Total Knee Arthroplasty in Morbidly Obese Patients Treated With Bariatric Surgery

AbstractIn the United States, one-third of adults are considered obese, and demand for total knee arthroplasty (TKA) is expected to rise in these patients. Surgeons are reluctant to operate on obese patients, but it is important to understand how obesity has affected TKA utilization. This study utilizes a national database to evaluate incidence, demographics, outcomes, charges, and cost in nonobese, overweight, nonmorbidly obese, and morbidly obese TKA patients. We queried the National Inpatient Sample from 2009 to 2016 for primary TKA patients identifying 4,053,037 nonobese patients, 40,077 overweight patients, 809,649 nonmorbidly obese patients, and 428,647 morbidly obese patients. Chi-square was used to analyze categorical variables, and one-way analysis of variance was used to analyze continuous variables. Nonmorbidly obese and morbidly obese patients represented 23.2% of all TKAs. TKA utilization increased 4.1% for nonobese patients, 121.6% for overweight patients, 73.6% for nonmorbidly obese patients, and 83.9% for morbidly obese patients. Morbidly obese patients were younger (p < 0.001), female (p < 0.001), Black (p < 0.001), poor (p < 0.001), and utilized private insurance (p < 0.001). They also had the longest length of stay (p < 0.001) and the highest mortality rate (p < 0.001). More morbidly obese patients were discharged to other facilities (p < 0.001), and they had the highest rate of complications (p < 0.001). Patients with morbid obesity had the highest charges (p < 0.001), but overweight patients had the highest costs (p < 0.001). The results of this study demonstrate the rise in obese and morbidly obese patients seeking TKAs, which may be reflection of the obesity epidemic in America. Although TKA utilization has increased for morbidly obese patients, this body mass index (BMI) category also has the highest rates of charges and complications, suggesting morbid obesity to be a modifiable risk factor leading to worse surgical and economic outcomes. Obese patients undergoing TKA may benefit from preoperative optimization of their weight, in an effort to reduce the risk of adverse outcomes.

Download Full-text

The Use of Stems for Morbid Obesity in Total Knee Arthroplasty

The Journal of Knee Surgery ◽

10.1055/s-0039-1681078 ◽

2019 ◽

Vol 32 (07) ◽

pp. 607-610 ◽

Cited By ~ 1

Author(s):

Blake J. Schultz ◽

Malcolm R. DeBaun ◽

James I. Huddleston

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

High Risk Patient ◽

Morbidly Obese ◽

Obese Patients ◽

Limited Data ◽

Implant Fixation ◽

Knee Motion ◽

Total Knee ◽

Nonobese Patients

AbstractMorbidly obese patients undergoing total knee arthroplasty have worse functional outcomes and implant survival, and increased revision rates compared with nonobese patients. In addition to increased medical comorbidities and difficult exposure, increased stress on the tibial implant and altered kinematics of knee motion contribute to aseptic loosening and medial collapse. Increased implant fixation, including use of a stemmed tibial implant, may be a way to help avoid these complications. While there is limited data on tibial stems in the morbidly obese patients specifically, cemented stemmed tibial implants should be strongly considered in these patients, especially if bone quality is poor. The initial increased cost of a stemmed implant can be justified in this high-risk patient population to minimize the risk of costly revisions related to compromised tibia component fixation.

Download Full-text

Safety of Bilateral Total Knee Arthroplasty in Morbidly Obese Patients

Orthopedics ◽

10.3928/01477447-20140225-57 ◽

2014 ◽

Vol 37 (3) ◽

pp. e252-e259 ◽

Cited By ~ 14

Author(s):

Adam A. Madsen ◽

Benjamin C. Taylor ◽

Craig Dimitris ◽

Dane C. Hansen ◽

Robert A. Steensen ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Morbidly Obese ◽

Obese Patients ◽

Bilateral Total Knee Arthroplasty ◽

Total Knee

Download Full-text

Preoperative risk stratification minimizes 90-day complications in morbidly obese patients undergoing primary total knee arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.103b6.bjj-2020-2409.r1 ◽

2021 ◽

Vol 103-B (6 Supple A) ◽

pp. 45-50

Author(s):

Yehuda E. Kerbel ◽

Mitchell A. Johnson ◽

Stephen R. Barchick ◽

Jordan S. Cohen ◽

Kimberly Lola Stevenson ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Risk Stratification ◽

Knee Arthroplasty ◽

Morbidly Obese ◽

Obese Patients ◽

Preoperative Risk ◽

Rehabilitation Facility ◽

Significant Difference ◽

Total Knee ◽

Preoperative Risk Stratification

Aims It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. Methods We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. Results Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). Conclusion With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45–50.

