Aims. We compared the outcome of total hip arthroplasty (THA) in obese patients who previously underwent bariatric surgery and those who did not, in a matched cohort study. Patients and Methods. There were 47 THAs in the bariatric group (42 patients), and 94 THAs in the comparison group (92 patients). The mean age of the patients was 57 years in both groups (24 to 79) and 57% of the patients in both groups were women. The mean time between bariatric surgery and THA was five years (four months to 12 years) in the bariatric group. The mean follow-up after THA was three years (2 to 9). . Results. The mean BMI improved from 49.7 kg/m. 2. (35 to 75) prior to bariatric surgery to 35.3 kg/m. 2 . (21 to 49) at the time of THA (p < 0.001). Patients in the comparison group had an increased risk of re-operation (Hazard Ratio (HR) 3.2; 95% confidence intervals (CI) 1.3 to 9.5, p = 0.01) and revision (HR 5.4; 95% CI 1.5 to 34.5, p = 0.01) when compared with the bariatric group. Conclusion. Patients had a dramatic improvement in BMI after bariatric surgery and those with prior bariatric surgery had a lower risk of re-operation and revision in the short- and mid-term after a subsequent THA. Larger prospective studies are required before it can be concluded that this extra surgery should be advised in these patients. Cite this article: Bone Joint J 2016;98-B:1180–4

Bariatric surgery has been advocated as a means of reducing body mass index (BMI) and the risks associated with total knee arthroplasty (TKA). However, this has not been proved clinically. In order to determine the impact of bariatric surgery on the outcome of TKA, we identified a cohort of 91 TKAs that were performed in patients who had undergone bariatric surgery (bariatric cohort). These were matched with two separate cohorts of patients who had not undergone bariatric surgery. One was matched 1:1 with those with a higher pre-bariatric BMI (high BMI group), and the other was matched 1:2 based on those with a lower pre-TKA BMI (low BMI group). In the bariatric group, the mean BMI before bariatric surgery was 51.1 kg/m. 2 . (37 to 72), which improved to 37.3 kg/m. 2. (24 to 59) at the time of TKA. Patients in the bariatric group had a higher risk of, and worse survival free of, re-operation (hazard ratio (HR) 2.6; 95% confidence interval (CI) 1.2 to 6.2; p = 0.02) compared with the high BMI group. Furthermore, the bariatric group had a higher risk of, and worse survival free of re-operation (HR 2.4; 95% CI 1.2 to 3.3; p = 0.2) and revision (HR 2.2; 95% CI 1.1 to 6.5; p = 0.04) compared with the low BMI group. . While bariatric surgery reduced the BMI in our patients, more analysis is needed before recommending bariatric surgery before TKA in obese patients. Cite this article: Bone Joint J 2015;97-B:1501–5

Aims. Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients. Methods. A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality. Results. From 156 potential studies, five were considered to be eligible for inclusion in the study. A total of 23 348 patients (657 who had undergone bariatric surgery, 22 691 who had not) were analysed. The evidence-base was moderate in quality. There was no statistically significant difference in outcomes such as superficial wound infection (relative risk (RR) 1.88; 95% confidence interval (CI) 0.95 to 0.37), deep wound infection (RR 1.04; 95% CI 0.65 to 1.66), DVT (RR 0.57; 95% CI 0.13 to 2.44), PE (RR 0.51; 95% CI 0.03 to 8.26), revision surgery (RR 1.24; 95% CI 0.75 to 2.05) or mortality (RR 1.25; 95% CI 0.16 to 9.89) between the two groups. Conclusion. For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are obese or morbidly obese. This finding is based on moderate quality evidence. Cite this article: Bone Joint J 2016;98-B:1160–6

Background. Total Knee Replacement (TKR) is technically demanding, time consuming and has higher complication rates in super obese (BMI>45) patients. Bariatric surgery can be considered for such patients prior to TKR although its effect on complications is unknown. Methods. All patients who underwent bariatric surgery and a TKR in the NHS in England between 2005 and 2009 were included. Hospital episode statistics data in the form of OPCS, ICD10 codes were used to establish 90-day DVT, PE and mortality rates (inpatient and outpatient). In addition, readmission to orthopaedics, joint revision and ‘return to theatre for infection’ rates were also established. Code strings for each patient were examined in detail to ensure the correct gastric procedures were selected. Fifty-three patients underwent bariatric surgery then TKR (44-1274 days) (group 1). Thirty-one patients underwent TKR then bariatric surgery (33-1398 days) (group 2). Results. In the 53 patients that underwent bariatric surgery first there was 1 DVT, no PE and 1 death at 90 days following knee replacement. There were no orthopaedic readmissions within one year of TKR, no revision at 18 months and no knee washouts for infection. In the 31 patients that underwent TKR first there were no DVT, PE or deaths at 90 days. There were four orthopaedic readmissions (12%) within 30 days of TKR and two infections of the knee replacement. Overall, one-year infection rate and readmission were higher if TKR was performed prior to the bariatric surgery. The statistical analysis is difficult due to small number of patients. Conclusions. This data suggests that timing of bariatric surgery appears to be crucial. Although complication rates appear high in patients who undergo both procedures, performing bariatric surgery first appears to reduce that risk of local complications

