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Obesity epidemic: The ‘hidden’ comorbidity in our patient care, Part 2

Issue: December 2015

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In part 2 of this Orthopedics Today Round Table on the obesity epidemic, 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. Click here, to read part 1 of the discussion.

Bryan D. Springer, MD
Moderator

Bryan D. Springer, MD: Dr. Della Valle, the literature suggests obese patients do as well functionally with joint replacements compared with non-obese patients, yet complications are higher in obese patients. Discuss what type of conversation you have in your office with an obese patient in need of joint replacement.

Craig J. Della Valle, MD: I would characterize the conversation as frank. I start by telling them what their BMI is. So let us say the patient has a BMI of 52. I explain that at a BMI of 30, you are considered obese, at 40 morbidly obese and more than 50 is considered super-morbidly obese. I then tell them the literature suggests a higher risk of complications in patients whose BMI is more than 30 and that the risk goes up substantially more than 40. Finally, I tell them that at a BMI of more than 50, the risk of complications may be so high that the risks of surgery may outweigh the benefits.

Next, I ask them if they have attempted a weight-loss program that was supervised by a physician or nutritionist and, if they have not done that, I suggest that is a good place to start. At this point, for patients with a BMI of greater than 40, I mandate they get nutritional counseling before proceeding with surgery. I also bring up the idea of weight loss surgery, as some data suggests it may lower the risks of complications postoperatively.

Finally, I generally talk to them about what they have eaten in the past 24 hours and try to provide some guidance on healthier eating to get them started, stressing the importance of staying away from processed sugar and attempting to increase their intake of lean protein and vegetables. I do not encourage them to try to lose weight rapidly before surgery, as I think that can lead to nutritional deficiency and not sustained weight loss. I usually close by explaining that healthy weight loss is 1 pound to 2 pounds per week and encourage setting realistic goals, emphasizing that a global change in the way they eat is probably needed to not only decrease their risks for surgery, but also to improve their overall health for the long-run.

Springer: In trauma, you do not get to choose your patients. What steps do you take to manage the obese patient perioperatively prior to surgery?

Paul Tornetta III, MD: This is a particularly difficult problem in trauma patients. As surgery is time-dependent, there is no possibility of preoperative management. We must accept the risks that the patient’s body habitus presents. As opposed to elective surgery, where any measure is possible to improve the risk profile, trauma patients must make a difficult decision regarding surgical intervention without the possibility of mitigating their obesity. In some situations, in particular complex acetabulum fractures, patients are put in the position of deciding whether a surgical procedure is worth the risk. Depending on the pattern of injury, a patient’s size may substantially reduce the chances of anatomic reduction and also increase the risk profile. For older patients, this may swing the decision to nonoperative treatment understanding they will be working toward weight reduction and a hip replacement under elective circumstances.

In addition, although obesity is related to increased caloric intake, many obese patients are malnourished. The injury and resultant hospitalization is an opportunity to have a proper nutritional assessment performed and attempt to have patients educated in good nutrition. Most trauma centers also have excellent bariatric programs. We use this resource to begin the process of improving nutritional status as well as the educational and supportive services needed to change the path of these patients’ eating habits going forward.

Kenneth A. Egol, MD: There is not much we can do other than decide whether to operate. Often times, I will use a negative pressure surgical dressing and/or use deep drains for cases, which I am concerned about dead space. Furthermore, I will often be more aggressive with venous thromboembolism prophylaxis. In some cases, when the patient’s size may limit mobility, I will indicate the patient for an inferior vena cava filter.

Springer: Are there special surgical techniques (incisions placement, wound management tips) that are useful for obese patients in the trauma setting?

Egol: Femoral fractures present a unique challenge to trauma surgeons given the higher incidence of complication within this patient group. Fixation via intramedullary (IM) nailing should be favored over plating when possible to maximize load sharing and encourage early weight-bearing, as the obese population is more likely to develop difficulty with early weight-bearing than their non-obese counterparts. Retrograde IM nailing is sometimes technically easier than anterograde nailing in these patients. When antegrade IM nailing is selected, the patient should be placed in the lateral decubitus position with a trochanteric entry point or piriformis more accessible.

