scholarly journals Clinical Pathways of Patients Denied Total Knee Arthroplasty Due to an Institutional BMI Cutoff

2021 ◽  
Author(s):  
Charlie D. Wilson ◽  
Kathleen F. Lundquist ◽  
Nathan H. Baruch ◽  
Ravindra Gaddipati ◽  
Kendall A.P. Hammonds ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Clinical Pathways ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Increased Risk ◽  
Total Knee ◽  
Strict Enforcement ◽  
Record Review

AbstractOut of concern for the increased risk of complications with morbid obesity, institutional body mass index (BMI) cutoffs for total knee arthroplasty (TKA) have become commonplace. We sought to answer the questions: what percentage of morbidly obese patients with knee osteoarthritis who present to an arthroplasty clinic will, within 2 years, undergo TKA at (1) a BMI less than 40 kg/m2 or (2) at a BMI greater than 40 kg/m2? Of those who do not undergo surgery, (3) what percentage lose enough weight to become TKA-eligible, and (4) what percentage do not? We performed an observational study of 288 patients, of which 256 had complete follow-up. Institutional electronic medical record review and patient follow-up by telephone were conducted to determine which patients underwent surgery, and at what BMI. For those that did not undergo TKA, BMI was examined to see if the patient ever lost enough weight to become TKA eligible. Twelve of 256 patients (4.7%) underwent TKA at a BMI less than 40 kg/m2, 64 patients (25%) underwent TKA at a BMI greater than 40 kg/m2, and 7 patients (2.7%) underwent surgery at an outside hospital. The average BMI at the time of surgery was 42.3 kg/m2. Thirty-seven of 256 patients (14.4%) lost enough weight to become TKA-eligible within 2 years of the initial visit but did not undergo surgery, while 136 patients (53.1%) neither underwent TKA nor became eligible. Strict enforcement of a BMI cutoff for TKA is variable among surgeons. In the absence of weight loss protocols, 19.1% of morbidly obese patients may be expected to reach the sub-40 kg/m2 BMI milestone.

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

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

Are surgeons still performing primary total knee arthroplasty in the morbidly obese?

2021 ◽  
Vol 103-B (6 Supple A) ◽  
pp. 38-44
Author(s):  
David E. DeMik ◽  
Christopher N. Carender ◽  
Natalie A. Glass ◽  
Timothy S. Brown ◽  
John J. Callaghan ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Primary Total Knee Arthroplasty ◽  
Wound Complications ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Improvement Program ◽  
Increased Risk ◽  
Total Knee ◽  
Infective Complications

Aims The purpose of this study was to assess total knee arthroplasty (TKA) volume and rates of early complications in morbidly obese patients over the last decade, where the introduction of quality models influencing perioperative care pathways occurred. Methods Patients undergoing TKA between 2011 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI < 40 kg/m2 and ≥ 40 kg/m2 and evaluated by the number of cases per year. The 30-day rates of any complication, wound complications, readmissions, and reoperation were assessed. Trends in these endpoints over the study period were compared between groups using odds ratios (ORs) and multivariate analyses. Results In total, 314,695 patients underwent TKA and 46,362 (15%) had BMI ≥ 40 kg/m2. The prevalence of morbid obesity among TKA patients did not change greatly, ranging between 14% and 16%. Reoperation rate decreased from 1.16% to 0.96% (odds ratio (OR) 0.81 (95% confidence interval (CI) 0.66 to 0.99)) for patients with BMI < 40 kg/m2, as did rates of readmission (4.46% to 2.87%; OR 0.61 (0.55 to 0.69)). Patients with BMI ≥ 40 kg/m2 also had fewer readmissions over the study period (4.87% to 3.34%; OR 0.64 (0.49 to 0.83)); however, the rate of reoperation did not change (1.37% to 1.41%; OR 0.99 (0.62 to 1.56)). Significant improvements were not observed for infective complications over time for either group; patients with BMI ≥ 40 kg/m2 had increased risk of both deep infection and wound complications compared to non-morbidly obese patients. Rate of any complication decreased for all patients. Conclusion The proportion of TKAs in morbidly obese patients has not significantly changed over the past decade. Although readmission rates improved for all patients, reductions in reoperation in non-morbidly obese patients were not experienced by the morbidly obese, resulting in a widening of the complication gap between these cohorts. Care improvements have not lowered the differential risk of infective complications in the morbidly obese. Cite this article: Bone Joint J 2021;103-B(6 Supple A):38–44.

scholarly journals When can total knee arthroplasty be safely performed following prior arthroscopy?

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Jin-Ning Ma ◽  
Xiao-Lin Li ◽  
Pan Liang ◽  
Sheng-Li Yu
Keyword(s):  
Total Knee Arthroplasty ◽  
Postoperative Complications ◽  
Knee Arthroplasty ◽  
Acl Injury ◽  
Control Group ◽  
Optimal Timing ◽  
Complication Rates ◽  
Increased Risk ◽  
Total Knee

Abstract Background The optimal timing to perform a total knee arthroplasty (TKA) after knee arthroscopy (KA) was controversial in the literature. We aimed to 1) explore the effect of prior KA on the subsequent TKA; 2) identify who were not suitable for TKA in patients with prior KA, and 3) determine the timing of TKA following prior KA. Methods We retrospectively reviewed 87 TKAs with prior KA and 174 controls using propensity score matching in our institution. The minimum follow-up was 2 years. Postoperative clinical outcomes were compared between groups. Kaplan-Meier curves were created with reoperation as an endpoint. Multivariate Cox proportional hazards regressions were performed to identify risk factors of severe complications in the KA group. The two-piecewise linear regression analysis was performed to examine the optimal timing of TKA following prior KA. Results The all-cause reoperation, revision, and complication rates of the KA group were significantly higher than those of the control group (p < 0.05). The survivorship of the KA group and control group was 92.0 and 99.4% at the 2-year follow-up (p = 0.002), respectively. Male (Hazards ratio [HR] = 3.2) and prior KA for anterior cruciate ligament (ACL) injury (HR = 4.4) were associated with postoperative complications in the KA group. There was a non-linear relationship between time from prior KA to TKA and postoperative complications with the turning point at 9.4 months. Conclusion Prior KA is associated with worse outcomes following subsequent TKA, especially male patients and those with prior KA for ACL injury. There is an increased risk of postoperative complications when TKA is performed within nine months of KA. Surgeons should keep these findings in mind when treating patients who are scheduled to undergo TKA with prior KA.

The Rise of Obesity among Total Knee Arthroplasty Patients

2020 ◽  
Author(s):  
Nequesha S. Mohamed ◽  
Wayne A. Wilkie ◽  
Ethan A. Remily ◽  
Iciar M. Dávila Castrodad ◽  
Mirlande Jean-Pierre ◽  
...  
Keyword(s):  
Morbid Obesity ◽  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
The United States ◽  
National Database ◽  
Categorical Variables ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Total Knee ◽  
Nonobese Patients

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.

The Use of Stems for Morbid Obesity in Total Knee Arthroplasty

2019 ◽  
Vol 32 (07) ◽  
pp. 607-610 ◽  
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.

Safety of Bilateral Total Knee Arthroplasty in Morbidly Obese Patients

Orthopedics ◽  
2014 ◽  
Vol 37 (3) ◽  
pp. e252-e259 ◽  
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

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

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.

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