Should orthopedic surgeons withhold surgery from patients who are obese until they are optimized?
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Not should, but how
The rate of obesity in the United States has reached epidemic proportions. In particular, the incidence of obese patients with end-stage OA outpaces that of the general population. When faced with the need for THA or TKA, the class III obese patient (morbidly obese BMI >40) presents several challenges. Studies published in the last decade show a clear association of increased relative risk of surgery in the morbidly obese patient. These studies have demonstrated longer operative times, higher cost, longer length of stay, higher rates of complications, higher risk of implant failure and development of PJI in obese patients. In addition, morbid obesity often clusters with other comorbid conditions, which places patients at even greater risk. Yet, some isolated studies show overall functional benefits, improved pain and quality of life in the morbidly obese patient who undergoes THA or TKA.
The issue is should morbidly obese patients be required to lose weight (BMI <40) prior to undergoing elective total joint arthroplasty. In my opinion, the question is not if, but how. We know the risks, and as health care providers, it is our duty to make patients as healthy as possible prior to surgery to ensure the lowest risk and best possible outcome. Numerous studies have shed insight into how difficult it is for obese patients to lose weight on their own. We, as orthopedic surgeons, lack the resources and in-depth knowledge to appropriately council our patients on weight loss. Most studies show that obese patients with arthritis cannot lose weight or maintain weight loss and they do not lose weight after TJA. However, obesity should be no different than any other comorbidity for which we may not chose to perform elective arthroplasty, such as uncontrolled diabetes, malnutrition and smoking. We need to develop best practice guidelines in conjunction with our bariatric colleagues to create pathways to help optimize morbidly obese patients prior to surgery.
Bryan D. Springer, MD, is the fellowship director at OrthoCarolina Hip and Knee Center and associate professor in the department of orthopedic surgery at Atrium Musculoskeletal Institute in Charlotte, North Carolina.
Disclosure: Springer reports no relevant financial disclosures.
Strict BMI criteria oversimplify the issue
Clearly, patients should be optimized before elective TJA. The issue is how one defines optimized. Obesity should be among all comorbidities that are factored into the decision to offer surgery. If there are risk factors that are modifiable that can reduce the patient’s risk in a reasonable time interval, then this should be pursued. I do not think it is right, however, for a health care system to enforce a strict BMI eligibility criterion in all patients.
Hard BMI eligibility criteria do not account for the true complexity of preoperative risk assessment. TJA risk calculators reveal that BMI is a weak predictor of complications and that complications are not suddenly reduced at a certain BMI threshold. Complications are rare and difficult to predict. Enforcing strict BMI eligibility criteria can thus result in denial of complication-free surgery to large numbers of patients to save one patient from a complication. This would be okay if BMI were readily modifiable for a majority of patients, but unfortunately this is not the case. Thus, well-intended, hard BMI eligibility criteria can effectively become insurmountable barriers to surgery for many patients who would not have had a complication.
Accepting elevated risk should be the subject of shared decision-making between the patient and surgeon. Unfortunately, there are currently few, if any, incentives for surgeons to accept patients who carry somewhat higher risk, particularly in this era of bundled payments. I do not believe this is good for society. TJA remains cost-effective, even in patients with high BMI.
Obviously, not all patients with high BMI are candidates for TJA. Similarly, not all orthopedic practices can appropriately care for high BMI patients. Patients should be optimized to the extent possible for all comorbidities, including obesity, prior to offering elective TJA, but an obese patient who is otherwise a suitable candidate for surgery, after a reasonable attempt at weight reduction, should have an opportunity somewhere in the health care system to undergo TJA.
- ACS-NSQIP risk calculator. Available at: https://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp. Accessed Nov. 26, 2018.
- American Joint Replacement Registry risk calculator. Available at: http://riskcalc.aaos.org/index.html. Accessed Nov. 26, 2018.
- Giori NJ, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.00120.
- Huffaker SJ, et al. Paper 136. Presented at: American Academy of Orthopedic Surgeons Annual Meeting; March 14-18, 2017; San Diego.
- Ponnusamy KE, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.02.031.
- Ponnusamy KE, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.08.023.
- Stanford Surgery Policy Improvement Research and Education Center TJA Risk Calculator. Available at: https://s-spire-clintools.shinyapps.io/TJARiskCalculator. Accessed Nov. 26, 2018.
- Unick JL, et al. Am J Med. 2013;doi:10.1016/j.amjmed.2012.10.010.
Nicholas J. Giori, MD, PhD, is with VA Palo Alto Health Care System in Palo Alto, California, and Stanford University in Stanford, California.
Disclosure: Giori reports no relevant financial disclosures.