Operative Techniques to Reduce Hip and Knee Arthroplasty Complications in Morbidly Obese Patients

Rankin, Kelsey A; Gibson, David; Schwarzkopf, Ran; O’Connor, Mary I.; Wiznia, Daniel H.

doi:10.1016/j.artd.2022.07.016

Cited by 10 publications

(5 citation statements)

References 79 publications

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“…Based on survey responses, the patient appears to bear the burden of increased surgical risk and responsibility related to BMI 22 . However, BMI-based surgical restrictions may be a resource allocation issue, whereby finite health system resources (e.g., financial, operational) are distributed on the basis of current priorities and preferences.…”

Section: Discussionmentioning

confidence: 99%

“…Surgeons may have had lower exposure to patients with high BMI in residency if their training institution enforced patient BMI limitations. Operative techniques 22 and surgical experience performing TJA in larger bodies 23 can influence surgical risk. Increasing exposure to patients with high BMI during surgical training and provision of adequate surgical resources will be key to ensuring equitable access and the best-quality care for individuals with larger bodies proceeding to TJA.…”

Section: Surgeon Beliefs and Biasesmentioning

confidence: 99%

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Consistent Factors Influence Body Mass Index Thresholds for Total Joint Arthroplasty Across Health-Care Systems

Godziuk,

Fast,

Righolt

et al. 2024

Journal of Bone and Joint Surgery

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Background: Body mass index (BMI) thresholds are used as eligibility criteria to reduce complication risk in total joint arthroplasty (TJA). This approach oversimplifies preoperative risk assessment and inadvertently restricts access to effective surgical treatment for osteoarthritis. A prior survey of orthopaedic surgeons in the United States identified complex underlying factors that influence BMI considerations. To understand whether similar factors exist and influence surgeons in a different health-care system setting, we investigated Canadian surgeons’ views and use of BMI criterion thresholds for TJA access. Methods: A cross-sectional online qualitative survey was conducted with orthopaedic surgeons performing TJA in the Canadian health-care system. Responses were anonymous and questions were open-ended to allow for candid perspectives. Survey data were coded and a systematic process was followed to identify major themes. Findings were compared with U.S. surgeon perspectives. Results: Sixty-nine respondents had a mean age of 49.0 ± 11.4 years (range, 33 to 79 years), with a mean surgical experience duration of 15.7 ± 11.4 years (range, 2 to 50 years). Surgeons reported variable use of BMI thresholds in practice. Twelve interconnected factors that influence BMI considerations were identified: (1) variable evidence interpretation, (2) surgical challenge, (3) surgeon beliefs and biases, (4) hospital differences, (5) access to resources, (6) health system bias, (7) patient health status, (8) patient body fat distribution, (9) patient decisional burden (to lose weight or accept risk), (10) evidence gaps and uncertainties, (11) need for innovation, and (12) societal views. Nine themes matched with findings from U.S. surgeons. Conclusions: Parallel to the United States, complex, interconnected factors influence Canadian orthopaedic surgeons’ variable use of BMI restrictions for TJA eligibility. Despite different health-care systems and reimbursement models, similar technical and personal factors were identified. With TJA practice guidelines advising against hard BMI criteria, attention regarding access to resources, surgical training, and innovations to address TJA complexity in patients with large bodies are critically needed. Future advancements in this sphere must balance barrier removal with risk reduction to ensure safe and equitable surgical care. Clinical Relevance: This study may influence surgeon behaviors with regard to hard BMI cutoffs for TJA and encourage critical thought about factors that influence decisions about surgical eligibility for patients with high BMI.

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Section: Discussionmentioning

confidence: 99%

Section: Surgeon Beliefs and Biasesmentioning

confidence: 99%

Consistent Factors Influence Body Mass Index Thresholds for Total Joint Arthroplasty Across Health-Care Systems

Godziuk,

Fast,

Righolt

et al. 2024

Journal of Bone and Joint Surgery

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“…Preoperatively, planning should be done to evaluate actions that may extend the operation and make decisions on whether these actions are essential or whether adjustments should be made to enhance the efficiency of the operation [1]. Efficiencies can be gained through radiographic templating and the use of modified instruments [12,29,35,42]. Surgical team efficiency plays a role in surgical duration.…”

Section: Discussion Of Key Findingsmentioning

confidence: 99%

Is Operative Time Associated With Obesity-related Outcomes in TKA?

