Abstract
Background
Elevated body mass index (BMI) is a risk factor for adverse outcomes following total
hip arthroplasty (THA). It is unknown if preoperative weight loss to a BMI <40 kg/m2 is associated with reduced risk of adverse outcomes.
Methods
We retrospectively reviewed elective, primary THA performed at an academic center
from 2015 to 2019. Patients were split into groups based on their BMI trajectory prior
to THA: BMI consistently <40 (“BMI <40”); BMI >40 at the time of surgery (“BMI >40”);
and BMI >40 within 2 years preoperatively, but <40 at the time of surgery (“Weight
Loss”). Length of stay (LOS), 30-day readmissions, and complications as defined by
Centers for Medicare and Medicaid Services were compared between groups using parsimonious
regression models and Fisher’s exact testing. Adjusted analyses controlled for sex,
age, and American Society of Anesthesiologists class.
Results
In total, 1589 patients were included (BMI <40: 1387, BMI >40: 96, Weight Loss: 106).
The rate of complications in each group was 3.5%, 6.3%, and 8.5% and the rate of 30-day
readmissions was 3.0%, 4.2%, and 7.5%, respectively. Compared to the BMI <40 group,
the weight loss group had a significantly higher risk of 30-day readmission (odds
ratio [OR] 2.70, 95% confidence interval [CI] 1.19-6.17, P = .02), higher risk of any complication (OR 2.47, 95% CI 1.09-5.59, P = .03), higher risk of mechanical complications (OR 3.07, 95% CI 1.14-8.25, P = .03), and longer median LOS (16% increase, P = .002). The BMI >40 group had increased median LOS (10% increase, P = .03), but no difference in readmission or complications (P > .05) compared to BMI <40.
Conclusion
Weight loss from BMI >40 to BMI <40 prior to THA was associated with increased risk
of readmission and complications compared to BMI <40, whereas BMI >40 was not.
Level of evidence
Level III – Retrospective Cohort Study.
Keywords
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References
- Projected U.S. State-level prevalence of adult obesity and severe obesity.N Engl J Med. 2019; 381: 2440-2450https://doi.org/10.1056/NEJMsa1909301
- Weight change and change in tibial cartilage volume and symptoms in obese adults.Ann Rheum Dis. 2015; 74: 1024-1029https://doi.org/10.1136/annrheumdis-2013-204488
- Surgical risks and costs of care are greater in patients who are super obese and undergoing THA.Clin Orthop Relat Res. 2016; 474: 2472-2481https://doi.org/10.1007/s11999-016-5039-1
- Delineating the impact of obesity and its relationship on recovery after total joint arthroplasties.Osteoarthritis Cartilage. 2012; 20: 511-518https://doi.org/10.1016/j.joca.2012.02.637
- Obesity and total joint arthroplasty: a literature based review.J Arthroplasty. 2013; 28: 714-721https://doi.org/10.1016/j.arth.2013.02.011
- The risk of surgical site infection and re-admission in obese patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively.Bone Joint J. 2014; 96-B: 629-635https://doi.org/10.1302/0301-620X.96B5.33136
- Effect of non-surgical, non-pharmacological weight loss interventions in patients who are obese prior to hip and knee arthroplasty surgery: a rapid review.Syst Rev. 2015; 4: 121https://doi.org/10.1186/s13643-015-0107-2
- Risk reduction compared with access to care: quantifying the trade-off of enforcing a body mass index eligibility criterion for joint replacement.J Bone Joint Surg Am. 2018; 100: 539-545https://doi.org/10.2106/JBJS.17.00120
- Preoperative weight loss for morbidly obese patients undergoing total knee arthroplasty: determining the necessary amount.J Bone Joint Surg Am. 2019; 101: 1440-1450https://doi.org/10.2106/JBJS.18.01136
- 2017 Procedure-Specific Measure Updates and Specifications Report Hospital-Level- Risk-Standardized Complication Measure: Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA).US Department of Health & Human Services, Washington, D.C.2017
- Development and validation of perioperative risk-adjustment models for hip fracture repair, total hip arthroplasty, and total knee arthroplasty.J Bone Joint Surg Am. 2016; 98: e2https://doi.org/10.2106/JBJS.N.01330
