Issue: August 2010
August 01, 2010
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Growing U.S. obesity problem presents opportunities to improve outcomes and change lives

Issue: August 2010
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The obesity problem in America impacts all sectors of the population, greatly affecting the health of many people. Currently, 38 states have a greater than 25% adult obesity rate with Mississippi topping the list with a rate of 33.8%, according to a new Trust for America's Health and Robert Wood Johnson Foundation report. This rise in adult obesity will remain a fact that orthopedic surgeons must deal with, unless it is somehow kept in check.

Many sources for this article commented that the multifactorial nature of the condition, which involves psychological, socioeconomic, metabolic and other factors, has largely kept the American medical community from doing a better job of impacting obesity. Orthopedic surgeons say that has also hampered their ability to help patients who are obese manage their weight and achieve a health lifestyle.

Michael S. Pinzur, MD,of the Loyola University Health System, Maywood, Ill., views obesity more as a societal than a medical issue, hence the reason he says it is a matter that is hard for orthopedic surgeons to tackle. “It is the same as the nonsmoking issue. Smokers and the morbidly obese know it is detrimental to their health, that they should quit smoking or lose weight, yet they don’t,” he said.

Various approaches

Concerning whether the specialty has adequately addressed obesity so far, "A lot of orthopedic surgeons talk about it, but most busy total joint surgeons have just given up," according to Pinzur, an Orthopedics Today Editorial Board member. Some perform total knee replacement (TKR) on patients who are obese hoping they will be able to lose weight afterwards, yet studies show that some may gain weight.

Michael S. Pinzur
Michael S. Pinzur, MD, urged orthopedic surgeons to advocate weight loss in their patients who are obese, which leads to increased mobility and fewer surgical complications.

Image: Pinzur MS

This raises the question of which approaches work best for dealing with obesity in orthopedics.

“It helps to let those who have particular expertise handle these problems in a coordinated fashion, while we concentrate on what we do best,” David G. Lewallen, MD, of the Mayo Clinic, Rochester, Minn., said. Among the Mayo Clinic disciplines that participate in the care of obese orthopedic patients: internal medicine, bariatric surgery and endocrinologists to help manage diabetes, to name a few.

“These are complex cases that need to be undertaken by teams that can approach this in a comprehensive way. If you want to reduce the complication rates that are inherently associated with orthopedic surgery performed on patients who are obese, try to provide some kind of overall program for managing these patients,” Lewallen said.

Tackling the complications

Within orthopedics, many academic centers and larger institutions, like Lewallen's, have adopted a multi-disciplinary approach to obesity, while smaller organizations refer patients when appropriate. Yet, a common goal is reducing the obese patient's risk for additional problems during the course of orthopedic care.

According to Pinzur, “No matter what steps you take with morbidly obese people, they are going to have a higher complication rate.”

Douglas G. Garland, MD, of Memorial Orthopedic Surgical Group, Long Beach, Calif., an Orthopedics Today editorial board member, said, “We need to get our house in order and address the issue up front.” That, he said, is critical for patients suffering from obesity and osteoarthritis (OA). “If you prevent obesity, you will prevent a lot of orthopedic complications.”

Coordination

At the Mayo Clinic, patients who are obese and patients who are morbidly obese, in particular, are required to have a thorough medical review prior to surgery as what would be done for individuals with major cardiac problems or other conditions known to affect their ability to safely undergo an orthopedic procedure.

“We have a team-approach to the management of all our patients here and that includes those who have obesity problems,” Lewallen said. As a result, professionals in nutrition, exercise, and physical therapy lend their expertise in a coordinated effort.

Following the comprehensive health assessment, “more important issues than their ‘bum knee’ or ‘bum hip’ will often turn up,” he noted.

Prepare for complications

Based on published literature, orthopedic surgeons already address an increasing array of complications and conditions in obese and patients who are morbidly obese, including OA, diabetes, cardiovascular disease, infection, reduced mobility, difficult rehabilitation, anesthesia issues and more complex fracture healing. If the current data on the obesity “epidemic” come true, they should prepare to see more.

