Bariatric Surgery Prior to Total Knee Arthroplasty is Associated With Fewer Postoperative Complications

doi:10.1016/j.arth.2014.11.039

The Journal of Arthroplasty

Volume 30, Issue 9, Supplement, September 2015, Pages 81-85

https://doi.org/10.1016/j.arth.2014.11.039 Get rights and content

Abstract

This study used a national database to compare 90 day postoperative complication rates between three groups of patients who underwent total knee arthroplasty (TKA): (1) non-obese patients (n = 66,523), (2) morbidly obese patients who did not have bariatric surgery (n = 11,294) and (3) morbidly obese patients who underwent bariatric surgery prior to TKA (n = 219). Morbidly obese patients who underwent bariatric surgery prior to TKA had reduced rates of major (OR 0.45, P = 0.001) and minor (OR 0.61, P = 0.01) complications compared to morbidly obese patients who did not have bariatric surgery. Bariatric surgery prior to TKA appears to be associated with less risk of postoperative complications, although not to the same level as non-obese patients.

Section snippets

Materials and Methods

All data were derived from a publicly available database of patients, the PearlDiver Patient Records Database (www.pearldiverinc.com; PearlDiver Inc, Fort Wayne, Indiana). The database contains procedure volumes, demographics, and average charge information for patients with International Classification of Diseases, 9th Revision (ICD-9) diagnoses and procedures or Current Procedural Terminology (CPT) codes. Data for the present study were derived from the Medicare database within the PearlDiver

Results

A total of 78,036 unique patients who underwent TKA were identified from 2005 to 2011, including 66,523 non-obese patients, 11,294 morbidly obese patients who did not undergo bariatric surgery and 219 morbidly patients who underwent bariatric surgery for weight loss prior to TKA. Of the 219 patients who underwent bariatric surgery prior to TKA, 70 had their TKA within 1 year of bariatric surgery, 59 underwent TKA between 1 and 2 years after bariatric surgery and 90 underwent TKA more than 2 years

Discussion

Obesity has been demonstrated to increase the risk of postoperative complications after total knee arthroplasty in numerous previous studies 24., 26., 42., 43., 44., 31., 45., 46.. While bariatric surgery has emerged as an option for weight loss and comorbidity control in morbidly obese patients, existing literature regarding such procedures prior to total knee arthroplasty have failed to demonstrate a significant reduction in postoperative complications 38., 39., 40., 41.. The present national

Conclusions

Obesity and its associated medical comorbidities place patients undergoing TKA at a significantly increased risk for both major and minor postoperative complications. Previous studies have failed to demonstrate a significant reduction in postoperative TKA complication rates with preoperative bariatric surgery, likely due to low patient numbers. The present study demonstrates that bariatric surgery prior to TKA appears to be associated with less risk of postoperative complications, although not

References (48)

D.M. Nguyen et al.
The epidemiology of obesity
Gastroenterol Clin North Am
(2010)
T.R. Wessel et al.
Relationship of physical fitness vs body mass index with coronary artery disease and cardiovascular events in women
JAMA
(2004)
G. Hu et al.
Relationship of physical activity and body mass index to the risk of hypertension: a prospective study in Finland
Hypertension
(2004)
S.M. Odum et al.
National obesity trends in total knee arthroplasty
J Arthroplasty
(2013)
T.K. Fehring et al.
The obesity epidemic: its effect on total joint arthroplasty
J Arthroplasty
(2007)
R.S. Namba et al.
Obesity and perioperative morbidity in total hip and total knee arthroplasty patients
J Arthroplasty
(2005)
K.M. Flegal et al.
Prevalence and trends in obesity among US adults, 1999–2008
JAMA
(2010)
National Center for Health Statistics
Health, United States, 2013: With Special Feature on Prescription Drugs
(2014)
D.P. Guh et al.
The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis
BMC Public Health
(2009)
N. Hartemink et al.
Combining risk estimates from observational studies with different exposure cutpoints: a meta-analysis on body mass index and diabetes type 2
Am J Epidemiol
(2006)

D.W. Haslam et al.

Obesity

Lancet

(2005)

L. Khaodhiar et al.

Obesity and its comorbid conditions

Clin Cornerstone

(1999)

P. Koh-Banerjee et al.

Changes in body weight and body fat distribution as risk factors for clinical diabetes in US men

Am J Epidemiol

(2004)

K.M. McTigue et al.