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

The August 2024 Knee Roundup. 360. looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis; Aspirin triumphs in knee arthroplasty: a decade of evidence; Efficacy of DAIR in unicompartmental knee arthroplasty: a glimpse from Oxford

The April 2023 Knee Roundup. 360. looks at: Does bariatric surgery reduce complications after total knee arthroplasty?; Mid-flexion stability in total knee arthroplasties implanted with kinematic alignment: posterior-stabilized versus medial-stabilized implants; Inflammatory response in robotic-arm-assisted versus conventional jig-based total knee arthroplasty; Journey II bicruciate stabilized (JII-BCS) and GENESIS II total knee arthroplasty: the CAPAbility, blinded, randomized controlled trial; Lifetime risk of revision and patient factors; Platelet-rich plasma use for hip and knee osteoarthritis in the USA; Where have the knee revisions gone?; Tibial component rotation in total knee arthroplasty: CT-based study of 1,351 tibiae

Aims. The aim of this study was to observe the implications of withholding total joint arthroplasty (TJA) in morbidly obese patients. Patients and Methods. A total of 289 morbidly obese patients with end-stage osteoarthritis were prospectively followed. There were 218 women and 71 men, with a mean age of 56.3 years (26.7 to 79.1). At initial visit, patients were given information about the risks of TJA in the morbidly obese and were given referral information to a bariatric clinic. Patients were contacted at six, 12, 18, and 24 months from initial visit. Results. The median body mass index (BMI) at initial visit was 46.9 kg/m. 2. (interquartile range (IQR) 44.6 to 51.3). A total of 82 patients (28.4%) refused to follow-up or answer phone surveys, and 149 of the remaining 207 (72.0%) did not have surgery. Initial median BMI of those 149 was 47.5 kg/m. 2. (IQR 44.6 to 52.5) and at last follow-up was 46.7 kg/m. 2. (IQR 43.4 to 51.2). Only 67 patients (23.2%) went to the bariatric clinic, of whom 14 (20.9%) had bariatric surgery. A total of 58 patients (20.1%) underwent TJA. For those 58, BMI at initial visit was 45.3 kg/m. 2. (IQR 43.7 to 47.2), and at surgery was 42.3 kg/m. 2. (IQR 38.1 to 46.5). Only 23 patients (39.7%) of those who had TJA successfully achieved BMI < 40 kg/m. 2. at surgery. Conclusion. Restricting TJA for morbidly obese patients does not incentivize weight loss prior to arthroplasty. Only 20.1% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and coordinated care are required to optimize patients prior to surgery. Cite this article: Bone Joint J 2019;101-B(7 Supple C):28–32

Given the growing prevalence of obesity around the world and its association with osteoarthritis of the knee, orthopaedic surgeons need to be familiar with the management of the obese patient with degenerative knee pain. The precise mechanism by which obesity leads to osteoarthritis remains unknown, but is likely to be due to a combination of mechanical, humoral and genetic factors. . Weight loss has clear medical benefits for the obese patient and seems to be a logical way of relieving joint pain associated with degenerative arthritis. There are a variety of ways in which this may be done including diet and exercise, and treatment with drugs and bariatric surgery. Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen. . Surgery for osteoarthritis in the obese patient can be technically more challenging and carries a risk of additional complications. Substantial weight loss before undertaking total knee replacement is advisable. More prospective studies that evaluate the effect of significant weight loss on the evolution of symptomatic osteoarthritis of the knee are needed so that orthopaedic surgeons can treat this patient group appropriately.

The prevalence of Class III Obesity (BMI ≥ 40 kg/m25) in black women is 18%, three times the 6 national average. Class III obesity is associated with mobility limitations, particularly hip joint 7 deterioration. Therefore black women are highly likely to come to the attention of orthopedic 8 surgeons. Weight loss associated with bariatric surgery should lead to enhanced success of hip 9 replacements. However, we present a case of a black woman who underwent Roux-en-y gastric 10 bypass with the expectation that weight loss would improve her ambulation and if necessary 11 make her a better surgical candidate for hip replacement. Her gastric bypass was successful as her BMI declined from 52.0 kg/m2 to 33.7 kg/m212. However, her hip circumference post weight 13 loss remained persistently high. As a consequence, the soft tissue tunnel geometry presented 14 major challenges. The tunnel depth as well as the immobility of the soft tissue envelope 15 interfered with retractor placement, tissue reflection and adequate surgical access to the 16 acetabulum. Therefore a traditional cup placement could not be achieved. Instead, a 17 hemiarthroplasty was performed. Her pre-surgery Harris Hip Score was 17.0. In the first few 18 months post surgery there were improvements, specifically a decrease in pain and a decreased 19 reliance on external support. But her overall functional independence never improved. This case 20 is presented to raise awareness that improved BMI category post bariatric surgery is not 21 sufficient to guarantee that orthopedic risks have been minimized. Overall, weight loss does 22 improve both the metabolic profile and anesthesia risk, but the success rate of total hip 23 arthroplasties will be low if fat mass (i.e. high hip circumference) in the operative field remains 24 high. We are now repeatedly recognizing this problem but are not finding any case reports on 25 this issue. Therefore we provide a practical approach to evaluate these patients and describe 26 ways we have found to successfully address intra-operative challenges

