In the United States, obesity has reached an incidence of approximately 35% in the general population, including one-third of total joint arthroplasty (TJA) patients, and is the most common modifiable risk factor in the TJA population.1–3 Increased complication rates following TJA in the setting of obesity have been well documented: increased length of stay, longer operative times, acute kidney injury, superficial infection, periprosthetic infection, cardiac arrest, reintubation, reoperation, and death.4–12 Current projections indicate that the prevalence of obesity will continue to rise in the TJA population to nearly half of all TJA candidates.3,13 The confluence of these factors offers an important area for potential risk mitigation in the setting of TJA.
An increased risk of complications following TJA in the obese patient has been demonstrated with any body mass index (BMI) greater than 30 kg/m2 and has been shown to increase in a stepwise fashion. The exact cutoff for a “safe” TJA is a topic of debate, with various studies citing 35, 40, or 50 kg/m2.6,9,14 Wagner et al15 found that rates of infection, reoperation, and revision surgery after total knee arthroplasty (TKA) were strongly associated with increasing BMI. Such results should encourage surgeons to advocate for all obese patients to reduce weight prior to surgery, with a special emphasis on patients with BMI greater than 40 kg/m2.
Various interventions have been proposed to address this growing problem.16–20 Bariatric surgery is an effective treatment for weight loss and lowering BMI prior to TJA.21–25 However, this additional procedure exposes patients to further risk.26 It remains unclear whether bariatric surgery truly reduces the risk of complication following TJA, even with successful weight loss.27–29 Moreover, a 2-year waiting period is recommended to fully achieve weight loss benefits as well as to allow metabolic normalization prior to TJA.30–32
The authors' institution implemented a BMI cutoff of 40 kg/m2 to define appropriate TJA candidates. Patients above the cutoff were referred for formal nutritional counseling with a dietician. The objective of this study was to evaluate the efficacy of the authors' protocol in optimizing patient BMI for successful and safe TJA. The authors also evaluated the fate of those patients who did not complete nutritional counseling.
Materials and Methods
This was a retrospective case series performed at a single tertiary-care TJA institution from July 2016 through July 2018. Institutional review board approval was received, and written consent was obtained from all patients. All candidates for primary TJA, including both TKA and total hip arthroplasty (THA), with a BMI greater than 40 kg/m2 were sent for consultation with the registered dietician at the authors' institution prior to surgery. All patients who participated in at least 1 counseling session and had a minimum follow-up of 4 months were included in this study (Figure 1). In some cases, visits with the dietician were covered by insurance on a limited basis, ranging from 2 to 10 visits per year. Alternatively, out-of-pocket payment was required. The dietician established a weight loss goal consistent with a BMI less than 40 kg/m2. She evaluated patients' current dietary practices, provided individualized meal plans and recommendations for diet changes, provided education, scheduled routine monthly follow-up, monitored and encouraged progress and accountability, and answered all questions. Preoperative reassessment with the surgeon was also arranged. Five fellowship-trained joint arthroplasty surgeons (F.R.O., M.F.H., Z.D.P., A.C.O., D.Y.P.) participated in the nutritional counseling program and followed a common perioperative protocol.
Flow diagram of patient capture, participation in nutritional counseling, and eventual total joint arthroplasty (TJA). Abbreviation: BMI, body mass index.
Outcomes included weight loss, change in BMI, duration of counseling, and surgical status. For postoperative patients, 90-day complications and reoperations were recorded. Patients who initiated nutritional counseling with a single visit and then did not return to the authors' institution were considered lost to follow-up. These patients were contacted by phone to inquire as to why they discontinued their nutritional counseling and whether they had surgery at a different institution.
From July 2016 to July 2018, a total of 133 patients met inclusion criteria and were seen by the dietician for TJA preoperative BMI optimization. This included 94 TKA and 39 THA candidate patients. The mean age of the TJA candidates was 62.6 years, and there were 80 women and 53 men. Demographics are presented in Table 1.
