Total Knee Arthroplasty in Morbidly Obese Patients Treated With Bariatric Surgery: A Comparative Study

doi:10.1016/j.arth.2012.03.005

The Journal of Arthroplasty

Volume 27, Issue 9, October 2012, Pages 1696-1700

https://doi.org/10.1016/j.arth.2012.03.005 Get rights and content

Abstract

Our objective was to compare outcomes (anesthesia time, total operative time, tourniquet time, duration of hospital stay, 90-day complication rate, and transfusion rates) of patients with total knee arthroplasty (TKA) who underwent bariatric surgery before or after TKA. One hundred twenty-five patients were included: TKA before bariatric surgery (group 1; n = 39), TKA within 2 years of bariatric surgery (group 2; n = 25), and TKA more than 2 years after bariatric surgery (group 3; n = 61). Patients with TKA more than 2 years after bariatric surgery had shorter anesthesia and total operative and tourniquet times than other groups; differences were significant between groups. Ninety-day complication and transfusion rates approached but did not meet statistical significance. Ninety-day complication rates and duration of hospital stay did not differ significantly between the 3 groups. The level of evidence was level II (cohort study).

Section snippets

Materials and Methods

A retrospective review of prospectively gathered data was undertaken using our institutional registry. Before data review, institutional review board approval was obtained. The database was searched from 1996 through June of 2008, allowing for follow-up from 22 months to 14 years. Criteria for inclusion were patients fit for operative therapy and having undergone both bariatric surgery for weight loss as well as TKA. Patients who underwent gastric bypass or gastric banding procedures were

Results

One hundred twenty-five patients met the inclusion criteria and were included in this study. No patients were lost to follow-up. Patient demographic data included age, sex, BMI, and weight and height at TKA (Table 1). Significant differences were noted in BMI (P = .015), weight (P < .001), and height (P = .021) across the 3 groups by ANOVA; comparison of each group to each other is shown in the table. Patients who underwent TKA before bariatric surgery (group 1) differed significantly from the

Discussion

This study analyzed if weight loss surgery with bariatric surgery before TKA would mitigate risk to the patient. Our findings suggest that regardless of the temporal relationship between TKA and bariatric surgery, the complication rate is high. We chose to distinguish groups 2 and 3 from each other, with the idea that patients who undergo gastric bypass surgery are relatively catabolic and have a metabolic imbalance in the first 2 years after the weight loss surgery 16, 17, 18, 19. Dalcanale et

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Cited by (87)

