Surgeon Decision-Making for Individuals With Obesity When Indicating Total Joint Arthroplasty

Sherman, William F.; Patel, Akshar H.; Kale, Nisha N.; Freiberger, Christina; Barnes, C. Lowry; Lee, Olivia

doi:10.1016/j.arth.2021.02.078

Cited by 33 publications

(13 citation statements)

References 31 publications

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“…The authors of this study reported in a large database that malnutrition, defined as hypoalbuminemia (<3.5), was the strongest risk factor for all complications evaluated [11]. It has been reported that individuals with obesity are at higher risk of complications; however, surgeons often indicate arthroplasty in patients with BMI over 40 for various reasons [12]. While there is debate regarding strict BMI cutoffs, insistence on smoking cessation, preoperative nutritional optimization, and HbA1C limits of 7.7 or less, the decision to offer a patient elective TJA is ultimately made by the surgeon taking into account the patient's entire risk profile and potential benefit of surgery [13,14].…”

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confidence: 87%

Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

Sherman

Patel

2021

Arthroplasty Today

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confidence: 87%

Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

Sherman

Patel

2021

Arthroplasty Today

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“…A recent survey by the American Association of Hip and Knee Surgeons found that 50% of orthopaedic surgeons refuse to perform arthroplasty to patients with Class III obesity (BMI $ 40 kg/m 2 ) in the United States [32]. Institutions with strict BMI cutoffs cite higher odds of a complication, readmission, or reoperation in patients with obesity [8,10,35,40,43].…”

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confidence: 99%

Does Operative Time Modify Obesity-related Outcomes in THA?

Abella

Angeles

Finlay

et al. 2023

Clin Orthop Relat Res

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Background Most orthopaedic surgeons refuse to perform arthroplasty on patients with morbid obesity, citing the higher rate of postoperative complications. However, that recommendation does not account for the relationship of operative time (which is often longer in patients with obesity) to obesity-related arthroplasty outcomes, such as readmission, reoperation, and postoperative complications. If operative time is associated with these obesity-related outcomes, it should be accounted for and addressed to properly assess the risk of patients with obesity undergoing THA. Questions/purposes We therefore asked: (1) Is the increased risk seen in overweight and obese patients, compared with patients in a normal BMI class, associated with increased operative time? (2) Is increased operative time independent of BMI class a risk factor for readmission, reoperation, and postoperative medical complications? (3) Does operative time modify the direction or strength of obesity-related adverse outcomes? Methods This retrospective, comparative study examined 247,108 patients who underwent THA between January 2014 and December 2020 in the National Surgical Quality Improvement Project (NSQIP). Of those, emergency cases (1% [2404]), bilateral procedures (1% [1605]), missing and/or null data (1% [3280]), extreme BMI and operative time outliers (1% [2032]), and patients with comorbidities that are not typical of an elective procedure, such as disseminated cancer, open wounds, sepsis, and ventilator dependence (1% [2726]), were excluded, leaving 95% (235,061) of elective, unilateral THA cases for analysis. The NSQIP was selected due to its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight, normal weight, overweight, Class I obesity, Class II obesity, and Class III obesity. Of the patients with a normal weight, 69% (30,932 of 44,556) were female and 36% (16,032 of 44,556) had at least one comorbidity, with a mean operative time of 86 ± 32 minutes and a mean age of 68 ± 12 years. Patients with obesity tend to be younger, male, more likely to have preoperative comorbidities, with longer operative times. Multivariable logistic regression models examined the effects of obesity on 30-day readmission, reoperation, and medical complications, while adjusting for age, sex, race, smoking status, and number of preoperative comorbidities. After we repeated this analysis after adjusting for operative time, an interaction model was conducted to test whether operative time changes the direction or strength of the association of BMI class and adverse outcomes. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were calculated, and the interaction effects were plotted. Results A comparison of patients with Class III obesity to patients with normal weight showed that the odds of readmission went from 45% (AOR 1.45 [95% CI 1.32 to 1.59]; p < 0.001) to 27% after adjusting for operative time (AOR 1.27 [95% CI 1.01 to 1.62]; p = 0.04), the odds of reoperation went from 93% (AOR 1.93 [95% CI 1.72 to 2.17]; p < 0.001) to 81% after adjusting for operative time (AOR 1.81 [95% CI 1.61 to 2.04]; p < 0.001), and the odds of a postoperative complication went from 96% (AOR 1.96 [95% CI 1.58 to 2.43]; p < 0.001) to 84% after adjusting for operative time (AOR 1.84 [95% CI 1.48 to 2.28]; p < 0.001). Each 15-minute increase in operative time was associated with a 7% increase in the odds of a readmission (AOR 1.07 [95% CI 1.06 to 1.08]; p < 0.001), a 10% increase in the odds of a reoperation (AOR 1.10 [95% CI 1.09 to 1.12]; p < 0.001), and 10% increase in the odds of a postoperative complication (AOR 1.10 [95% CI 1.08 to 1.13]; p < 0.001). There was a positive interaction effect of operative time and BMI for readmission and reoperation, which suggests that longer operations accentuate the risk that patients with obesity have for readmission and reoperation. Conclusion Operative time is likely a proxy for surgical complexity and contributes modestly to the adverse outcomes previously attributed to obesity alone. Hence, focusing on modulating the accentuated risk associated with lengthened operative times rather than obesity is imperative to increasing the accessibility and safety of THA. Surgeons may do this with specific surgical techniques, training, and practice. Future studies looking at THA outcomes related to obesity should consider the association with operative time to focus on independent associations with obesity to facilitate more equitable access. Level of Evidence Level III, therapeutic study

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“…In 2013, the American Association of Hip and Knee Surgeons (AAHKS) put forth clinical guidelines recommending that TJA be delayed in patients with a BMI >40, given that the increased complication profile in this patient cohort may negatively outweigh the functional benefits of surgery 14 . However, a recent 2020 survey of AAHKS members demonstrated that only 50% of hip and knee surgeons had a strict BMI cutoff of 40, only 30% of respondents had institutional cutoffs, and furthermore, 13% of respondents had no BMI cutoff at all 15 . Multiple factors contribute to surgeon-driven BMI cutoffs for elective TJA in morbidly obese patients including poorer perioperative outcomes, wound complications, prosthetic joint infection (PJI), implant loosening, and hospital readmission.…”

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Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient

et al. 2023

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Obesity, defined as body mass index (BMI) $30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly.» From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI $40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI $30) or morbidly obese (BMI $40).» In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI $40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A938).

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Surgeon Decision-Making for Individuals With Obesity When Indicating Total Joint Arthroplasty

Cited by 33 publications

References 31 publications

Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

Letter to the Editor: “Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?”

Does Operative Time Modify Obesity-related Outcomes in THA?

Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient

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