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Prepare to treat more obese patients in the future
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The recent literature and demographic studies show that orthopaedic surgeons worldwide can expect to see a steady increase in the number of patients who are obese. It is well documented that obesity, which is defined as the state of being severely overweight or having a body mass index of 30 or more, has a negative effect on patients. But much less information has been disseminated on the effect this health condition has on the regular practices of orthopaedic surgeons, nurses, operating room staff, hospitals, health systems and insurance companies.
Unquestionably, orthopaedists will all face some significant clinical challenges in the future that center on the issue of the treatment of obese patients, regardless of our orthopaedic specialty areas. Therefore, we need to prepare now to deal with this situation.
Supporting our patients
If we take the position that we want to help — and can help — our patients who are obese, the management of obese patients takes on a completely different mindset. One way orthopaedic surgeons can do this is to encourage patients to lose weight, particularly if they are indicated for surgery. Being obese puts individuals at risk for various perisurgical complications. It is widely recognized that they are more likely to develop anesthesia-related problems intraoperatively than normal weight patients and obesity makes all rehabilitation after surgery more challenging to the patient, as well as the physiotherapist.
In lower limb surgery, deep venous thrombosis, deep infection and wound healing problems are significantly increased in the obese patient, and these risks increase exponentially with each added point of a patient’s body mass index (BMI).
Helping our obese patients to lose weight by referring them to physicians or professionals who can help them with weight loss will benefit all parties involved. Although studies still have not shown distinct benefits to significant and durable weight loss, in my opinion there is no other way to go in the future because the global obesity problem impacts societal, economic and cultural issues.
It is undoubtedly a difficult task to stem the tide of obesity in patients with musculoskeletal conditions. We, as orthopaedic surgeons, would be wise to lead the way and also involve our political partners in efforts to solve this problem.
At the clinical level
Another approach which some orthopaedists take is to refuse to perform surgery when the patient’s excess weight is believed to be a factor that affects how the surgery is performed, the final outcome or recovery process. But, can we ethically deny our patients surgery due to obesity? Although severely obese patients may face increased risks during anesthesia and immediately after surgery, we should remember that an operation to replace a joint or improve mobility also may be lifesaving and could significantly increase the quality of life.
In results of a poll on total knee arthroplasty (TKA) in obese patients at Healio.com/Orthopaedics, the website for Orthopaedics Today Europe, 41% of respondents said they already ask their patients who are obese to lose weight prior to TKA, but do not refuse the surgery for patients who do not lose the weight. However, 15% of those polled ask their obese patients to lose weight and also refuse doing the surgery. About 23% of those polled encourage patients to participate in a weight loss program and indicated they re-evaluate them afterwards if they lose weight and another 20% do not ask their obese patients to lose weight at all.
Even with the challenges of treating patients who are obese, including issues related to properly positioning them on the operating room table or using a special size table, some literature suggests few differences in outcomes for TKA and other procedures for obese vs. non-obese patients. However, I wonder if this is true in all cases, as obese patients always are more complicated to operate on. Also, there must be a learning curve for performing these types of cases, as there are negative consequences should obese patients be operated on by less experienced surgeons or surgeons who are not skilled in their treatment.
Reimbursement is at risk
Surgeons may eventually be faced with yet another consequence of obesity due to the increased risk of complications in this patient population during and after surgery. Insurance companies may decide to offer lower reimbursement rates or choose to not reimburse orthopaedic surgeons at all when complications develop. It is possible insurers may decide to deny payment whenever surgery is done in a patient whose BMI exceeds a certain limit.
Obesity among our patients is an area where orthopaedic surgeons can make a difference. We can encourage patients to lose weight, maintain an ideal body weight, and lead a healthy, active lifestyle that will prove better for them long term, or refer them to a weight loss program. We also have the option of refusing to operate on an obese patient until they lose enough weight to bring their BMI into a more normal range. By taking these steps, we can support our patients to make changes that will have positive life-long implications.
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- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen has no relevant financial disclosures.