Twenty-two patients discontinued nutritional counseling after 1 visit. These patients were contacted regarding the reason for discontinuing therapy, and their responses are presented in Table 2. Most commonly, this was related to the cost of the dietician visits (n=10). Other reasons given included unrelated illness or personal issues (n=3) or decision to immediately pursue surgery at an alternative institution without a BMI cutoff (n=3). Four patients could not be reached for questioning. Of those lost to follow-up (n=22), 5 (23%) patients confirmed that they ultimately underwent TJA at an alternate institution, although not all of these patients listed this as their primary motivation for ceasing dietary counseling.
Reasons for Not Continuing Dietary Counseling
A total of 111 patients participated in more than 1 nutritional counseling visit. Of these, 102 (92%) achieved weight loss during a mean of 154 days (Table 3). Patients lost a mean of 17 lb, which translated to a decrease in their BMI of 2.7 points. Of all patients who participated in counseling, 43% achieved a BMI of 40 kg/m2 or less, and 55% achieved a BMI of less than 41 kg/m2. Interestingly, for patients who did not ultimately undergo TJA, the mean treatment time with the dietician was longer (198 days vs 129 days). Change in BMI vs number of visits for all patients is shown in Figure 2. The distribution of visits with the dietician of all patients is shown in blue in Figure 3. Patients who went on to have surgery are indicated in orange.
Weight Loss Quantification Stratified by Counseling Participation
Number of visits with the dietician vs change in body mass index (BMI) for all patients who participated in counseling.
Distribution of number of visits with the dietician. Blue indicates all patients who participated in counseling. Orange indicates patients who participated in counseling and went on to have total joint arthroplasty performed at the authors' institution.
Of the patients who participated in more than 1 nutritional counseling visit, 64% subsequently went on to have TJA performed at the authors' institution. This included 49 TKA and 22 THA patients, which were 52% and 56% of the patients who initiated counseling for each procedure, respectively. Their mean beginning BMI was 42.87 kg/m2 (range, 40.1–51 kg/m2). Mean weight loss achieved was 17.9 lb (2.9 kg/m2), and mean BMI at the time of surgery was 39.9 kg/m2. Of the patients who underwent TJA at the authors' institution following counseling, 64.8% were able to achieve a BMI 40 kg/m2 or less, and 81.7% achieved a BMI less than 41 kg/m2.
Postoperative complications are listed in Table 4, which include delayed wound healing (n=2), periprosthetic fracture (n=2), and superficial infection (n=1). There were 4 (5.4%) reoperations required: superficial wound infection (n=1), fracture (n=2), and manipulation under anesthesia (n=1). One distal femoral peri-prosthetic fracture occurred at just more than 2 months following primary TKA and necessitated revision to a distal femoral replacement, at which time poor bone quality was noted. This was a 64-year-old woman who had lost 45 lb during 238 days and decreased her BMI by 8.4 points prior to proceeding with TKA. The other periprosthetic fracture occurred in a 58-year-old man 4 months after primary THA and resulted in loosening of the femoral component, which required revision to a diaphyseal-fit prosthesis with cerclage cables. This patient had lost 35 lb during 98 days and decreased his BMI by 4.5 points prior to THA. These 2 fractures represent 2.7% of the TJA population in this study.
Complications Following Total Joint Arthroplasty for Patients Who Completed Nutritional Counseling
Nutritional and BMI optimization prior to TJA have recently been a focus of arthroplasty research. The optimal preoperative protocol for morbidly obese patients is still unknown. With this study, the authors have described a novel approach, using an in-house dietician with regular follow-up, to address the concerns of both BMI and nutrition preoperatively. A majority of the patients were able to complete the protocol and achieve satisfactory weight loss. This protocol offers a safe and effective optimization strategy for morbidly obese TJA candidates.