Donald Bergman, MD

“The only way to finally deal with this worldwide epidemic in obesity is with a feeling of community spirit. You need a partner.”
— Donald Bergman, MD

Research has also shown that performing orthopedic surgery on patients who are obese may increase their rates of such adverse events as deep venous thrombosis, blood loss, infection, hip dislocations and wound healing problems.

To mitigate these problems, many orthopedists discuss with patients who are obese the importance of losing weight, especially prior to surgery, however Pinzur warned such attempts may prove ineffective.

“The statistics on losing weight and keeping it off are not very good,” he said. “None of the diets have been shown to be effective and weight loss surgery, bariatric surgery, does not have a high yield rate. A significant number of people who have bariatric surgery gain the weight back. So when you talk about making a difference, there is a limit to what you can do.”

Preoperative dialogue

Just as is the case with someone with known serious heart disease set to undergo total joint replacement (TJR), when obesity is at issue, “It is important that both the patient and surgeon know what they are getting into,” Pinzur said.

This may involve a more-detailed consent process and/or including family members in all preoperative discussions about risks.

Lewallen and colleagues found markedly increased surgical complication rates among patients who are morbidly obese with a body mass index (BMI) greater than 50, including a 24% risk of having a single major complication when undergoing total hip replacement. When they included minor complications, one in three patients experienced some problem. In the researchers’ investigation into TKR results in patients who are obese, 38% had at least one complication. “About half of those were major complications,” Lewallen noted.

“That means a very different approach to these patients is warranted with careful perioperative management and assessment, decision-making about weight management, and making arthroplasty one part of a coordinated overall medical plan for the individual,” he said.

Endocrine health

Orthopedists should be aware of any underlying endocrine disorders in patients whose BMI is 30 to 35.

According to Donald Bergman, MD, of the Division of Endocrinology, Mt. Sinai School of Medicine, New York, a waist size of 40” in men and 35” in women suggests insulin resistance (pre-diabetes), Easy bruising, proximal muscle weakness, an increased supraclavicular fat pad (signs of Cushing syndrome) and dry skin, hair loss and constipation (signs of hypothyroidism) are among the findings that should alert the orthopedist that something more involved is perhaps behind the patient’s weight problem.

“A BMI of 25 to 30 is overweight. It is time to start proper nutrition and a physical activity regimen. Obesity — BMI of 30 to 40 — calls for referral to a nutritionist or a specialist in weight loss. Above a BMI of 40, it is an urgent situation, possibly warranting surgical intervention,” said Bergman, who is involved with “Power of Prevention,” the American College of Endocrinology’s public awareness campaign about endocrine disorders, which includes a guide discussing physical activity’s role in a healthy lifestyle.

Partner with professionals

When dealing with a patient who is obese, “ruling out specific underlying endocrine/metabolic disease should come first,” Bergman explained.

“If the patient has a big waist or the other symptoms mentioned, you should refer them on. Orthopedists should get their patients to lose some weight before fixing their ligaments or replacing their joints if delay in surgery is possible. That would be a big service.”

However, Bergman told Orthopedics Today, “The only way to finally deal with this worldwide epidemic in obesity is with a feeling of community spirit. You need a partner,” which he explained is an area where the Power of Prevention program has been effective. It has successfully paired children with their parents who are obese and patients who are obese with professionals to garner motivation for losing weight.

Managing OA

Concerning how specific orthopedic problems relate to obesity, it is widely debated whether patients who are obese' joints wear faster than those of their normal weight counterparts. "People who are in the 30 to 35 BMI range having surgery do quite well and really are pretty typical of our patient population," Lewallen said.

When consulting with patients with obesity about TJR, Garland believes it is important to discuss the role of obesity as a cause of joint deterioration. While some downplay the worn-out joint concept as a cause of OA in patients who are obese, others say an inflammatory process links obesity with OA and other conditions.