C.D. Watts, J.R. Martin, M. T. Houdek, M. P. Abdel, D. G.Lewallen, M. J. Taunton Prior bariatric surgery may decrease the rate of reoperation and revision following total hip arthroplasty. Bone Joint J 2016;98-B:1180–1184

Introduction. Morbid obesity (BMI>40) is a significant risk factor for complications following total joint arthroplasty (TJA). As such many have a restrictive practice of withholding elective primary TJA in the morbidly obese. The purpose of this study was to observe the implications of this practice. Methods. From 2012 to 2014, 289 patients with morbid obesity and end-stage OA of the hip or knee were prospectively followed. At initial visit, patients were given a packet on risks of TJA in the morbidly obese and referral information to a weight loss clinic. Patients were contacted at 6, 12, 18 and 24 months from initial visit for PROs, and BMI changes. The average age of patients was 56 (26.7–79.1) there were 218 females and 71 males. Results. The average BMI at initial visit was 46.9 (39.9–68.2). 85 patients (29%) refused additional follow up or to answer phone surveys regarding their status. 146 patients (50.5%) have not had surgery. Initial BMI in this cohort was 47.4 (39.9–68.6) and at last follow up was 46.8 (28.9–70.8). Of those, 11 (7.5%) had a last follow up BMI≤40. Only 23% of patients went to the bariatric clinic and 13% had bariatric surgery. Fifty-eight patients (20.1%) underwent TJA. BMI at initial visit was 45.3 (40.3–55.4), and at the time of surgery was 41.3 (27.5–69.5). Only 20 patients (6.9% of those followed) have successfully achieved BMI < 40 and had surgery. Of those, 14 (70%) had a last follow up BMI≤40, and 2 (10%) had a last follow up BMI≤30. Conclusions. The practice of restricting total joint replacement to morbidly obese patients does not serve as an incentive to lose weight prior to arthroplasty. Only 20% of patients ultimately underwent TJA and the majority of those remained morbidly obese. Better resources and collaborative care among specialties is required to optimize patients prior to surgery

The following papers will be discussed during this session: 1) Staph Screening and Treatment Prior to Elective TJA; 2) Unfulfilled Expectations Following TJA Procedures; 3) Thigh Pain in Short Stem Cementless Components in THR; 4) Is the Direct Anterior Approach a Risk Factor for Early Failure?; 5) THA Infection - Results of a 2nd 2-Stage Re-implantation - Clinical Trial of Articulating and Static Spacers; 6) THA Revision - Modular vs. Non Modular Fluted Tapered Stems-Total Femoral Replacement for Femoral Bone Loss - Cage + TM Augment vs. Cup Cage for Acetabular Bone Loss; 7) Do Injections Increase the Risk of Infection Prior to TKA?; 8) Long-Acting Opioid Use Predicts Perioperative Complication in TJA; 9) UKA vs. HTO in Patients Under 55 at 5–7 years; 10) Stemming Tibial Component in TKA Patients with a BMI > 30; 11) The Effect of Bariatric Surgery Prior to Total Knee Arthroplasty; 12) Oral Antibiotics and Reinfection Following Two-Stage Exchange; 13) Two-Stage Debridement with Prosthetic Retention for Acute TKA Infections; 14) Patient-Reported Outcomes Predict Meaningful Improvement after TKA; 15) Contemporary Rotating Hinge TKA; 16) Liposomal Bupivacaine in TKA; and 17) Noise Generation in Modern TKA: Incidence and Significance

