg/m. 2. (morbidly obese). Results. Compared with the normal and obese groups, the mean LOS was longer by one day (95% confidence interval (CI) 0 to 2) in the morbidly obese group (p = 0.003 and p = 0.001 respectively). The 30-day re-admisison rate was also higher in the morbidly obese group compared to the obese group (OR 2.323, 95% CI 1.101 to 4.900, p = 0.024); and showed a higher trend compared to the normal group (OR 1.850, 95% CI 0.893 to 3.831, p = 0.100). However, the morbidly obese group had a smaller drop in post-operative Hb level by a mean of 0.5 g/dl (0.3 to 0.6) and 0.3 g/dl (0.1 to 0.5), when compared with the normal and obese groups respectively (both p < 0.001). Furthermore, the mean improvement in Oxford Knee Score (OKS) and Knee Society Knee Score (KSKS) at two years follow-up was three points (two to four) and five points (two to seven) more in the morbidly obese group than in the normal group (both p < 0.001). The mean improvement in Knee Society Function Score, and Physical and Mental Component Scores of Short Form-36 were comparable between the three BMI groups (p = 0.736, p = 0.739 and p = 0.731 respectively). The ten-year rate of survival was 98.8% (98.0 to 99.3), 98.9% (98.5 to 99.2) and 98.0% (95.8 to 100), for the normal, obese and morbidly obese groups, respectively (p = 0.703). Conclusion. Although morbidly obese patients have a longer LOS and higher 30-day re-admission rate after TKA, they have a smaller drop in post-operative Hb level and larger improvement in OKS and KSKS at two years follow-up. The ten-year rate of survival of TKA was also comparable with those with a normal BMI. . Take home message: Morbidly obese patients should not be excluded from the benefits of TKA. Cite this article: Bone Joint J 2016;98-B:780–5

Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

Purpose. Obesity has previously been demonstrated to be an independent risk factor for increased complications following total hip (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare the effects of obesity and BMI to determine whether the magnitude of the effect was similar for both procedures. Materials & Methods. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who underwent primary THA or TKA between 2010 and 2014. Patients were stratified by procedure and classified as non-obese, obese, or morbidly obese according to BMI. Thirty-day rates of wound complications, deep infection, total complications, and reoperation were compared using univariate and multivariate logistic regression analyses. Results. We identified 64,648 patients who underwent THA and 97,137 patients who underwent TKA. Obese THA patients had significantly higher rates of wound complications (1.53% vs 0.96%), deep infection (0.31% vs 0.17%), reoperation rate (2.11% vs 1.02%), and total complications (5.22% vs. 4.63%) compared to TKA patients. Morbidly obese patients undergoing THA were also found to have significantly higher rates of wound complications (3.25% vs 1.52%), deep infection (0.84% vs 0.23%), reoperation rate (3.65% vs 1.60%), and total complications (7.36% vs. 5.57%). Multivariate regression analysis identified increasingly higher odds of each outcome measure as BMI increased. Conclusions. This study demonstrates the impact of obesity on postoperative complications is more profound for THA than TKA. This emphasizes the importance of considering patient comorbidities in the context of the specific procedure (hips and knees should be analyzed independently) when assessing risks of surgery

