Obesity and Joint Replacement Surgery

Orthopedic Surgeons do not possess the tools or the clinical skills needed to guide patients in the treatment of obesity. I am a knee specialist in Scottsdale, Arizona, and I face this dilemma daily. The Hippocratic Oath instructs physicians to “do no harm” to the people we treat.

Morbid Obesity, defined as a BMI (body mass index) of greater than 40, is a proven risk factor for adverse events before, during and after orthopedic surgery. There is an increased likelihood of knee infections, blood clots, wound healing problems, reoperation and readmission to the hospital. There are specific anesthesia risks such as vascular access (harder IV placement), accurate vital sign monitoring (usually need arterial line), harder breathing tube placement, difficulty getting oxygen into the lungs, and problems with safe positioning on operating room tables. Finally, there is a greater chance for serious heart and lung problems during and in the days following surgery. Patients with normalized body weight are more likely to have an uneventful surgery free of complications. For the stated reasons, I embrace the Hippocratic Oath and avoid joint replacement surgery in my patients with morbid obesity.

The paradox is apparent – we, the medical community, are not smart enough to help our patients afflicted with obesity to overcome their disease. Sadly, modern medicine does not have a predictable treatment for obesity.

Orthopedic Surgeons do not possess the tools or clinical skills needed to guide patients in the treatment of obesity. Race, ethnicity and gender contribute to the obesity epidemic in poorly understood ways. Cultural differences between blacks, caucasians and latinos need to be better defined for treatment programs to be successful.

In America there is a lack of knowledge as to how to best incorporate a variety of medical and non medical specialists to combat obesity. There is no network of treatment resources to address the multitude of obstacles obese patients require to treat malnutrition and psychological disease (anxiety/depression). For some, socioeconomic inequalities such as lack of healthy food marketplaces and lack of public places to safely exercise propagate the problem.

Obese patients know they have a life threatening disease. Obese patients do not want to be heavy. America must come together to find answers to treat our sickest citizens. The answer lies in finding ways to alter cultures, environments, economics, and education. We have to do better. Neglect is not a treatment plan. Knee arthritis surgery is not the first step in the treatment plan for curing obesity because it is not safe to perform major surgical procedures on our morbidly obese patients – the health risk is too great.

I believe the orthopedic surgeon should optimize patient function with mobility assist devices such as bracing, canes, walkers, scooters and Segway’s. We will manage pain with oral and topical medications, knee injections, and low impact land and water based exercise. As always we will provide our patients with clear rational, reasoning as the basis for our recommendations and treatments.

Orthopedic surgeons need help from our medical colleagues. Patients will need treatment of the emotional component of their disease. We suggest the patient explore culturally specific guidance. Some of our patients need guidance with shopping and eating healthier. It is the duty of health professionals to mandate exercise.

Lastly, as physicians, we offer support, encouragement and guidance. Our American system has to do better – Our Patients Need Help.

Infection Risk After Knee Replacement Skyrockets in Morbidly Obese

The benefits of joint replacement should be carefully considered since there is a high risk of infection when joint replacement is performed in patients that are morbidly obese (defined as BMI > 30).

Study from July 2012 Journal of Bone and Joint Surgery.

Infection rate if normal weight is 4 in one thousand cases.

Infection rate if morbidly obese is 1 in ten cases.

A morbidly obese person is 25 times more likely to suffer an infection after joint replacement.
These risks are even higher if there is both Diabetes and Obesity.

The mental, physical and monetary cost to treat an infected total joint include minimum 2 more surgeries including removal of implant for a period of months, mobility with a walker, hard to drive and go to work for months, intravenous antibiotics for 4-8 weeks, and cost is at least $50,000 “extra” compared to no infection.

Current best practices recommend advising most patients to optimize body weight and exercise to improve leg function prior to Total Joint Replacement surgery. There are rare exceptions when the benefits of surgery warrant taking such a high risk.

Obesity Doubles Failure Rates After Total Knee Replacement

Complications after Total Knee Replacement (TKR) can require reoperation, implant removal, and months of intravenous antibiotics and months off work. Avoidance of complications include Patient Health Optimization to address and correct risk factors known to lead to adverse outcomes prior to surgery. It makes sense for the patient and it makes sense for society (cost and loss of productivity burden is high with TKR complications).

From J Bone Joint Surg Am, 2012 Oct .

Obesity (body mass index ≥30 kg/m²) is a well-documented risk factor for the development of osteoarthritis. An increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades.

Infection occurred more often in obese patients, with an odds ratio of 1.90. Deep infection occurred more often in obese patients, with an odds ratio of 2.38. Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason. Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30.
Conclusions:

Obesity had a negative influence on outcome after total knee arthroplasty.

Patient Health Optimization: Why You Have To Lose the Weight Before Knee Surgery

Patient Health Optimization is the most significant issue patients and their Orthopedic Surgeons face today.

Optimize body weight, control diabetes and stop smoking.

Why ?

Show the doctor that you are willing to help yourself by losing weight and exercising regularly – if you can not help yourself with weight loss and exercise prior to surgery studies shows it is unlikely that you will be able to make these changes after the surgery. Surgeons are unlikely to initiate a treatment path that has a high likelihood of a poor result or a serious complication.

Better outcomes: Studies show higher satisfaction rating by patients with optimal health status.

