Nutritional Counseling Program for Morbidly Obese Patients Enables Weight Optimization for Safe Total Joint Arthroplasty

Abstract

Obesity affects one-third of total joint arthroplasty (TJA) patients and is the most common modifiable risk factor for increased complications in the TJA population. The authors' institution implemented a body mass index (BMI) cutoff of 40 kg/m 2 to define appropriate TJA candidates. Patients above the cutoff were referred for nutritional counseling. The study objective was to evaluate the efficacy of this protocol in optimizing patient BMI for safe and successful TJA. Between 2016 and 2018, the authors examined 133 patients (mean age, 62.6 years) with a BMI greater than 40 kg/m 2 seeking TJA (94 knee, 39 hip) seen by an arthroplasty surgeon and then a dietitian. Outcomes included weight loss, change in BMI, duration of counseling, and surgical status. For postoperative patients, 90-day complications were recorded. A total of 102 (92%) patients achieved weight loss during a mean 154 days (range, 8–601 days). Patients lost a mean of 17 lb, lowering their BMI by 2.7 points (range, +6.3 to −17.7 points). Twenty-two patients discontinued nutritional counseling after 1 visit, most commonly secondary to cost when not covered by insurance. Seventy-one patients successfully underwent TJA, representing 64% of those patients who participated in nutritional counseling. Complications included delayed wound healing (n=2), periprosthetic fracture (n=2), infection (n=1), cellulitis (n=1), and peroneal nerve palsy (n=1). Surgeons must actively counsel obese patients about weight optimization as part of the preoperative standard of care. Nutritional counseling with a dietitian and follow-up with the surgeon translated to safe and successful TJA in a majority of patients. [ Orthopedics . 2020;43(4):e316–e322.]

Elective Surgery in Adult Patients with Excess Weight: Can Preoperative Dietary Interventions Improve Surgical Outcomes? A Systematic Review

“…From 4597 articles retrieved, 184 duplicates were removed using EndNote X8 (Clarivate Analytics, Philadelphia, PA, USA) and the remaining abstracts screened, with 53 full-text articles assessed for eligibility. A total of 14 studies met inclusion criteria and were included in our systematic review: four randomised controlled trials (RCTs) [24][25][26][27], one pilot RCT [28], five single-cohort [29][30][31][32][33], three retrospective cohort studies [34][35][36], and one retrospective case series [37].…”

“…Table 2 shows the characteristics of the included studies. Publication dates ranged over 24 years, with the oldest study published in 1997 [33] and the most recent in 2021 [29], with eight of the 14 studies published in the last five years [24][25][26][28][29][30]36,37].…”

“…A majority of studies were carried out in westernised countries, with five studies from the United States of America [24,25,31,34,37] and two studies each from Australia [28,29], the United Kingdom [26,30], and Canada [32,35], with one study each from Japan [36], Spain [27], and Finland [33].…”

“…The intervention locations were mostly in hospital-based or large medical centre outpatient settings, with most settings described as "hospitals" [26,30,33,36] and some described as surgical specialty facilities [31,37], while some appeared to be university settings [27].…”

“…Eleven out of the 14 studies set inclusion criteria according to BMI cut-offs [25][26][27][28][29][31][32][33]37]. One of these used a combination of BMI and waist circumference [36].…”