“Inflammation plays a major role in OA at the cellular and tissue level,” rheumatologist Roy D. Altman, MD, said.

Garland recommended broaching the subject of weight loss combined with exercise to all patients who are obese with a BMI greater than 30 to help them better manage their OA. He has found that when he asks the patient’s weight or weighs them is an ideal time to discuss whether bariatric surgery is appropriate for them, ways to increase their activity level postoperatively or referring them for nutritional or other counseling.

“The orthopedist plays an important role in the fight against obesity,” Garland said.

Activity and weight loss

In patients with arthritis who are obese, diet and exercise are critical for weight control and managing OA, even if it only burns minimal calories. “You have to do them both,” said Altman, who is an OA specialist in the internal medicine/rheumatology department at the University of California-Los Angeles. He suggested patients who are obese be directed to low-impact physical activities, like swimming or stationary bicycle riding.

Altman recommended doing this in a spirit of trying to help patients who are obese, rather than challenging them.

Dietary changes

Since moving and exercising may be difficult for patients who are obese with hip or knee OA, during the office visit Garland recommends they make small dietary changes to kick-start weight loss. For example, he advises patients who are obese to eliminate all sugary beverages, like soda and juice. They can cut hundreds of calories from their daily diet that way. The initial weight loss that results may be just enough to encourage an obese individual to embark on a manageable low-impact exercise program, he said.

Small steps like these can assist patients who are obese with needed weight loss, said Garland, who has prescribed glucosamine to some to provide safe relief of symptoms when exercising rather than NSAIDs. It gives them a mental edge, as well, he added.

“We encourage people to participate in lower-impact exercises that are safe,” Lewallen said. He explained exercises to avoid are those that put the patient at risk of falling and sustaining a fracture and they should especially be avoided in those recovering from a fracture.

Since postoperative rehabilitation of a patient with obesity can be particularly challenging following lower extremity surgery, Altman recommended they see a physical therapist well before their procedure to develop their upper body strength.

“Obesity makes your preoperative, cardiac, and respiratory care more difficult and in the end it causes arthritis. It makes our surgery more risky and makes complications more prevalent. It taxes every aspect of the orthopedist’s job,” Garland said.

But, perhaps one of the best ways to support obese orthopedic patients as they lose weight or attempt an exercise program is to be a good role model, Lewallen noted. “It is important to show in our own lifestyles the benefits of healthy living. It is a day-to-day struggle, but we all have to work at it to be the best we can, to maintain appropriate body weight and to minimize the health consequences that come with added weight and age.” – by Susan M. Rapp

References:

  • Cooper, C. Arthritis Rheum. 2000; 43:995-1000.
  • F as in Fat: 2010 — How obesity threatens America’s future 2010. June 2010.
  • Polga DJ, Altenburg A, Trousdale RT, Lewallen DG. Complications following total hip arthroplasty in the superobese, BMI>50. Paper #256.
  • Polga DJ, Altenburg A, Trousdale RT, Lewallen DG. Complications following total knee arthroplasty in the superobese, BMI>50. Paper #280. Both presented at the 2009 AAOS Annual Meeting. Feb. 25-28, 2009. Las Vegas.
  • www.powerofprevention.com

  • Roy D. Altman, MD, can be reached at 9854 W. Bald Mountain Court, Agua Dulce, CA 91390; 661-268-7328; e-mail: journals@royaltman.com.
  • Donald Bergman, MD, can be reached at 119 Park Ave., Suite 1F, New York, NY 10029; 212-876-7333; e-mail: donaldbergman@msn.com.
  • Douglas E. Garland, MD, can be reached at 2760 Atlantic Ave., Long Beach, CA 90806; 562-424-6666; e-mail: dougarland@msn.com.
  • David G. Lewallen, MD, can be reached at 200 1st St., SW, Rochester, MN 55905; 507-284-4896; e-mail: lewallen.david@mayo.edu.
  • Michael S. Pinzur, MD, can be reached at 2160 South First Ave., Maywood, IL 60153; 708-216-4993; e-mail: mpinzu1@lumc.edu.

