What is the Impact of Body Mass Index Cutoffs on Total Knee Arthroplasty Complications?

Published:December 21, 2021DOI:https://doi.org/10.1016/j.arth.2021.12.024

      Abstract

      Background

      Body mass index (BMI) cutoffs are commonly used to decide whether to offer obese patients elective total knee arthroplasty (TKA). However, weight loss goals may be unachievable for many patients who are consequentially denied complication-free surgery. The purpose of this study was to assess the impact of different BMI cutoffs on the rates of complication-free surgery after TKA.

      Methods

      Patients undergoing elective, primary TKA from 2015 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27447. The BMI and rates of any thirty-day complication were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if TKA would have been allowed or denied based on the BMI.

      Results

      A total of 314,719 patients underwent TKA, and 46,386 (14.7%) had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 268,333 (85.3%) patients would have undergone TKA. A total of 282,552 (94.8%) would experience complication-free surgery, and 17.3% of all complications would be prevented. TKA would proceed for 309,479 (98.3%) patients at a BMI cutoff of 50 kg/m2. A total of 293,108 (94.7%) would not experience a complication, and 2.8% of complications would be prevented. A BMI cutoff of 35 kg/m2 would prevent 36.6% of all complications while allowing 94.8% of complication-free surgeries to proceed.

      Conclusion

      Lower BMI cutoffs can reduce complications, but will limit access to complication-free TKA for many patients. These data do not indicate TKA should be performed without consideration of risks from obesity; however, a holistic assessment and shared decision-making may be more valuable when deciding on appropriate goal weight reduction.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Inoue Y.
        • Qin B.
        • Poti J.
        • Sokol R.
        • Gordon-Larsen P.
        Epidemiology of obesity in adults: latest trends.
        Curr Obes Rep. 2018; 7: 276-288https://doi.org/10.1007/s13679-018-0317-8
        • Hales C.M.
        • Fryar C.D.
        • Carroll M.D.
        • Freedman D.S.
        • Ogden C.L.
        Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016.
        JAMA. 2018; 319: 1723-1725https://doi.org/10.1001/jama.2018.3060
        • Gelber A.C.
        • Hochberg M.C.
        • Mead L.A.
        • Wang N.-Y.
        • Wigley F.M.
        • Klag M.J.
        Body mass index in young men and the risk of subsequent knee and hip osteoarthritis.
        Am J Med. 1999; 107: 542-548https://doi.org/10.1016/S0002-9343(99)00292-2
        • Apold H.
        • Meyer H.E.
        • Nordsletten L.
        • Furnes O.
        • Baste V.
        • Flugsrud G.B.
        Weight gain and the risk of knee replacement due to primary osteoarthritis: a population based, prospective cohort study of 225,908 individuals.
        Osteoarthritis Cartilage. 2014; 22: 652-658https://doi.org/10.1016/j.joca.2014.03.002
        • Manninen P.
        • Riihimaki H.
        • Heliövaara M.
        • Suomalainen O.
        Weight changes and the risk of knee osteoarthritis requiring arthroplasty.
        Ann Rheum Dis. 2004; 63: 1434-1437https://doi.org/10.1136/ard.2003.011833
        • Kulkarni K.
        • Karssiens T.
        • Kumar V.
        • Pandit H.
        Obesity and osteoarthritis.
        Maturitas. 2016; 89: 22-28https://doi.org/10.1016/j.maturitas.2016.04.006
        • Dawson J.
        • Juszczak E.
        • Thorogood M.
        • Marks S.-A.
        • Dodd C.
        • Fitzpatrick R.
        An investigation of risk factors for symptomatic osteoarthritis of the knee in women using a life course approach.
        J Epidemiol Community Health. 2003; 57: 823-830https://doi.org/10.1136/jech.57.10.823