Lower chance of complications: If a patient has the above risk factors which are out of control the chances of problems/pain after Knee Replacement with a Failure of the Surgery (instability, bone fracture, continued pain, infection) are a strong possibility. IT IS NOT EVEN WORTH TRYING THE SURGERY IF THE ABOVE FACTORS EXIST – a disappointing result is to be avoided.

Live longer: Above risk factors shorten life expectancy up to 6 years.

Feel Better: This speaks for itself – if your health is optimized you feel better and will live a happier life.

How to Lose Weight on your own:

Change your behavior patterns regarding eating and exercise
Eliminate wasted calories – Soda/Sweetened drinks is number one
Keep a record of what you eat – Food Journals are shown to be effective way to help with weight loss.

Whether your knee hurts or not – Exercise 30 minutes every day – even if you are tired or do not have time.

Stefan D. Tarlow MD

Dr. Tarlow is the only Orthopedic Surgeon to limit his practice to encompass Adult Reconstruction and Sports Medicine for the diagnosis and treatment of knees. Dr. Tarlow’s practice focuses on excelling in the art of Knee Diagnosis and Surgery. He performs the full spectrum of Knee Surgery from Knee Arthroscopy, ACL Reconstruction, Patellar Stabilization and Cartilage Restoration to Makoplasty Partial Knee Replacement to Total Knee Replacement to Revision Total Knee Replacement. His focus is exceptional customer service and he endeavors to exceed the diverse expectations of his patients.

Comments

Deedee Lewis says

September 29, 2017 at 8:56 pm

I am doing a report on obesity for college and was surprised to find out that the infection rate from a joint replacement surgery is so much higher for obese people than normal weight individuals. It is understandable now that some patients have to lose weight before they can have their joint replacement surgery. Thank you for a very informative article on joint replacement.

Susan Mulkern says

October 10, 2017 at 3:22 pm

Reading this article confirmed my worst fears regarding knee replacement surgery. In addition to being obese, I have chronic venous insufficiency in the very leg I need the knee replacement. Add to this the fact that I have Factor V Leiden and an extensive blood clotting history. I have been in severe pain for almost two years now. I take Percocet; have had injections that do not work, and my knee is now beginning to buckle on me unexpectedly. I have been told I would not have a successful knee replacement and the outcome would not be good. The same doctor stated I could die or, worse yet, lose my leg. I am 67. Maybe I am the patient who should look into a scooter and put this idea of replacement behind me and try to live the best life I can.

- Stefan D. Tarlow MD says
  
  April 20, 2018 at 12:44 pm
  
  Susan, you are quite asutue. As much as we want to help you surgery is not always the answer. Complications after TKA are devastating. High risk patients such as your self are often better served with non surgical treatments.
  
Laura A says

March 20, 2018 at 6:09 pm

You put EVERYTHING you say above into question by using such a demeaning, fat-shaming cartoon that insists that people dealing with weight issues just need to do a little exercise.

I used to exercise 10-15 hours a WEEK (swimming, pilates, racquetball, bellydancing, cardio, and weights, WITH a personal trainer). Over six months I lost 5 of my 270 pounds. At the time, I was eating a diet of less than 1000 calories a day.

Clearly, it’s a lot more complicated than just the “eat less and exercise more I get from doctors who eat MORE and exercise LESS than I do–or did until my knees went. Now, I cannot get a knee replacement and I cannot exercise. But boy, your cartoon just made EVERYTHING better.

Do no harm indeed…

- Stefan D. Tarlow MD says
  
  April 20, 2018 at 12:27 pm
  
  I appreciate your constructive feedback. The cartoon has been eliminated. My goal is to help, not demean people. These are complicated issues that have far reaching implications for our society and health care system . We all need to do our best.
  
John Myers says

May 29, 2019 at 8:06 pm

If all you say is correct, why has the new studies shown that Morbidly Obese did as well as others? Here are a couple of sites:

https://healthfully.com/347183-success-of-obese-people-knee-replacements.html
https://www.hss.edu/newsroom_knee-replacements-morbidly-obese-individuals.asp

My obese aunt had replacement (both knees) going on two years ago and doing fine.
If there is structural integrity and no major health concerns (heart, cardio, etc.), why wouldn’t the obese be as successful as any other. The health issues that are are pointed to omit the obese from TKR could also be an issue with any other group.

Sorry if I sound critical but some general clarification would help.

Dana Walker says

June 8, 2019 at 9:44 pm

My surgery was to be in 10 days .
The surgeon and the PA saw me in April when I was in excruciating pain.
They both scheduled me for surgery .
They also weighed me that day .
Now after my preop tests , I receive a call saying I’m too above the BMI ( yes I am a whale of a fatty ) and that the risks are too high .
I can’t lose the 20-45 pounds in 10 days .
My frustration is high .
My life has stopped completely because I can’t walk .
They saw me in April and said nothing .
Now two months later if I had known I could have maybe lost the 20 pounds.
I believe in the risks and I’m nervous about them .
Now they are talking about Coumadin.
I also believe that overweight folks do not receive the same level of communication as al weight
If I go the doctor for any reason , the reason is always a weight one.
For example the flu is not weight driven except for fat people.
Your article speaks to the risks for treatment .
As a healthcare professional I understand .
However your tone is not a compassionate one nor is it very understanding .
To ask someone to live with crippling pain is very disheartening .

Obesity and Joint Replacement Surgery: What You Need to Know