Go Big or Go Home: Obesity and Total Joint Arthroplasty
2023, Journal of Arthroplasty
Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.
Bariatric surgery prior to elective shoulder arthroplasty: a Nationwide Inpatient Sample analysis
2023, Seminars in Arthroplasty JSES
Obesity has been linked to adverse outcomes after various orthopedic procedures, and bariatric surgery is an effective surgical treatment for morbid obesity. This study assesses whether prior bariatric surgery is associated with differences in hospital length of stay (LOS), discharge destination, and inpatient complication rate for elective shoulder arthroplasty.
The Nationwide Inpatient Sample database was queried from years 2003 to 2014 for all elective anatomic and reverse total shoulder arthroplasty cases. Two groups were defined: morbidly obese without prior bariatric surgery (MO cohort) and prior bariatric surgery without morbid obesity (BS cohort). Outcome measures were LOS (extended if greater than the 75th percentile), discharge destination (home or non-home), and any inpatient complication. Patients under age of 18 years and those with missing information were excluded. National estimates were calculated using weights provided by the Nationwide Inpatient Sample database. Chi-squared tests were performed for demographics and comorbidities. Binomial multivariate logistic regression was performed using significant demographics and comorbidities.
A weighted-total of 19,877 patients were included in the study, of which 2783 were in the BS cohort and 17,094 were in the MO cohort. The BS group was younger (62.9 years vs. 66.0 years), had more females (73% vs. 69%), and was more likely to be anemic (15% vs. 10%). The MO group was more likely to have diabetes (40% vs. 22%), hypertension (83% vs. 65%), and peripheral vascular disease (3% vs. 1%). Multivariate analysis showed that the BS cohort had decreased odds of extended LOS (odds ratio [OR], 0.68), non-home discharge destination (OR, 0.67), and developing any inpatient complication (OR, 0.42).
In the setting of anatomic and reverse total shoulder arthroplasties, patients with prior bariatric surgery and without morbid obesity had more favorable hospital LOS, discharge destination, and inpatient complication rate than morbidly obese patients with no prior bariatric surgery. Further studies are warranted to better elucidate the relationship between bariatric surgery and shoulder arthroplasty.
Bariatric surgery, osteoarthritis and arthroplasty of the hip and knee in Swedish Obese Subjects – up to 31 years follow-up of a controlled intervention study
2023, Osteoarthritis and Cartilage
To study the long-term effect of obesity and bariatric surgery on incidences of osteoarthritis and arthroplasty of hip and knee.
Hazard ratios (HR) and incidence rates (IR) of osteoarthritis and arthroplasty of hip and knee were studied in the prospective, controlled, non-randomized Swedish Obese Subjects (SOS) study (bariatric surgery group, n = 2007; matched controls given usual obesity care, n = 2040) and the SOS reference cohort (n = 1135, general population). Osteoarthritis diagnosis and arthroplasty for osteoarthritis were captured from the National Swedish Patient Register. Median follow-up time was 21.2 (IQR 16.4–24.8), 22.9 (IQR 19.1–25.7), and 20.1 years (IQR 18.7–20.9) for the control group, surgery group and reference cohort, respectively.
The surgery group displayed lower incidence of hip osteoarthritis (IR 5.3, 95% CI 4.7–6.1) compared to controls (IR 6.6, 95% CI 5.9–7.5, adjHR 0.83, 95% CI 0.69–1.00) but similar incidence of hip arthroplasty. Similar incidence of knee osteoarthritis was observed in the surgery group and controls, but knee arthroplasty was more common in the surgery group (IR 7.4, 95% CI 6.6–8.2 and 5.6, 95% CI 4.9–6.4, adjHR 1.45, 95% CI 1.22–1.74). The reference cohort displayed lower incidences of osteoarthritis and arthroplasty of hip and knee compared with the surgery group and controls.
Bariatric surgery did not normalize the increased risk of knee and hip osteoarthritis in patients with obesity but was associated with an increased incidence of knee arthroplasty compared to the control group. With the limitations inherent to the present data, additional studies are needed to confirm these results.
clinicaltrials.gov Identifier: NCT01479452.
A Multidisciplinary Approach to the Nonambulatory Bariatric Patient With Bilateral Knee Osteoarthritis
2023, Arthroplasty Today
Obesity and lower-extremity arthritis are challenging problems to address as they are often mutually exacerbating. Due to the known perioperative risk of morbid obesity, the modality and timing of weight loss prior to arthroplasty is debated. We present a case of a 55-year-old nonambulatory female patient with an initial body mass index of 80.3 kg/m². This individual underwent a staged bariatric and joint replacement surgical pathway employing personnel of differing treatment disciplines. Our patient successfully lost a substantial amount of weight and has been able to ambulate, exercise, and engage in new, strenuous physical activities. In the care of the nonambulatory bariatric patient, employing a multidisciplinary treatment plan can produce successful results.
2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery
2022, Surgery for Obesity and Related Diseases
Major updates to 1991 National Institutes of Health guidelines for bariatric surgery
- •
  Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) ≥35 kg/m², regardless of presence, absence, or severity of co-morbidities.
- •
  MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m².
- •
  BMI thresholds should be adjusted in the Asian population such that a BMI ≥25 kg/m² suggests clinical obesity, and individuals with BMI ≥27.5 kg/m² should be offered MBS.
- •
  Long-term results of MBS consistently demonstrate safety and efficacy.
- •
  Appropriately selected children and adolescents should be considered for MBS.
Does bariatric surgery really benefit patients before total knee arthroplasty? A systematic review and meta-analysis
2022, International Journal of Surgery
At present, whether bariatric surgery before total knee arthroplasty (TKA) affects the prognosis of subsequent TKA has been a topic of debate in the academic community. The primary purpose of this systematic review and meta-analysis was to investigate the effect of previous bariatric surgery on prosthetic revisions and postoperative complications after TKA.
We included prospective and observational studies published in English involving patients who had undergone bariatric surgery prior to TKA and compared them with morbidly obese patients with no history of bariatric surgery. The Newcastle-Ottawa Scale was used to assess the methodological quality of non-randomized case-control studies. The outcomes included revisions, infections, venous thromboembolism (VTE), blood transfusion, mortality, stiffness or manipulation under anesthesia (MUA), and medical complications.
Of the 9 included studies with 166047 patients, 4 were matched cohort studies, 2 were unmatched cohort, and 3 were database studies. Methodological quality was high in ten studies and moderate in thirteen studies. Our analysis demonstrated that patients with TKA who had undergone prior bariatric surgery were associated with increased risks of long-term revision, long-term infection, long-term stiffness or MUA and blood transfusions, whereas prior bariatric surgery did not increase the risk of short-term complications and short-term revision.
This meta-analysis highlights the risks of bariatric surgery prior to TKA and suggests that prior bariatric surgery may increase the risk of perioperative blood transfusion and also the risk of revision and infection in long-term follow-up. Surgeons can use this information to help counsel patients undergoing bariatric surgery before primary TKA.

View all citing articles on Scopus

: The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2012.03.005.

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Published by Elsevier Inc.

Total Knee Arthroplasty in Morbidly Obese Patients Treated With Bariatric Surgery: A Comparative Study

Abstract

Section snippets

Materials and Methods

Results

Discussion

J Arthroplasty

Surg Obes Relat Dis

Gastroenterol Clin North Am

Surgeon

J Arthroplasty

J Arthroplasty

Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association

Circulation

Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement

Am J Clin Nutr

Health implications of obesity: an NIH Consensus Development Conference

Int J Obes

Effects of physical activity, body mass index, waist-to-hip ratio and waist circumference on total mortality risk in the Swedish National March Cohort

Eur J Epidemiol

Obesity increases the likelihood of total joint replacement surgery among younger adults

Int Orthop

Role of obesity on the risk for total hip or knee arthroplasty

Clin Orthop Relat Res

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Results of Roux-en-Y gastric bypass in morbidly obese vs superobese patients: similar body weight loss, correction of comorbidities, and improvement of quality of life

Arch Surg