Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention, Treatment Decisions, and Treatment Outcomes

Foreman, Cameron; Callaghan, John J.; Brown, Timothy S.; Elkins, Jacob M.; Otero, Jesse E.

doi:10.1016/j.arth.2019.08.019

Cited by 39 publications

(16 citation statements)

References 11 publications

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“…The policies may have prevented access to surgery for patients in need of surgery, but who were unable or unwilling to lose sufficient weight to reach eligibility thresholds. Studies suggest that patients with BMI 40+ rarely find it possible to lose significant weight through lifestyle and pharmacological interventions alone when advised to do so for surgery, and that their response to being asked to lose weight may be to cease their pursuit of care for their joint symptoms despite needing surgery [ 31 , 32 ]. This may account for some of the reduction in rate of surgery in the obese patient group.…”

Section: Discussionmentioning

confidence: 99%

What effect have NHS commissioners’ policies for body mass index had on access to knee replacement surgery in England?: An interrupted time series analysis from the National Joint Registry

et al. 2022

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Objective To assess the impact of local commissioners’ policies for body mass index on access to knee replacement surgery in England. Methods A Natural Experimental Study using interrupted time series and difference-in-differences analysis. We used National Joint Registry for England data linked to the 2015 Index of Multiple Deprivation for 481,555 patients who had primary knee replacement surgery in England between January 2009 and December 2019. Clinical Commissioning Group policies introduced before June 2018 to alter access to knee replacement for patients who were overweight or obese were considered the intervention. The main outcome measures were rate per 100,000 of primary knee replacement surgery and patient demographics (body mass index, Index of Multiple Deprivation, independently-funded surgery) over time. Results Rates of surgery had a sustained fall after the introduction of a policy (trend change of -0.98 operations per 100,000 population aged 40+, 95% confidence interval -1.22 to -0.74, P<0.001), whereas rates increased in localities with no policy introduction. At three years after introduction, there were 10.5 per 100,000 population fewer operations per quarter aged 40+ compared to the counterfactual, representing a fall of 14.1% from the rate expected had there been no change in trend. There was no dose response effect with policy severity. Rates of surgery fell in all patient groups, including non-obese patients following policy introduction. The proportion of independently-funded operations increased after policy introduction, as did the measure of socioeconomic deprivation of patients. Conclusions Body mass index policy introduction was associated with decreases in the rates of knee replacement surgery across localities that introduced policies. This affected all patient groups, not just obese patients at whom the policies were targeted. Changes in patient demographics seen after policy introduction suggest these policies may increase health inequalities and further qualitative research is needed to understand their implementation and impact.

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Section: Discussionmentioning

confidence: 99%

What effect have NHS commissioners’ policies for body mass index had on access to knee replacement surgery in England?: An interrupted time series analysis from the National Joint Registry

et al. 2022

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“…Some surgeons recommend deferring THA and TKA for patients with obesity category III (BMI 40 to 45), 20 given evidence in the literature demonstrating increased complications in this morbid obesity category. 42 However, the ethics of denial of TJA in patients with a BMI of > 40 is debated because some investigators have found no or only modest, increased risk, 43 particularly when controlling for nutrition status and other obesity-related comorbidities. 44-46 Although there may be an increase in perioperative complications, the outcomes of TJA remain excellent, even in the morbidly obese cohort.…”

Section: Clinical Implications Of Obesity Related To Total Knee Arthr...mentioning

confidence: 99%

Movement Is Life—Optimizing Patient Access to Total Joint Arthroplasty: Obesity Disparities

Sabesan

Rankin

Nelson

2022

J Am Acad Orthop Surg

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Thirty five percent of the American population is considered obese (body mass index [BMI] . 30). Obesity disproportionately affects African Americans, Hispanics, and women. Obesity is associated with postoperative complications, including wound complications, infections, and revision total joint arthroplasty (including total hip arthroplasty and total knee arthroplasty). Current BMI benchmarks (many institutions rely on a BMI of 40) selectively preclude patients from having surgery. Patients in these underserved populations can be optimized through the lens of shared decision making through the assessment of food security (eg, food deserts and food swamps), ability to afford healthy food, knowledge of social safety net and community resources to access healthy food, nutrition and weight loss referrals to programs that accept all forms of insurance, weight loss measurements as a percentage of body weight lost instead of BMI cutoffs, pharmacologic modalities, and bariatric surgery.O besity, defined as body mass index (BMI) . 30, is an ever-expanding challenge for adult reconstructive surgeons. Currently, 35% of the US population is considered obese, and the percentage of obese adults continues to increase in the United States and worldwide. 1 Moreover, there is an association between obesity and knee osteoarthritis; therefore, there will likely be increasing numbers of obese and morbidly obese individuals needing total joint arthroplasty (TJA) in the coming years. In addition, many obese individuals are surprisingly malnourished, with low levels of serum albumin, vitamin D, and iron. 2 Both nutrition and obesity are intricately linked to food security, with 10.5% of the American households being food insecure. 3 Food insecurity and the rates of obesity are higher in Hispanics, African Americans, and women, as well as those of lower socioeconomic status (SES). [3][4][5][6][7][8] Unfortunately, rates of obesity are higher in those who experience long-term chronic stress, 8 positioning women of color at the apex of risk for obesity. Collectively, this showcases that intersectionality creates a compounded risk for populations who are already marginalized in American society.Breaking the vicious cycle of joint pain is challenging for those of lower SES. Obesity is associated with osteoarthritis, and osteoarthritis is associated with

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“…For patients deemed to be at unacceptably high risk secondary to obesity, surgeons will often deny TJA and prescribe weight loss, with a goal BMI of <40 kg/m 2 [ 13 ]. Recently, the effectiveness of withholding surgery to incentivize weight loss in the morbidly obese has come under question, as nearly half of patients who are prescribed weight loss do not return for a second office visit, and of the half that do, less than half eventually undergo TJA, at a mean BMI exceeding 40 kg/m 2 [ [14] , [15] , [16] ]. Furthermore, recent investigation has paradoxically associated rapid weight loss preceding elective TJA with an increased risk for complications [ 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

Prevalence of Sarcopenia and Sarcopenic Obesity in an Academic Total Joint Arthroplasty Practice

et al. 2022

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Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention, Treatment Decisions, and Treatment Outcomes

Cited by 39 publications

References 11 publications

What effect have NHS commissioners’ policies for body mass index had on access to knee replacement surgery in England?: An interrupted time series analysis from the National Joint Registry

What effect have NHS commissioners’ policies for body mass index had on access to knee replacement surgery in England?: An interrupted time series analysis from the National Joint Registry

Movement Is Life—Optimizing Patient Access to Total Joint Arthroplasty: Obesity Disparities

Prevalence of Sarcopenia and Sarcopenic Obesity in an Academic Total Joint Arthroplasty Practice

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