Point/Counterpoint

Do you change your joint arthroplasty protocol for patients who are obese?

Point

Preparing for complications

Eric R. Bohm
Eric R. Bohm

Yes. Because of the significant effect of obesity on arthroplasty, I counsel patients who are obese preoperatively about the role their weight has likely played in their arthritis and explain that losing weight preoperatively may reduce their risk of arthritis developing in other joints and that it can decrease their pain and increase their overall mobility postoperatively. I strongly encourage them to pursue weight loss before surgery.

The rates of hip and knee arthroplasty are increasing for patients who are obese based on our regional registry where people who are overweight and undergo surgery, particularly knee arthroplasty, have more complications the higher their BMI is. Complications are usually related to wound drainage following surgery or infection that may require some oral antibiotics. However, despite the risk of possibly more complications, patients who are obese report being quite satisfied following surgery, which is reassuring.

Since the literature is conflicting about rates of increased arthroplasty complications in patients who are obese, I review our local experience with them, which shows complications typically increase in patients with a BMI greater than 40, but actually start to change at a BMI of 35 to 40.

My hospital does a lot of arthroplasty surgery, so the anesthetists and nursing staff are used to working with these patients. We tend to monitor them more closely for sleep apnea problems. Occasionally I will use MIS instruments to better position components or an intramedullary rod to align the tibial cut if it’s a very difficult TKR case.

We have a very active rehabilitation team that helps us screen patients preoperatively and works with patients who are obese on weight loss, as well. Hospital stays tend to be a bit longer because patients who are obese may take a little longer to mobilize, but we don’t deny surgery based on a patient’s BMI. My group firmly believes in having a well-informed patient who knows their risks of surgery and what to expect.

Eric R. Bohm, MD, is an orthopedic surgeon practicing at the Concordia Hip and Knee Institute in Winnipeg, Canada.

Counter

No major changes

Mathias P.G. Bostrom
Mathias P.G. Bostrom

No, but I spend a lot of time making sure patients who are obese understand that their risk of complications is much higher. I don’t calculate BMI, but do ask them what their weight is. Basically I know when they’re obese and when they’re morbidly obese.

Looking at the arthroplasty complication rates at Hospital for Special Surgery, one of the highest rates is with morbid obesity; more than cardiac disease, more than diabetes. It’s really the major issue in terms of complications. Like everyone else, I try to get patients who are obese to lose weight. The reality is very few of them ever do. I view the obese patient and the morbidly obese patient in two different categories. If they’re truly morbidly obese they are in the 350 plus-pound range depending on their height. I tell the patients who are morbidly obese to lose significant amounts of weight, because they’re at such high medical risk. With the merely patients who are obese, who, depending on their height, are in the 250 to 300 pound range, the reality is they rarely lose weight on average. Therefore, this group of patients is much more difficult to handle.

Preoperatively, I make sure all my patients who are obese see the cardiologist and get a stress test, echocardiogram and whatever other cardiac work-up is necessary. We try to do as much as we can to optimize their medical condition. Postoperatively, I don’t change my protocol much except that I mobilize my patients as quickly as possible. Obviously this can be quite challenging for our physical therapists.

Consenting the obese patient is also more difficult and involved because they need more information. I like to have the patient’s family there so that everyone hears the same thing. I don’t beat around the bush. I tell them very clearly they’re higher risk patients. I also tell them they’re not going to get a mini incision. Amazingly, many patients who are obese come in and think they’re going to have a tiny little incision. I am very clear to emphasize the technical challenges I face placing a hip implant in these patients.

Mathias P.G. Bostrom, MD, an orthopedic surgeon at the Hospital for Special Surgery in New York, specializes in hip and knee surgery.