Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

Total Knee Replacement Fact: Obesity Puts Patients at Risk

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obesity and total knee replacement

Much is said about Total Knee Replacement. While many agree that it is a perfectly safe procedure, there are those who say that the surgery can be risky. One of the most common factors that increase the risk for knee replacement is obesity. There is a circulating belief that people who are obese are not fit to undergo TKR. There is higher risk for complications for patients who are obese, they say. How true is this and if so, what are the possible serious complications? Let us find out.

Let us take a closer look into this study conducted by Mayo Clinic which was published in 2016. The study seeks to the address the following question: Is Total Knee Replacement a more risky procedure in patients with high body mass index (BMI)? Luckily, this was answered in the same study.

The study used and reviewed the data of 22,000 patients who underwent Total Knee Replacement. The average BMI of the patients is 31. Out of the 22,000 patients included in the study, 5,500 have a BMI above 35. Based on the results of the study, there was an increased rate of repeat knee surgery (including revision total knee replacement surgery) as well a striking increase of knee joint infection, a serious complications in the morbidly obese group (BMI 35-40).

Complications arose following the Total Knee Replacement among the patients belonging to this group. This answers the question as to the complications that obese patients might encounter after undergoing TKR.

However, in the same study, it has been noted that the risk for complication can be minimized by delaying surgery until obesity and other modifiable risk factors are reversed. While obese patients are at risk for complications when undergoing the procedure, the case is not totally hopeless. In fact, the case can be remedied and these patients can still continue with their treatment with less risk. The risks can be minimized through best practices. This calls for experienced and reliable professionals. If the surgeons employ best practices and proven strategies, they can maximize patient outcomes and surgical success, as well as minimize risk for serious complications among obese patients. In other words, the key to lowering or totally eliminating the risk for such patients during and following TKR is to have the procedure conducted only by trusted and proven professionals.

So if you are obese and you have knee problems, don’t consider yourself as a hopeless cause. You can still have your knee issue fixed without having to worry about serious complications following the knee replacement. As already said, it’s just a matter of employing best practices With the right preparation and right measures before, during a and after the procedure, you will have a successful TKR operation. To reiterate, the key to a successful surgery is a reliable, trustworthy and experienced surgeon.

If you are obese and are having doubts whether to continue with the procedure or not, give us a call. You do not have to look further to find the right surgeon who can ensure a successful, risk-free procedure. We know exactly what needs to be done and what’s appropriate for you and your condition. Our surgeon has the right experience, expertise, knowledge, practices and passion for this kind of procedure to work. Make an appointment with us today for a consultation.

Improving Total Knee Replacement Surgery Results: Optimize Risk Factors PreOp

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Knee surgery risks photo

One way of improving the results of Total Knee Replacement Surgery is to optimize the risk factors. The common patient risk factors include the following: uncontrolled diabetes (Blood Sugar >150, HbA1C>8), Smoking, Obesity (BMI > 40), Opioid use, and Kidney disease. All these risk factors should be corrected prior to having the surgery.

There are treatments available to reverse these risk factors. Uncorrected, the above listed factors increase the chance a patient will suffer an prosthetic joint infection, a return to the operating room for another knee procedure, wound healing problems, revision knee surgery or an unsatisfactory surgical result.

Knee Replacement Surgery Risks

Like any other surgery, total knee replacement carries some risks. However, the occurrence of these risks is quite low: infection, nerve damage, stroke or blood clot. The aforementioned risks are those that might occur during or after the surgery. What we are going to focus on are the factors that might affect the outcome of the surgery. Such factors or risks must be corrected before the surgery is conducted. They include the following: uncontrolled diabetes, smoking, obesity, opioid use and kidney disease.

Uncontrolled Diabetes

  • The Risks

According to a number of studies, people with diabetes face a higher risk of postsurgical complications. The possible complications that a patient may experience if he/she undergoes a surgery such as total knee replacement with uncontrolled diabetes are the following: joint loosening, fracture around the implant, blood clot, stroke and wound infection.