Obesity is a leading public health concern and it is increasing in prevalence over the last 20 years. Obesity prevalence has doubled in adults and tripled in adolescents. The United States is the leading country in terms of percent obesity. Most alarming is the fact that the fastest growing rates of obesity are in the highest BMI groups. The issue of obesity is a particular concern to arthroplasty surgeons since there is an association between the increasing incidence of obesity and the increasing rate of joint replacement. Also of concern is that obese patients tend to be younger and complication rates and revision rates are higher in young patients which is only compounded by the presence of obesity. The risk of virtually every major complication is substantially higher in obese patients. Of concern, however, is a recent study indicating that bariatric surgery with successful weight loss does not necessarily decrease the complication rate. Obesity is also associated with substantially higher costs. There is some evidence that obesity doesn't necessarily affect implant survival. There is also evidence that the clinical outcomes may not be substantially compromised by the presence of obesity. Based on data from studies such as this, some centers have stated that it is difficult to justify withholding surgery based on BMI alone. The data on weight loss following surgery indicates the vast majority of patients did not lose weight following joint replacement. In one study a higher proportion of patients gained weight than lost weight

Outcomes of THA after Hip Arthroscopy. Hip Injections and Rapidly Progressing Joint Degeneration. Procedure Duration Wound Complications & LOS. Losing Weight Following TKA and its Influence on Outcome. Radiographic Severity of Arthritis & Patient Satisfaction in TKA. Intra-wound Vancomycin Powder Reduces Infections in TJA. Increased Non-stemmed Tibial Failures with BMI ≥ 35. Influence of Component Alignment on Outcome in Varus TKA. New TKA Designs - Do Patients Notice?. Bariatric Surgery Prior to TKA Associated with Fewer Complication. Metal Sensitivity Correlates with Pain in Patients with TJA. Blood Culture Bottles vs. Swabs for Microbial Detection in PJI. I&D Prior to 2 Stage Revision TKA Doesn't Increase Risk of Failure. Outpatient Total Joint Leads to Substantial Burden of Phone Calls. Wear and lysis of HXL Sockets: Effect of Head Size @ 10–14 Years. Surface Finish & Survivorship of Cemented Stems in THA. Patient Reported Outcome as a Tool for Appropriateness in THA. Neuraxial Anesthesia and Post-op Complications and Transfusions

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

What are the data on obesity and THA risk? Which complications are elevated? If you decide on surgery, how can you minimise complications? These are timely questions because the rates of obesity are rising in the US and in many other parts of the world. Does obesity increase risk of THA complications? Answer: yes: at least for some complications. Complications which are increased: infection, wound healing, nerve injury; possibly: dislocation, periprosthetic fractures. The data are mixed on whether aseptic loosening and/or bearing surface wear problems are increased in the obese. Higher BMI may be offset by lower activity levels, particularly in a congruent joint such as the hip. Outcomes of THA in obese: Lower function scores and activity scores compared to nonobese. But good pain relief and the preoperative to postoperative change in functional scores is similar to non-obese. Is there a critical BMI threshold above which complications become unacceptable? Several studies show BMI ≥40 associated with strong risk of complications. One study from Mayo Clinic on patients with BMI ≥50 showed a 39% surgical complication rate, a 12% medical complication rate, and a high mortality rate in the several years after THA. Individualise operative decisions based on risk/benefit analysis for each patient. If you decide to operate, how can you minimise risk? Lose weight before surgery by diet: often ineffective, but worth trying. Lose weight before THA with bariatric surgery: effective in producing weight loss, but beware of the “malnourished” obese patient. In surgery: care with patient positioning, sufficient incision length, greater exposure, avoid sciatic nerve injury, fractures, care with acetabular component positioning, extra drains in subcutaneous tissue and wound compression. Engage patient in discussion of risks/benefits before surgery: shared decision making

Weight loss is commonly recommended as a treatment for back pain. However, there is little literature to support this. A recent systematic review has identified only studies relating to bariatric surgery. There are no other studies that address whether weight loss improves back pain. Forty-five consecutive consenting patients were recruited following enrolment in a tertiary multidisciplinary weight management program. These patients were referred primarily for treatment of obesity. The program consisted of consultation and on-going supervision by a sub-specialty weight management physician, and group and individual sessions addressing diet, exercise and behaviour modification. Patients were assessed by independent observers prior to start of program and at twelve weeks into the program with standardised and validated outcomes tools measuring baseline factors, back pain and related functional disability at twelve weeks follow-up. Prior to starting the program, forty-two patients (93%) reported some degree of low back pain of which 40% rated their pain as moderate (n = 12) or severe (n = 6). Using the Oswestry Low Back Pain Disability Index, 73% patients reported moderate (n = 18) or severe disability (n = 15). At twelve weeks, thirty-seven (82%) patients were available for assessment. There were significant improvement in VAS pain scores (mean change = 1.5, 95% CI: 0.7 to 2.4) and in Oswestry Low Back Disability Index (mean change= 8.6, 95% CI: 3.9 to 13.2). There were significant reductions in the prevalence of moderate or severe back pain (p = 0.04) and moderate or severe disability (p = 0.007) in the entire group. This is the first study to provide empirical evidence on the positive effects of a weight loss program on back pain. These results lay the groundwork for longer follow-up and comparative studies

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.