Overall, few special surgical techniques exist at present for the surgical care of the obese trauma patient. Special consideration must be given the overall operative plan to meet the unique needs of the obese patient. The availability of the proper OR equipment is vital. Standard operating tables may not support weights more than 450 pounds and certain radiolucent fracture tables only safely support weight less than 400 pounds. The surgical instrumentation used routinely may not be large enough for the obese patient. Instrumentation such as extra-large retractors must be readily available for adequate visualization. Special instrument sets for the obese patient can minimize frustration and operative times. Patient positioning within the OR is critical as obese patients are at increased risk for rhabdomyolysis, pressure sores and compressive neuropathies intraoperatively. When possible, patients should be positioned in the lateral decubitus position to maximize ventilation. Incision size must be adapted for increasing BMI to provide adequate exposure. As always, tension placed upon the skin should be minimized by proper incision selection as wound complication is 5-times more likely in a morbidly obese patient compared with the non-obese counterpart.

Tornetta: In central locations such as the pelvis, careful dead space management is paramount. Retention sutures deep and the use of drains may prevent hematoma formation and subsequent infection. A number of authors have advocated the use of incisional negative pressure dressings to help to drain the wound as well as seal the skin faster. While there is little level 1 evidence, many surgeons have adopted these methods. In more peripheral areas, it is important to place the skin incision in a different location than the deep incision so if the skin breaks down, the deep incision and coverage over implants is not immediately lost. Negative pressure dressings, in some cases circumferential, may also benefit the wound by isolating it from the hospital environment, but also by increasing the tensile strength of the closure.

Springer: Dr. Della Valle, you have done a lot of work on nutrition and obesity. Discuss paradoxical malnutrition and how it impacts outcome after joint replacement. Do you routinely test for it on every patient?

Della Valle: Paradoxical malnutrition is seen where despite being obese, patients have nutritional deficiencies. These patients are unfortunately usually ingesting a large amount of food that is usually calorie-rich, but nutrient and protein poor. All patients at Rush have an albumin performed as part of their preoperative evaluation and, if hypoalbuminemia is identified, then surgery is delayed until it has been corrected.

While at this point I understand hypoalbuminemia is a crude and probably not entirely accurate way of assessing protein nutrition, we have examined both our own patients and patients in the National Surgical Quality Improvement Program database and identified hypoalbuminemia as a risk factor for complications, such as infection and other problems including readmission. Hence, while it may not be a linear reflection of nutritional status (it is also highly tied to systemic inflammation), it does seem to correlate with poor outcomes and we therefore hold off on surgery until it is corrected. In my brief experience with changes in diet, it seems to correct within a few months.

Springer: Are we at a point, knowing all the complications associated with obesity and joint replacement, where we should restrict access to joint replacement due to obesity? If so, what should the cut-off be?

Della Valle: That is a tricky question and I think a deeply philosophical one. If you are a “batting average doctor,” then I would say you should not offer surgery to obese patients as they are at higher risk for complications. Being at a tertiary care center, our approach is to try and care for these patients and explain we want to help them. However, we need to optimize them preoperatively before performing surgery. A constructive and caring approach is usually well-received.

Springer: Should we restrict access to shoulder replacement in patients who are obese? If so, what should that cut-off be?

Stephen F. Brockmeier, MD: Establishing a strict cut-off — a “line in the sand” — is a slippery slope. Every patient is different and BMI or obesity classification is one variable that needs to be accounted. That said, the evidence presented in some of our studies as well as many others, appears to delineate an incremental effect of increasing BMI on risks and negative outcomes in arthroplasty. While based on this evidence, it is clearly paramount that surgeons consider patient BMI as a factor in recommending elective shoulder surgery to patients. As physicians, we cannot lose sight of individual experience and the art of practicing medicine. Each patient needs to be looked at as an individual, and a number of variables should be assessed and optimized prior to proceeding with elective surgery.

• 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.
• Craig J. Della Valle, MD, can be reached at Rush University Medical Center, 1611 W. Harrison, Ste. 300, Chicago, IL 60612; email: craigdv@yahoo.com.
• 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.