Introduction. Rapid recovery protocols after joint replacement have been implemented widely to decrease hospital length of stay (LOS). Minimally-invasive total knee arthroplasty (MIS-TKA) may facilitate rapid recovery for patients. Increased complications and LOS have been documented in morbidly obese TKA patients. The objective of the current study was to retrospectively evaluate the impact of morbid obesity on MIS-TKA patients. Methods. We conducted a retrospective chart review on patients that underwent MISTKA at a high volume orthopedic center between August 2012 and September 2015 (N = 4173). All surgeries were performed by one of six fellowship trained surgeons utilizing the same implant. MISTKA was performed utilizing a mid-vastus approach under tourniquet. All patients experienced rapid recovery protocols utilizing multi-modal pain management pathways, same day physical therapy, and absence of CPM machines. We evaluated patient age, gender, operative time, LOS, and 90-day readmission for morbidly obese (BMI≥40; n = 597), and non-morbidly obese (BMI<40; n = 3576) patients. Statistical analysis was conducted using Minitab 16 Statistical Software. Results. Morbidly obese patients had significantly higher mean LOS (1.74 days) compared to non-morbidly obese patients (1.62 days, p=0.035), and significantly higher 90-day readmissions (12.45% and 6.65% respectively, p= 0.001). In patients over the age of 65, with BMI under 40, females had significantly higher mean LOS than males (1.70 and 1.47 days respectively, p< 0.001). And in non-morbidly obese patients under the age of 65, females still experienced significantly higher mean LOS compared to males (1.35 and 1.11 days respectively, p<0.001). Conclusions. Our findings indicate that despite implementation of rapid recovery protocols, morbidly obese patients experienced significantly higher LOS than non-morbidly obese patients. Compared to their male counterparts, non-morbidly obese female patients had significantly higher LOS

Obesity and the diseases linked to it such as diabetes have been associated with higher complication rates and increased medical costs following total hip arthroplasty (THA). Due to the rising prevalence of obesity and the adverse impact it has on the development of osteoarthritis, there has been a worldwide surge in the number of obese patients presenting for THA procedures, including those morbidly obese (BMI > 40) and those who are super-obese (BMI > 50). The Reward. When THA is successful (as is true for the majority of morbidly obese patients) the operation is just as dramatically effective as it is for other patients. Excellent pain relief and dramatically improved function is the result, even though obese patients generally achieve a lower overall level of function than non-obese patients. Morbidly obese patients with a successful THA and without early complications are some of the most grateful of patients. This is especially true if they have been denied surgery for prolonged periods due to their weight and have had to bear severe joint changes and symptoms during a long period of time leading up to arthroplasty. The Risks. There is a nonlinear increase in complications, reoperations, and especially infection with increasing BMI that begins between a BMI of 25 to 30, and rises thereafter with a relative inflection point in some incidence curves for complications at around a BMI of 40. This has caused some surgeons to suggest a BMI of 40 as an upper limit for elective hip arthroplasty. Risks continue to rise after a BMI of 40 and when the BMI is over 50, in our series 52% of patients had at least one complication. Of these 24% had at least one major complication and 33% at least one minor complication with some suffering more than one complication overall. These data make it reasonable to ask whether the outcomes in some morbidly obese patients might be improved by weight loss, bariatric surgical intervention and other measures aimed at optimizing the multiple companion comorbidities and medical conditions (such as diabetes) that often accompany excess weight. Unfortunately there has been limited information to date on the best means for optimizing of these patients, and as important the effectiveness of these interventions, so that the timing and performance of the eventual arthroplasty procedures might have the highest possible success rate. The Costs. The adverse impact of obesity on medical resource utilization and costs associated with THA has been well documented, Due to longer initial length of stay, greater resource utilization, higher early complication rates and any readmissions and reoperations the costs for even a single individual patient can climb dramatically. In a review of data on primary THA patients from our institution, even after adjusting for age, sex, type of surgery, and other comorbidities, for every 5 unit increase in BMI beyond 30 kg/m2 there was an associated $500 higher cost of hospitalization and an increase of $900 in 90-day total costs (p=0.0001). The Future. The numbers of morbidly obese patients with severe osteoarthritis presenting for possible THA will only continue to increase in the years ahead. Comprehensive multidisciplinary programs are urgently needed to better manage obese patients with weight reduction options, optimization of medical comorbidities, and treatment of any associated issues, such as protein malnutrition. When end-stage joint changes and symptoms occur we must have such help to maximise the benefit and reduce the complications of hip arthroplasty in this high risk patient population

