Obesity epidemic: The ‘hidden’ comorbidity in our patient care

Issue: November 2015

Obesity has reached epidemic proportions, with more than a half a billion people classified as obese. In addition to rising rates in overall obesity, there has been an increase in the number of patients with class 3 or morbid obesity. It is estimated that 7% of the U.S. population is morbidly obese. Between 2000 and 2010, this number has increased by 70%.

In orthopedic surgery, we are seeing an increase in the number of obese patients who seek or require surgery. In particular, this is often a younger and less healthy group, often with multiple medical comorbidities. As such, both elective and nonelective surgeries are associated with a higher rate of complications.

In this Orthopedics Today Round Table, I have asked experts in their respective fields of adult reconstruction, shoulder surgery and trauma to discuss the challenges they face today in the management of obese surgical patients.

Bryan D. Springer, MD
Moderator

Bryan D. Springer, MD: What does the literature tell us about trauma, obesity and outcomes?

Roundtable Participants

Moderator
Bryan D. Springer, MD
Charlotte

Stephen F. Brockmeier, MD
Charlottesville, Va.

Paul Tornetta III, MD
Boston

Kenneth A. Egol, MD
New York City

Paul Tornetta III, MD: Obesity in orthopedic trauma patients is a risk for many problems. These patients are less mobile, have higher infection rates (particularly in central locations), and have more challenges in the perioperative period including prolonged intubation and deep venous thrombosis/pulmonary emboli risk. Due to increased comorbidities and limited ability to maintain restrictions needed in injuries such as periarticular fractures, morbidly obese and super-obese patients are more likely to be discharged to another facility rather than to home, again increasing their potential complication rates. Although little data is currently available regarding the long-term outcomes of fractures in this population, some injuries will logically be affected by obesity. Articular injuries, such as pilon, calcaneus, plateau and midfoot injuries, have high rates of arthrosis even after well-performed reconstructions due to cartilage injury. Increasing the weight above the joint increases the joint reaction force and is likely to accelerate post-traumatic arthritis. Even some more simple injuries, such as syndesmotic disruptions or fracture dislocations of the ankle, may be negatively affected. For this reason, it is important the surgeon have these patients evaluated by and involved with a qualified bariatric program and nutritionists. Weight reduction may preserve function in morbidly obese patients with periarticular injuries.

Kenneth A. Egol, MD: The literature is mixed. There are certain fractures and wounds that have higher incidences of wound and other complications. These patients are also associated with extended hospital stays and lower quality measures. These include lower extremity fractures, such as hip and acetabular fractures, and upper extremity fracture including proximal and distal humeral fractures; while other types of fractures, such as those about the ankle, have not demonstrated a higher incidence of postoperative complications.

Springer: Dr. Brockmeier, you published a study on national data and implications of obesity on shoulder surgery. Can you discuss what you found?

Stephen F. Brockmeier, MD: Obesity has become a major public health concern within the United States, and the current health care climate makes it critical for clinicians to risk stratify and identify factors that may predispose patients to inferior outcomes or an increased risk for complications after elective surgery. In the absence of a national registry, one of the better available resources for population-based study are national databases.

We published a study on the impact of morbid obesity on outcomes after total shoulder arthroplasty (TSA) using a national inpatient database. The study demonstrated an increased risk of postoperative complications, length of stay and higher costs in obese patients. We have subsequently utilized a separate database to research the impact of “super-obesity” defined by a BMI of greater than or equal to 50 kg/m² on outcomes and complications after TSA, as well a risk factors associated with early revision after TSA. Obesity was found to be one of the major factors associated with revision of primary TSA during the first year postoperatively and was associated with significantly increased rates of complications including infection, prosthetic dislocation, component loosening and medical complications. Furthermore, we found super-obesity to be associated with significantly increased rates of several complications, even when compared with obese or morbidly obese patients.

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Springer: How does this impact your practice?

Brockmeier: At our institution, we utilize a number of factors to risk stratify patients prior to elective shoulder surgery. In recent years, patient BMI has become one of the factors I find myself addressing most frequently as we counsel patients on whether they are appropriate candidates for shoulder arthroplasty. It has been my experience that most patients are open and self-aware when you take the time to discuss the impact of BMI on the risk of perioperative complications and outcomes after surgery. Having avenues available for patients to work on weight loss, improved dietary habits, realistic exercise regimens and improvement in their overall health is critical.

A note from the editors

Look for part 2 of this Round Table discussion in the December issue where the experts in joint replacement, shoulder and trauma discuss paradoxical malnutrition and special techniques to use for these patients.

References:
Griffin JW, et al. J Shoulder Elbow Surg. 2014; doi: 10.1016/j.jse.2013.12.027.
Werner BC, et al. J Shoulder Elbow Surg. 2015; doi: 10.1016/j.jse.2015.05.035.
Werner BC, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2015.05.046.

For more information:
Stephen F. Brockmeier MD, can be reached at the University of Virginia School of Medicine, Department of Orthopaedic Surgery, P.O. Box 800159, Charlottesville, VA 22908; email: sfb2e@hscmail.mcc.virginia.edu.
Kenneth A. Egol, MD, can be reached at 301 E. 17th St., Suite 1402, New York, NY 10003; email: kenneth.egol@nyumc.org.
Bryan D. Springer, MD, can be reached at OrthoCarolina, 2001 N. Vail Ave., Suite 200A, Charlotte, NC, 28207; email: bryan.springer@orthocarolina.com.
Paul Tornetta III, MD, can be reached at Boston Medical Center, 850 Harrison Ave., D2N, Boston, MA 02118; email: ptornetta@gmail.com.

Disclosures: Brockmeier and Springer report no relevant financial disclosures. Egol reports he receives royalties from and is a paid consultant for Exactech Inc. and receives research support from OMEGA, OREF and Synthes. Tornetta receives royalties from Smith & Nephew.