Abella,

Angeles,

Finlay

et al. 2023

Clin Orthop Relat Res

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Background Obesity-based cutoffs in TKA are premised on higher rates of postoperative complications. However, operative time may be associated with postoperative complications, leading to an unnecessary restriction of TKA in patients with obesity. If operative time is associated with these obesity-related outcomes, it should be accounted for in order to ensure all measurable factors associated with negative outcomes are examined for patients with obesity after TKA. Questions/purposes We asked: (1) Is operative time, controlling for BMI class, associated with readmission, reoperation, and postoperative major and minor complications? (2) Is operative time associated with a difference in the direction or strength of obesity-related adverse outcomes? Methods In this comparative study, we extracted all records on elective, unilateral TKA between January 2014 and December 2020 in the American College of Surgeons National Surgical Quality Improvement Program database, resulting in an initial sample of 394,381 TKAs. Patients with emergency procedures (0.1% [270]) and simultaneous bilateral TKAs (2% [8736]), missing or null data (1% [4834]), and those with operative times less than 25 minutes (0.1% [548]) were excluded, leaving 96% (379,993) of our original sample size. The National Surgical Quality Improvement Program database was selected because of its inclusion of operative time, which is not found in any other national database. BMI was subdivided into underweight (BMI < 18.5 kg/m2, < 1% [719]), normal weight (BMI 18.5 to 24.9 kg/m2, 9% [34,513]), overweight (BMI 25.0 to 29.9 kg/m2, 27% [101,538]), Class I obesity (BMI 30.0 to 34.9 kg/m2, 29% [111,712]), Class II obesity (BMI 35.0 to 39.9 kg/m2, 20% [76,605]), and Class III obesity (BMI ≥ 40.0 kg/m2, 14% [54,906]). The mean operative time was 91 ± 36 minutes, 61% of patients were women (233,062 of 379,993), and the mean age was 67 ± 9 years. Patients with obesity tended to be younger and more likely to have preoperative comorbidities and longer operative times than patients with normal weight. Multivariable logistic regression models examined the main effects of operative time with respect to 30-day readmission, reoperation, and major and minor medical complications, while adjusting for BMI class and other covariates including age, sex, race, smoking status, and number of preoperative comorbidities. We then evaluated the potential interaction effect of BMI class and operative time. This interaction term helps determine whether the association of BMI with postoperative outcomes changes based on the duration of the surgery, and vice versa. If the interaction term is statistically significant, it implies the association of BMI with adverse postoperative outcomes is inconsistent across all patients. Instead, it varies with the operative time. Adjusted odds ratios and 95% confidence intervals were calculated, and interaction effects were plotted. Results After controlling for obesity, longer procedure duration was independently associated with higher odds of all outcomes (30-minute estimates; adjusted ORs are per minute), including readmission (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), reoperation (15% per half-hour of surgical duration; adjusted OR 1.005 [95% CI 1.004 to 1.005]; p < 0.001), postoperative major complications (9% per half-hour of surgical duration; adjusted OR 1.003 [95% CI 1.003 to 1.004]; p < 0.001), and postoperative minor complications (18% per half-hour of surgical duration; adjusted OR 1.006 [95% CI 1.006 to 1.007]; p < 0.001). The interaction effect indicates that patients with obesity had lower odds of reoperation than patients with normal weight when operative times were shorter, but higher odds of reoperation with a longer operative duration. Conclusion We found that operative time, a proxy for surgical complexity, had a moderate, differential association with obesity over a 30-minute period. Perioperative modification of surgical complexity such as surgical techniques, training, and team dynamics may make safe TKA possible for certain patients who might have otherwise been denied surgery. Decisions to refuse TKA to patients with obesity should be based on a holistic assessment of a patient’s operative complexity, rather than strictly assessing a patient’s weight or their ability to lose weight. Future studies should assess patient-specific characteristics that are associated with operative time, which can further push the development of techniques and strategies that reduce surgical complexity and improve TKA outcomes. Level of Evidence Level III, therapeutic study.

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“…Intraoperative considerations in obese patients include meticulous soft-tissue handling, deep vein thrombosis prophylaxis selection, the necessary size of the surgical team, specialized instruments and tables, stems and components with a cortical interface, and robust wound closure to prevent chronic serosanguinous drainage 26 . Postoperative considerations include techniques to minimize wound drainage, length of stay, and post-discharge costs 27 . Robotic-assisted surgery may assist in minimizing component malalignment 28 .…”

Section: Beneficencementioning

confidence: 99%

Total Joint Arthroplasty in Patients Who Are Obese or Morbidly Obese

Lachance,

Steika,

Lutton

et al. 2024

Journal of Bone and Joint Surgery

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Operative Techniques to Reduce Hip and Knee Arthroplasty Complications in Morbidly Obese Patients

Cited by 10 publications

References 79 publications

Consistent Factors Influence Body Mass Index Thresholds for Total Joint Arthroplasty Across Health-Care Systems

Consistent Factors Influence Body Mass Index Thresholds for Total Joint Arthroplasty Across Health-Care Systems

Is Operative Time Associated With Obesity-related Outcomes in TKA?

Total Joint Arthroplasty in Patients Who Are Obese or Morbidly Obese

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