Obesity and Joint Replacement
Obesity and Joint Replacement - Cause for Concern
“Your next patient has bilateral knee pain and is interested in having knee replacement surgery, oh yeah, their BMI is 54.”
What do you tell these patients with elevated BMI?
The number of obese patients receiving TKA is steadily rising. The cost of treating obese patients rises as BMI deviates from normal, as does the incidence of revision surgery. Therefore, providers must be active in counseling patients on weight optimization as part of preoperative standard of care.(1) As a tertiary referral center for the patients that have experienced complications from TKA (specifically infections), we understand the impact that a joint revision surgery has on an individual. It is truly “life-changing” having to put everything on pause while having existing hardware removed, an antibiotic spacer placed, PICC line placed for IV antibiotics, as well as repeating labs and aspirations after completion of the antibiotic regimen. Finally, having to endure another surgery for placement of the revision components.
In our practice, we try to convey all of this information to the patient at their initial visit when we discuss their elevated BMI. We discuss the importance of weight loss and offer a multitude of conservative treatment options. We have a long discussion regarding diet and exercise as well as the improved outcomes of patients who are able to decrease their weight prior to surgery. It isn’t an easy conversation to have with patients, and there are often tears, sometimes anger, and comments such as, “You’re saying I’m too fat for surgery.” Usually, if you are up front with them and are thorough discussing the risks involved with elevated BMI, they will be more understanding. Providing them with a goal weight and asking them when they would like to return for a follow-up and a “weight check” allows them to feel like they are in control.
What is the real risk with patients with an increased BMI?
Orthopedic surgeons and PAs should convey to overweight and obese patients that they have at least a 130% increased relative risk and a 30% absolute risk of revision TKA for an early infection if referred for revision TKA.(2) An elevated BMI is a risk factor for early referral to a tertiary care center for revision TKA.
Too many times this is the situation in our clinic. I am in a total joint practice and it is easier for the practices in our community to tell the patient that their leg is “too big” to have surgery at their community hospital, than tell them that they are at increased risks of complications because of their BMI (Body Mass Index). When these patients present to our practice, we have to have a hard discussion with them. The patients present to us as a total joint practice expecting us to be able to operate on bigger patients and handle the complications that go along with increased BMI.
How common is this in your practice and how do you handle it?
1. Roche, M Effect of Obesity on Total Knee Arthroplasty Costs and Revision Rate. J Knee Surg. 2018 Jan;31(1):38-42. doi: 10.1055/s-0037-1608933. Epub 2017 Dec 7.
2. Electrical, AJ Elevated Body Mass Index Is Associated With Early Total Knee Revision for Infection. J Arthroplasty. 2017 Jan;32(1):252-255. doi: 10.1016/j.arth.2016.05.071. Epub 2016 Jun 7.