Download Full-text

Letter to the Editor on “Cemented vs Cementless Total Knee Arthroplasty in Morbidly Obese Patients”

The Journal of Arthroplasty ◽

10.1016/j.arth.2016.12.045 ◽

2017 ◽

Vol 32 (5) ◽

pp. 1709

Author(s):

Sandeep Patel ◽

Tungish Bansal

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Morbidly Obese ◽

Obese Patients ◽

Letter To The Editor ◽

Total Knee

Download Full-text

Ten-Year Mortality and Revision After Total Knee Arthroplasty in Morbidly Obese Patients

The Journal of Arthroplasty ◽

10.1016/j.arth.2018.03.049 ◽

2018 ◽

Vol 33 (8) ◽

pp. 2518-2523 ◽

Cited By ~ 12

Author(s):

Mina Tohidi ◽

Susan B. Brogly ◽

Katherine Lajkosz ◽

Heather J. Grant ◽

Elizabeth G. VanDenKerkhof ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Morbidly Obese ◽

Obese Patients ◽

Total Knee

Download Full-text

Insulin Dependence Increases the Risk of Failure After Total Knee Arthroplasty in Morbidly Obese Patients

The Journal of Arthroplasty ◽

10.1016/j.arth.2015.08.026 ◽

2016 ◽

Vol 31 (1) ◽

pp. 256-259 ◽

Cited By ~ 19

Author(s):

Chad D. Watts ◽

Matthew T. Houdek ◽

Eric R. Wagner ◽

Matthew P. Abdel ◽

Michael J. Taunton

Keyword(s):

Total Knee Arthroplasty ◽

Knee Arthroplasty ◽

Morbidly Obese ◽

Obese Patients ◽

Risk Of Failure ◽

Insulin Dependence ◽

Total Knee

Download Full-text

Mid-Term Follow Up Results of Mini-Subvastus Approach for Total Knee Arthroplasty in Obese Patients

Reconstructive Review ◽

10.15438/rr.7.3.174 ◽

2017 ◽

Vol 7 (3) ◽

Author(s):

Aditya laxmikant Kekatpure ◽

Nilen A Shah ◽

Prithviraj Prabhakar Nistane ◽

Pritam K Agrawal

Keyword(s):

Total Knee Arthroplasty ◽

Obese Patient ◽

Knee Arthroplasty ◽

Patient Population ◽

Morbidly Obese ◽

Obese Patients ◽

Subvastus Approach ◽

Functional Scores ◽

Total Knee

Background: Use of mini-subvastus approach for total knee arthroplasty (TKA ) in obese patients is still debated . We had hypothesized in our study published in July 2010 , that obesity should not be considered as a problem for patients undergoing a TKA with the mini-subvastus approach as the anatomy of the quadriceps in the obese and the non-obese patient population is the same. We present a mid-term follow-up study of the same set of patients with an average follow up of 96 months.Materials and Methods: 97 obese patients (109 knees) 81 females + 16 males with mean age 64 years underwent TKA by mini-subvastus approach between January 2006 to July 2007. 16 patients (18 knees) were morbidly obese. Out of the total number of patients, 08 were lost in follow up and 01 died because of unrelated causes. Out of these 09 patients, two were operated for bilateral TKR. Thus, we have a midterm follow up results of 98 knees in 88 patients. Knee society and functional scores were used for patient evaluation and compared to their pre-operative and earlier follow up scores.Results: At our latest follow-up of 96 months the Knee Society Score and functional scores were 84(range 64-90) and 58(range 45-75) respectively. One morbidly obese lady had aseptic loosening of tibial component at 42 months which needed a revision.Conclusion: Our mid-term results show that the mini-subvastus approach can be considered for TKA in obese and morbidly obese patient population with outcomes comparable to standard surgical approach.Keywords: Mini-subvastus approach, Total knee arthroplasty ,Obesity

Download Full-text