        • Holmberg S.
        • Thelin A.
        • Thelin N.
        Knee osteoarthritis and body mass index: a population-based case-control study.
        Scand J Rheumatol. 2005; 34: 59-64https://doi.org/10.1080/03009740510017922
        • Felson D.T.
        • Zhang Y.
        • Anthony J.M.
        • Naimark A.
        • Anderson J.J.
        Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study.
        Ann Intern Med. 1992; 116: 535-539https://doi.org/10.7326/0003-4819-116-7-535
        • Nicholls A.S.
        • Kiran A.
        • Javaid M.K.
        • Hart D.J.
        • Spector T.D.
        • Carr A.J.
        • et al.
        Change in body mass index during middle age affects risk of total knee arthoplasty due to osteoarthritis: a 19-year prospective study of 1003 women.
        Knee. 2012; 19: 316-319https://doi.org/10.1016/j.knee.2011.06.008
        • George J.
        • Klika A.K.
        • Navale S.M.
        • Newman J.M.
        • Barsoum W.K.
        • Higuera C.A.
        Obesity epidemic: is its impact on total joint arthroplasty underestimated? An analysis of national trends.
        Clin Orthop Relat Res. 2017; 475: 1798-1806https://doi.org/10.1007/s11999-016-5222-4
        • Cram P.
        • Lu X.
        • Kates S.L.
        • Singh J.A.
        • Li Y.
        • Wolf B.R.
        Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010.
        JAMA. 2012; 308: 1227-1236https://doi.org/10.1001/2012.jama.11153
        • Odum S.M.
        • Springer B.D.
        • Dennos A.C.
        • Fehring T.K.
        National obesity trends in total knee arthroplasty.
        J Arthroplasty. 2013; 28: 148-151https://doi.org/10.1016/j.arth.2013.02.036
        • Derman P.B.
        • Fabricant P.D.
        • David G.
        The role of overweight and obesity in relation to the more rapid growth of total knee arthroplasty volume compared with total hip arthroplasty volume.
        J Bone Joint Surg Am. 2014; 96: 922-928https://doi.org/10.2106/JBJS.L.01731
        • Zusmanovich M.
        • Kester B.S.
        • Schwarzkopf R.
        Postoperative complications of total joint arthroplasty in obese patients stratified by BMI.
        J Arthroplasty. 2018; 33: 856-864https://doi.org/10.1016/j.arth.2017.09.067
        • D’Apuzzo M.R.
        • Novicoff W.M.
        • Browne J.A.
        The John Insall Award: morbid obesity independently impacts complications, mortality, and resource use after TKA.
        Clin Orthop Relat Res. 2015; 473: 57-63https://doi.org/10.1007/s11999-014-3668-9
        • Meller M.M.
        • Toossi N.
        • Gonzalez M.H.
        • Son M.-S.
        • Lau E.C.
        • Johanson N.
        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
        • Ward D.T.
        • Metz L.N.
        • Horst P.K.
        • Kim H.T.
        • Kuo A.C.
        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
        • Wagner E.R.
        • Kamath A.F.
        • Fruth K.M.
        • Harmsen W.S.
        • Berry D.J.
        Effect of body mass index on complications and reoperations after total hip arthroplasty.
        J Bone Joint Surg Am. 2016; 98: 169-179https://doi.org/10.2106/JBJS.O.00430
        • George J.
        • Piuzzi N.S.
        • Ng M.
        • Sodhi N.
        • Khlopas A.A.
        • Mont M.A.
        Association between body mass index and thirty-day complications after total knee arthroplasty.
        J Arthroplasty. 2018; 33: 865-871https://doi.org/10.1016/j.arth.2017.09.038
        • Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee
        Obesity and total joint arthroplasty: a literature based review.
        J Arthroplasty. 2013; 28: 714-721https://doi.org/10.1016/j.arth.2013.02.011
        • Foreman C.W.
        • Callaghan J.J.
        • Brown T.S.
        • Elkins J.M.
        • Otero J.E.