Currently, there is a paucity of data regarding nutritional counseling prior to TJA.17,19 This multidisciplinary approach could help address patients' morbid obesity and malnutrition and the increased risk profile associated with both. Gandler et al16 conducted a randomized, controlled trial of 40 obese patients prior to TJA. A BMI cutoff of greater than 30 kg/m2 was used as an inclusion criterion. The intervention group (n=22) received 4 visits with a dietician, either in person or over the phone, prior to TJA. This was compared with the control group (n=18), which received no additional counseling. At 12 months postoperatively, the intervention group demonstrated greater change in BMI compared with the control group: 1.38 kg/m2 vs −0.84 kg/m2, respectively (P=.01). They also reported that a higher percentage of patients in the treatment group (80%) were able to maintain and not gain weight postoperatively vs the control group (43.8%).
Cao et al33 examined short-term nutritional supplementation immediately prior to and following TJA. Rates of albumin transfusion, electrolyte disturbance, and complications were used as outcome parameters. Patients were given nutritional powder the evening prior to and following surgery, along with a shorter window of restricted enteral intake. They demonstrated statistically significant reductions in the rate of albumin transfusion, shorter hospital stays, and lower rates of certain electrolyte disturbances in the treatment group. Fewer patients in the treatment group experienced complications, including superficial infection, deep infection, and wound complications. However, no statistical significance could be reached regarding these findings, likely secondary to the low power of the study, which included 162 patients divided equally between the treatment and control groups.
Other studies have stratified complication rates following TJA based on BMI. Jeschke et al34 found that 90-day complications occurred at a rate of 12.4% for a BMI 40 kg/m2 or greater. At the time of surgery, the mean BMI of the authors' surgical intervention group was 39.9 kg/m2, with a 12.3% incidence of complications. Although the current study was not powered to directly compare complication rates, its complication rates are consistent with this literature. The authors conclude that in the setting of their nutritional counseling program, patients safely underwent TJA.
One commonly recommended treatment for weight loss prior to TJA is bariatric surgery.21–25 Despite reliably assisting in weight loss, it is uncertain whether this intervention leads to decreased complication rates following TJA.28,29 The exact mechanism that confers the persistently elevated risk following bariatric surgery is still unknown. It has been demonstrated that, following bariatric surgery, the absorption of calcium, vitamin D, and other micronutrients is altered. This leads to changes in bony metabolism and a decrease in bone mineral density.35–38 This could be considered a “second hit” to the patient's bone health, because many morbidly obese patients are paradoxically malnourished.39,40 Malnutrition itself has been demonstrated to be an independent risk factor for the same complications as obesity following TJA.41–46 As a result, following bariatric surgery, it is recommended that procedure-specific supplementation be administered to mitigate the resultant osteopenia and malnutrition.47 A 2-year waiting period may also be required to allow metabolic normalization prior to additional elective surgery.32
Following bariatric surgery, patients have been shown to be at an increased risk of fracture, possibly due to this alteration in bony metabolism.48–50 The effect of decreased bone mineral density may be most pronounced in postmenopausal women.51 In the current series of patients, there were 2 periprosthetic fractures necessitating revision. The increased risk of fracture following weight loss by any method must be carefully considered by surgeons recommending this as part of their preoperative optimization protocol for morbidly obese TJA candidates. Additionally, obesity leads to technical challenges during surgery, as evidenced by longer operative times and an increased risk of periprosthetic fracture.5,11,12,52,53 Periprosthetic fracture is multifactorial. The current study did not allow the authors to conclude any causal relationship between weight loss and fracture, but the authors recommend a heightened awareness of this potential complication in this patient population.
Limitations of this study included that the authors did not capture patients referred for nutritional counseling who did not begin the program. Thus, the number of patients who are appropriate for this sort of program is greater than the authors have represented in their study. Likewise, the number of patients lost to follow-up underestimates those unwilling to participate in nutritional counseling. How best to motivate these patients to attend and complete counseling recommendations should be considered because those who did had a high rate of successful and safe TJA. Another limitation was that the authors did not measure nutritional laboratory values to evaluate the metabolic impact of weight reduction during a short period or how nutritional counseling may affect these parameters preoperatively.