  • The Treatment

Diabetes is an important consideration before a patient undergoes a surgical procedure. The research suggests that patients need to control their diabetes before undergoing a major surgery such as total knee replacement. While your blood sugar will be tightly monitored right before and after surgery, it’s up to you to make the long-term lifestyle changes necessary to ensure you get the best outcome. This is an important conversation to have with both your surgeon and the physician or provider who helps you manage your diabetes. Eating well and exercising (if appropriate and with approval from your providers) can help you get your body ready for surgery.

Smoking

  • The Risks

Research shows that there is a correlation between smoking and the success of knee surgery. Some studies put the chance of redoing the surgery at a rate ten times higher in smokers than in non-smokers. Smokers also show higher rate of surgical complications which include blood clots, kidney problems, urinary tract infections, and abnormal or irregular heartbeats. This is because nicotine constricts the blood vessels, which interfere with and affect the healing process.

  • The Treatment

The best way to get rid of the risks is to quit smoking. You may have tried to do so in the past and not found success, but if you’re going to have total knee replacement surgery, let this be the big push you need to finally quit. In addition to the possibility of increased post-surgical complications, just imagine trying to find a place to smoke while you’re recuperating. Talk with your primary care provider about available techniques and support.

Obesity

  • The Risks

Obesity is the root of various health conditions and diseases like type 2 diabetes, obstructive sleep apnea, cardiovascular diseases, hypertension and metabolic syndrome.  All these conditions increase the risk of knee replacement surgery. Aside from these, patients with obesity are also more at risk to experience the following postsurgical risks: blood clots, difficulty breathing, poor and slow wound healing, infection and pulmonary embolism.

  • The Treatment

To lower the risks and to promote a better result, patients with obesity are advised to lose some weight. It is important that the patient is in good health and weight prior the surgery. Try hard to lose some weight and eat healthy before the scheduled surgery. Your immediate post-surgical health will improve—and along with your new knee, being in better shape will give you a new lease on life.

Opioid Use

  • The Risks

One of the total knee replacement precautions a patient must know concerns opioid use.  One study showed chronic opioid use before a total knee arthroplasty led to worse outcomes for patients, including “longer hospital stays, more postoperative pain, and higher complication rates… [patients] were also more likely to need additional procedures, require referrals for pain management, suffer from unexplained pain or stiffness, and have lower function and less motion in the replaced knee.”

  • The Treatment

The FDA suggests that patients undergoing knee replacement surgery should decrease the duration and amount of opioid use. There are many other pain management treatments available besides opioids, and you should explore them with your pain management physician—not just because of your surgery, but because chronic opioid use itself brings a whole host of problems you don’t want.

Kidney Disease

  • The Risks

Patients with kidney disease, particularly chronic renal disease, have increased risk for readmission after the surgery. The success of knee replacement surgery is also low and the occurrence of common complications is high among patients with kidney problems.

  • The Treatment

If you have kidney disease and need to have surgery—any kind of surgery—you and the doctor managing your disease, as well as the surgeon, need to work closely together to assess your risk and make sure surgery is the right course for you. If you and your providers move ahead, techniques like post-operative dialysis, substituting or changing the normal dose of medications like antibiotics given before and during surgery and avoiding pain medications that are known to cause problems are all good strategies to keep you healthy.

Reducing Total Knee Replacement Complications

We, the patient and the doctor, both want something in common. That is, the best outcome possible of the surgery. Knowing how to reduce the complications is powerful information. It is very important that you follow the tips mentioned in this article and control the risks mentioned to improve the results of your total knee replacement surgery.

If you’re contemplating knee replacement, schedule an appointment to see me and the rest of the team here at Advanced Knee Care. Assessing your needs and the appropriate treatment for you is our top priority.

Obesity and Joint Replacement Surgery: What You Need to Know

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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.

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