Obesity in older adults: a systematic review of the evidence for diagnosis and treatment

Obesity (Silver Spring)

(2006)

F.X. Pi-Sunyer

Comorbidities of overweight and obesity: current evidence and research issues

Med Sci Sports Exerc

(1999)

K.M. Rexrode et al.

Abdominal adiposity and coronary heart disease in women

JAMA

(1998)

A.R. Folsom et al.

Associations of general and abdominal obesity with multiple health outcomes in older women: the Iowa Women's Health Study

Arch Intern Med

(2000)

I. Janssen et al.

Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines

Arch Intern Med

(2002)

L.L. Boland et al.

Hyperinsulinemia, dyslipidemia, and obesity as risk factors for hospitalized gallbladder disease. A prospective study

Ann Epidemiol

(2002)

T. Kurth et al.

Prospective study of body mass index and risk of stroke in apparently healthy women

Circulation

(2005)

K.M. Rexrode et al.

A prospective study of body mass index, weight change, and risk of stroke in women

JAMA

(1997)

C.I. Ardern et al.

Discrimination of health risk by combined body mass index and waist circumference

Obes Res

(2003)

S. Salih et al.

Obesity, knee osteoarthritis and knee arthroplasty: a review

BMC Sports Sci Med Rehabil

(2013)

J.W. Bijlsma et al.

Osteoarthritis: an update with relevance for clinical practice

Lancet

(2011)

Cited by (73)

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.
An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty
2023, Orthopedic Clinics of North America
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.
Clinical Outcomes of Bariatric Surgery Before Spinal Fusion: A Systematic Review
2023, World Neurosurgery
Morbidly obese patients are at increased risk for intraoperative and postoperative complications following spinal fusion. Preoperative weight loss can improve clinical outcomes. The present systematic literature review is aimed to evaluate the hypothesis that bariatric surgery before spinal fusion surgery is associated with higher rates of complications and revisions.
Three databases were queried for literature pertaining to bariatric surgery prior to spinal fusion. A 2-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Methodologic index for non-randomized studies criteria was used to objectively assess the methodologic quality of the studies reviewed. Retrospective cohort studies in which the patients underwent bariatric surgery were included.
Four retrospective cohort studies consisting of a total of 180,090 patients were included. Length of stay was significantly shorter for the bariatric surgery (BS) group patients than the control (C) groups patients (P = 0.009). There were no significant differences in 1-year mortality rate (P = 1.0), readmission rate (P = 0.86), overall postoperative complications (P = 0.83), and postoperative infections (P = 0.97) between the BS and C groups.
There were no consistent differences in rates of postoperative complications, infections, hospital readmission, and mortality between obese patients with bariatric surgery prior to spinal fusion and control group patients. The present study does not support the hypothesis that bariatric surgery before spinal fusion contributes to a higher rate of postoperative complications in patients undergoing spinal fusion.

View all citing articles on Scopus

: One ormore of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2014.11.039.

View full text

Bariatric Surgery Prior to Total Knee Arthroplasty is Associated With Fewer Postoperative Complications

Abstract

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Gastroenterol Clin North Am

JAMA

Hypertension

J Arthroplasty

J Arthroplasty

J Arthroplasty

Prevalence and trends in obesity among US adults, 1999–2008

JAMA

Health, United States, 2013: With Special Feature on Prescription Drugs

The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis

BMC Public Health

Combining risk estimates from observational studies with different exposure cutpoints: a meta-analysis on body mass index and diabetes type 2

Am J Epidemiol

Obesity

Lancet

Obesity and its comorbid conditions

Clin Cornerstone

Changes in body weight and body fat distribution as risk factors for clinical diabetes in US men

Am J Epidemiol

Obesity in older adults: a systematic review of the evidence for diagnosis and treatment

Obesity (Silver Spring)

Comorbidities of overweight and obesity: current evidence and research issues

Med Sci Sports Exerc

Abdominal adiposity and coronary heart disease in women

JAMA

Associations of general and abdominal obesity with multiple health outcomes in older women: the Iowa Women's Health Study

Arch Intern Med

Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines

Arch Intern Med

Hyperinsulinemia, dyslipidemia, and obesity as risk factors for hospitalized gallbladder disease. A prospective study

Ann Epidemiol

Prospective study of body mass index and risk of stroke in apparently healthy women

Circulation

A prospective study of body mass index, weight change, and risk of stroke in women

JAMA

Discrimination of health risk by combined body mass index and waist circumference

Obes Res

Obesity, knee osteoarthritis and knee arthroplasty: a review

BMC Sports Sci Med Rehabil

Osteoarthritis: an update with relevance for clinical practice

Lancet