Further study should prospectively examine the influence of BMI reduction on the rate of complications following TJA. Currently, there is a large prospective, randomized, controlled study being conducted to evaluate the effect of bariatric surgery prior to TJA, referred to as the SWIFT trial.54 Further study should also evaluate the prevalence and effect of malnutrition in the setting of dramatic BMI reduction as part of the preoperative optimization for TJA. The authors recommend measuring nutritional laboratory values such as serum albumin and total lymphocyte count in this patient population.
The unique design of the treatment protocol, which is thus far underrep-resented in the arthroplasty literature, was a strength of this study. Currently, there are no other studies evaluating pre-operative referral to a dietician and the resultant change in BMI prior to TJA. Given the forecasted increase in obesity and need for arthroplasty, it is essential that all possible measures to curb the increased complication rate and subsequent burden of revision surgery be fully evaluated.
The authors demonstrated that formal nutritional counseling with a dietitian translated to weight reduction and successful and safe TJA in a majority of morbidly obese patients. This program may be an alternative to more invasive interventions such as preoperative bariatric surgery, which has not conclusively demonstrated risk reduction after TJA. Surgeons must take an active role in advocating for weight optimization in morbidly obese patients at a known increased risk of complications following TJA. The authors also offer a caution regarding the potential for malnutrition and altered bone metabolism in this patient population, particularly after dramatic weight reduction, and believe that further research is warranted.
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- Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and uni-lateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24(6)(suppl):84–88. doi:10.1016/j.arth.2009.05.016 [CrossRef] PMID:19604665
- Zusmanovich M, Kester BS, Schwarzkopf R. Postoperative complications of total joint arthroplasty in obese patients stratified by BMI. J Arthroplasty. 2018;33(3):856–864. doi:10.1016/j.arth.2017.09.067 [CrossRef]
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|Age, mean±SD (range), y||62.6±8.50 (25–82)|
|Male, No.||53 (39.9%)|
|Female, No.||80 (60.2%)|
|Knee osteoarthritis, No.||94 (68.6%)|
|Hip osteoarthritis, No.||39 (31.4%)|
|Body mass index, mean±SD (range), kg/m2||44.6±3.9 (40–61.9)|
|Charlson Comorbidity Index, mean±SD (range)||3.0±1.07 (1–6)|
|Length of treatment, mean±SD (range), d||147.2±137 (8–601)|
|Dietician visits, mean±SD, No.||3.8±2.6 (1–18)|
Reasons for Not Continuing Dietary Counseling
|Unrelated illness or personal issues||3||13.6|
|Pursued surgery elsewhere||3||13.6|
|Unable to be reached||4||18.2|
|Sought alternative treatment||1||4.5|
|Dissatisfied with counseling||1||4.5|
Weight Loss Quantification Stratified by Counseling Participation
|Patient Demographic||Mean±SD (Range)|
|Patients Lost to Follow-up||All Patients Who Participated in Counseling||Patients Who Successfully Went on to Total Joint Arthroplasty|
|Initial body mass index, kg/m2||45.0±3.2 (40–51.6)||44.6±4.0 (40.1–61.9)||42.9±2.25 (40.1–51)|
|Change in body mass index, kg/m2||0.39±1.84 (−4.6–3.2)||2.70±2.6 (−6.3–17.7)||2.92±1.91 (−4.6–8.4)|
|Weight loss, lb||3.21±10.1 (−21–20)||17.1±14 (−30–83)||18.0±11.1 (−6–46)|
|Duration of care, d||-||154±141 (8–601)||129±116 (8–601)|
|Visits with dietician, No.||1||4.1±2.7 (1–18)||4±2.2 (1–12)|
Complications Following Total Joint Arthroplasty for Patients Who Completed Nutritional Counseling
|Complication||No. of Patients||Required Reoperation||Percent Total Joint Arthroplasty Population|
|Wound healing delayed||2||No||2.7|
|Periprosthetic fracture||2||Yes (2)||2.7|
|Superficial infection||1||Yes (1)||1.4|
|Manipulation under anesthesia||1||Yes (1)||1.4|
|Peroneal nerve palsy||1||No||1.4|
|Inpatient medical complications||1||No||1.4|
|Hematoma with cellulitis||1||No||1.4|