- Markers for malnutrition and BMI status in total joint arthroplasty and pharmaconutrient therapy.JBJS Rev. 2019; 7: e3https://doi.org/10.2106/JBJS.RVW.18.00056
- Total knee replacement in morbidly obese patients. Results of a prospective, matched study.J Bone Joint Surg Br. 2006; 88: 1321-1326https://doi.org/10.1302/0301-620X.88B10.17697
- Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI.J Arthroplasty. 2015; 30: 42-46https://doi.org/10.1016/j.arth.2015.03.045
- Effect of body mass index on reoperation and complications after total knee arthroplasty.J Bone Joint Surg Am. 2016; 98: 2052-2060https://doi.org/10.2106/JBJS.16.00093
- Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.J Bone Joint Surg Am. 2007; 89: 33-38https://doi.org/10.2106/JBJS.F.00163
- Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates.J Arthroplasty. 2009; 24: 84-88https://doi.org/10.1016/j.arth.2009.05.016
- Statistical methods dictate the estimated impact of body mass index on major and minor complications after total joint arthroplasty.Clin Orthop Relat Res. 2018; 476: 2418-2429
- Bariatric surgery prior to total joint arthroplasty may not provide dramatic improvements in post-arthroplasty surgical outcomes.J Arthroplasty. 2014; 29: 1359-1364https://doi.org/10.1016/j.arth.2014.02.021
- Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis.Bone Joint J. 2016; 98-B: 1160-1166https://doi.org/10.1302/0301-620X.98B9.38024
- Bariatric surgery does not improve outcomes in patients undergoing primary total knee arthroplasty.Bone Joint J. 2015; 97-B: 1501-1505https://doi.org/10.1302/0301-620X.97B11.36477
- Bariatric surgery improves outcomes after lower extremity arthroplasty in the morbidly obese: a propensity score-matched analysis of a New York statewide database.J Arthroplasty. 2018; 33: 2062-2069.e4https://doi.org/10.1016/j.arth.2017.11.056
- Does prior bariatric surgery improve outcomes following total joint arthroplasty in the morbidly obese? A meta-analysis.J Arthroplasty. 2019; 34: 577-585https://doi.org/10.1016/j.arth.2018.11.018
- Bariatric surgery prior to total knee arthroplasty is associated with fewer postoperative complications.J Arthroplasty. 2015; 30: 81-85https://doi.org/10.1016/j.arth.2014.11.039
- Impact of bariatric surgery on inpatient complication, cost, and length of stay following total hip or knee arthroplasty.J Arthroplasty. 2019; 34: 2884-2889.e4https://doi.org/10.1016/j.arth.2019.07.012
- Percent body fat is more predictive of function after total joint arthroplasty than body mass index.J Bone Joint Surg Am. 2016; 98: 849-857https://doi.org/10.2106/JBJS.15.00509
- Malnutrition in bariatric surgery candidates: multiple micronutrient deficiencies prior to surgery.Obes Surg. 2016; 26: 833-838https://doi.org/10.1007/s11695-015-1844-y
- Preoperative malnutrition negatively correlates with postoperative wound complications and infection after total joint arthroplasty: a systematic review and meta-analysis.J Arthroplasty. 2019; 34: 1013-1024https://doi.org/10.1016/j.arth.2019.01.005
- Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an Urban Academic Hospital.J Arthroplasty. 2014; 29: 272-276https://doi.org/10.1016/j.arth.2013.06.019
- Low albumin levels, more than morbid obesity, are associated with complications after TKA.Clin Orthop. 2015; 473: 3163-3172https://doi.org/10.1007/s11999-015-4333-7
- The cost of malnutrition in total joint arthroplasty.J Arthroplasty. 2020; 35: 926-932.e1https://doi.org/10.1016/j.arth.2019.11.018
Article info
Publication history
Published online: November 19, 2021
Accepted:
November 16,
2021
Received in revised form:
November 3,
2021
Received:
August 21,
2021
Footnotes
Disclosure: I (and my co-authors) have nothing to disclose.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Source of Funding: None.
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2021.11.024.
Identification
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