Obesity has been associated with degenerative osteoarthritis of knee joint The over all incidence of osteoarthritis of the knee is also more in patients with obesity. Increasing obesity leads to faster progression of OA, which is due to increased joint load. Body mass index (BMI), dividing an individual’s weight (in kg) by his or her height (in square meters). BMI: Normal = 18.5 to 24.9, Overweight BMI −25–29.9 Obese=30 to 39.9, Morbidly Obese BMI 40 or Greater. Recent article focused on the thigh girth of obese patients and opined that if thigh girth > 55cms, subvastus approach should not be utilized, as it is difficult to evert the patella. We believed that obesity should not really cause a problem for the patients undergoing a TKA with the mini subvastus approach as the anatomy of the quadriceps in the obese and the non-obese patient population is the same. We decided to evert the patella only after osteotomy of tibia and the femur. All patients who underwent primary total knee arthroplasty with minisubvastus approach between January 2006 to July 2007 and who were obese (BMI> 30) were included in our study. Out of 425 primary Total knee arthroplasty were performed during this period. Out of these, there were total 97 obese patients with 109 knees which form the part of the study. There were 81 females and 16 males and 12 patients had staged bilateral knee arthroplasty. The weight varied from 63 to 125 kgs. 91 patients had varus deformity of < 15 degree, 15 patients had varus deformity of > 15 degree, 3 patients had valgus deformity. The thigh girth in obese group (BMI: 30–40) ranged from 45 to 58 cms with average of 50.17. The thigh girth in morbidly obese (BMI > 40) group ranged between 55 to 67 with average of 61.01 cms. Mini-subvastus approach provided satisfactory exposure in all knees that were operated. In no case was this approach abandoned. The average surgical time was 90 minutes with range. The average blood loss was 400 cc. The patellar tracking was immaculate in every case and in fact it was difficult to displace patella laterally after 30 degrees of knee flexion. Our 89 patients had flexion of > 120 0,and 20 patients had flexion of > 90 but < 120. The knee society score improved from average 42 (range 17–62) preoperatively to 89 (range 72–95) post operatively. The Knee Society functional score improved from 48 (range 15–60) pre operatively to 65 (range 50–80) post operatively. Mini subvastus approach offers adequate intraoperative exposure even in obese and morbidly obese patients. It did not result in increased complications in our hands even in morbidly obese patients with higher thigh girth. It is extremely patient friendly and its wider use is recommended

Aims

Obesity is associated with an increased risk of hip osteoarthritis, resulting in an increased number of total hip arthroplasties (THAs) performed annually. This study examines the peri- and postoperative outcomes of morbidly obese (MO) patients (BMI ≥ 40 kg/m²) compared to healthy weight (HW) patients (BMI 18.5 to < 25 kg/m²) who underwent a THA using the anterior-based muscle-sparing (ABMS) approach.

Aims

This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists.

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.

Aims

Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability.

Aims

It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients.

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Aims

The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred.

Aims

Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment.

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.

Aims

As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients.

The results of 41 consecutive total knee replacements performed on morbidly obese patients with a body mass index > 40 kg/m², were compared with a matched group of 41 similar procedures carried out in non-obese patients (body mass index < 30 kg/m²). The groups were matched for age, gender, diagnosis, type of prosthesis, laterality and pre-operative Knee Society Score. We prospectively followed up the patients for a mean of 38.5 months (6 to 66). No patients were lost to follow-up. At less than four years after operation, the results were worse in the morbidly obese group compared with the non-obese, as demonstrated by inferior Knee Society Scores (mean knee score 85.7 and 90.5 respectively, p = 0.08; mean function score 75.6 and 83.4, p = 0.01), a higher incidence of radiolucent lines on post-operative radiographs (29% and 7%, respectively, p = 0.02), a higher rate of complications (32% and 0%, respectively, p = 0.001) and inferior survivorship using revision and pain as end-points (72.3% and 97.6%, respectively, p = 0.02).

Patients with a body mass index > 40 kg/m² should be advised to lose weight prior to total knee replacement and to maintain weight reduction. They should also be counselled regarding the inferior results which may occur if they do not lose weight before surgery.