        Total joint arthroplasty in the morbidly obese: how body mass index ≥40 influences patient retention, treatment decisions, and treatment outcomes.
        J Arthroplasty. 2020; 35: 39-44https://doi.org/10.1016/j.arth.2019.08.019
        • Springer B.D.
        • Roberts K.M.
        • Bossi K.L.
        • Odum S.M.
        • Voellinger D.C.
        What are the implications of withholding total joint arthroplasty in the morbidly obese? A prospective, observational study.
        Bone Joint J. 2019; 101-B: 28-32https://doi.org/10.1302/0301-620X.101B7.BJJ-2018-1465.R1
        • DeMik D.E.
        • Carender C.N.
        • Glass N.A.
        • Brown T.S.
        • Callaghan J.J.
        • Bedard N.A.
        Are surgeons still performing primary total knee arthroplasty in the morbidly obese?.
        Bone Joint J. 2021; 103-B: 38-44https://doi.org/10.1302/0301-620X.103B6.BJJ-2020-1966.R1
        • Godziuk K.
        • Prado C.M.
        • Beaupre L.
        • Jones C.A.
        • Werle J.R.
        • Forhan M.
        A critical review of weight loss recommendations before total knee arthroplasty.
        Joint Bone Spine. 2021; 88: 105114https://doi.org/10.1016/j.jbspin.2020.105114
        • Inacio M.C.S.
        • Kritz-Silverstein D.
        • Raman R.
        • Macera C.A.
        • Nichols J.F.
        • Shaffer R.A.
        • et al.
        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
        • Giori N.J.
        • Amanatullah D.F.
        • Gupta S.
        • Bowe T.
        • Harris A.H.S.
        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
        • ACS NSQIP Participant Use Data File
        American College of Surgeons.
        • Shiloach M.
        • Frencher S.K.
        • Steeger J.E.
        • Rowell K.S.
        • Bartzokis K.
        • Tomeh M.G.
        • et al.
        Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program.
        J Am Coll Surg. 2010; 210: 6-16https://doi.org/10.1016/j.jamcollsurg.2009.09.031
        • Zhang J.C.
        • Matelski J.
        • Gandhi R.
        • Jackson T.
        • Urbach D.
        • Cram P.
        Can patient selection explain the obesity paradox in orthopaedic hip surgery? An analysis of the ACS-NSQIP registry.
        Clin Orthop Relat Res. 2018; 476: 964-973https://doi.org/10.1007/s11999.0000000000000218
        • Roth A.
        • Anis H.K.
        • Emara A.K.
        • Klika A.K.
        • Barsoum W.K.
        • Bloomfield M.R.
        • et al.
        The potential effects of imposing a body mass index threshold on patient-reported outcomes after total knee arthroplasty.
        J Arthroplasty. 2021; 36: S198-S208https://doi.org/10.1016/j.arth.2020.08.060
        • Watts C.D.
        • Houdek M.T.
        • Wagner E.R.
        • Taunton M.J.
        Subcutaneous fat thickness is associated with early reoperation and infection after total knee arthroplasty in morbidly obese patients.
        J Arthroplasty. 2016; 31: 1788-1791https://doi.org/10.1016/j.arth.2016.02.008
        • Elkins J.M.
        • Simoens K.J.
        • Callaghan J.J.
        Lower extremity geometry in morbid obesity-considerations for total knee arthroplasty.
        J Arthroplasty. 2018; 33: 3304-3312https://doi.org/10.1016/j.arth.2018.03.060
        • Babu J.M.
        • Kalagara S.
        • Durand W.
        • Antoci V.
        • Deren M.E.
        • Cohen E.
        Sarcopenia as a risk factor for prosthetic infection after total hip or knee arthroplasty.
        J Arthroplasty. 2019; 34: 116-122https://doi.org/10.1016/j.arth.2018.09.037
        • Ardeljan A.D.
        • Polisetty T.S.
        • Palmer J.
        • Vakharia R.M.
        • Roche M.W.
        Comparative analysis on the effects of sarcopenia following primary total knee arthroplasty: a retrospective matched-control analysis.
        J Knee Surg. 2020; https://doi.org/10.1055/s-0040-1713355