We carried out a prospective, continuous study on 529 patients who underwent primary total knee replacement between January 2006 and December 2007 at a major teaching hospital. The aim was to investigate weight change and the functional and clinical outcome in non-obese and obese groups at 12 months post-operatively. The patients were grouped according to their pre-operative body mass index (BMI) as follows: non-obese (BMI < 30 kg/m²), obese (BMI ³ 30 to 39 kg/m²) and morbidly obese (BMI > 40 kg/m²). The clinical outcome data were available for all patients and functional outcome data for 521 (98.5%). Overall, 318 (60.1%) of the patients were obese or morbidly obese.

At 12 months, a clinically significant weight loss of ≥ 5% had occurred in 40 (12.6%) of the obese patients, but 107 (21%) gained weight. The change in the International Knee Society score was less in obese and morbidly obese compared with non-obese patients (p = 0.016). Adverse events occurred in 30 (14.2%) of the non-obese, 59 (22.6%) of the obese and 20 (35.1%) of the morbidly obese patients (p = 0.001).

We evaluated the outcome of primary total hip replacement (THR) in 3290 patients with the primary diagnosis of osteoarthritis at a minimum follow-up of two years. They were stratified into categories of body mass index (BMI) based on the World Health Organisation classification of obesity. Statistical analysis was carried out to determine if there was a difference in the post-operative Western Ontario and McMaster Universities osteoarthritis index, the Harris hip score and the Short-Form-12 outcome based on the BMI.

While the pre- and post-operative scores were lower for the group classified as morbidly obese, the overall change in outcome scores suggested an equal if not greater improvement compared with the non-morbidly obese patients. The overall survivorship and rate of complications were similar in the BMI groups although there was a slightly higher rate of revision for sepsis in the morbidly obese group.

Morbid obesity does not affect the post-operative outcome after THR, with the possible exception of a marginally increased rate of infection. Therefore withholding surgery based on the BMI is not justified.

Aims

The purpose of our study is to summarise the current scientific findings regarding the impact of obesity on total hip arthroplasty (THA); specifically the influence of obesity on the timing of THA, incidence of complications, and effect on clinical and functional outcomes.

We compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings.

Survival at five years using revision surgery as an endpoint, was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the non-obese group (p < 0.001). The morbidly obese patients had a higher rate of complications (22% vs 5%, p = 0.012), which included dislocation and both superficial and deep infection.

In light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life.

We audited the relationship between obesity and the age at which hip and knee replacement was undertaken at our centre. The database was analysed for age, the Oxford hip or knee score and the body mass index (BMI) at the time of surgery. In total, 1369 patients were studied, 1025 treated by hip replacement and 344 by knee replacement. The patients were divided into five groups based on their BMI (normal, overweight, moderately obese, severely obese and morbidly obese).

The difference in the mean Oxford score at surgery was not statistically significant between the groups (p > 0.05). For those undergoing hip replacement, the mean age of the morbidly obese patients was ten years less than that of those with a normal BMI. For those treated by knee replacement, the difference was 13 years. The age at surgery fell significantly for those with a BMI > 35 kg/m² for both hip and knee replacement (p > 0.05). This association was stronger for patients treated by knee than by hip replacement.

A prospective, multi-centre study was carried out on 1421 total hip replacements between January 1999 and July 2007 to examine if obesity has an effect on clinical outcomes.

The patients were categorised into three groups: non-obese (body mass index (BMI) < 30 kg/m²), obese (BMI 30 to 40 kg/m²) and morbidly obese (BMI > 40 kg/m²). The primary outcome measure was the change in Oxford hip score at five years. Secondary outcome measures included dislocation and revision rates, increased haemorrhage, deep infection, deep-vein thrombosis and pulmonary embolism, mean operating time and length of hospital stay. Radiological analysis assessing heterotopic ossification, femoral osteolysis and femoral stem positioning was performed. Data were incomplete for 362 hips (25.5%)

There was no difference in the change in the Oxford hip score, complication rates or radiological changes at five years between the groups. The morbidly obese group was significantly younger and required a significantly longer operating time. Obese and morbidly obese patients have as much to gain from total hip replacement as non-obese patients.