Issues related to obese patients who require orthopaedic, trauma surgery call for special attention

GENEVA — Orthopaedic surgeons see a higher percentage of obese patients in the clinic and hospital vs. the general population. Therefore, they must understand and be prepared to address the increased rates of fractures, total joint arthroplasty dislocation, surgical site infections and other problems among obese patients, according to symposium presenters at 17th EFORT Annual Congress, here.

Sebastien Parratte, MD, PhD, of Marseilles, France, who moderated, the symposium, said, “If you ask an orthopaedic surgeon, you may not solve the problem of obesity in the world … especially with our knife. But, we have to take care of these patients. It is a reality. It is a fact. All these patients are going to come and see you. You really have to treat obese patients in trauma cases for everything,” Parratte said, noting 10% of patients in Europe today are obese.

Sebastien Parratte

Because patients who are obese and are faced with orthopaedic or trauma surgery are at higher risk of more problems than normal weight patients, he recommended they undergo a special presurgical consent process.

Parratte explained that if bariatric surgery is something an obese patient who is a candidate for total knee arthroplasty (TKA) will consider, TKA should then be delayed 2 years after the bariatric surgery.

Tilman Pfitzner, MD, of Berlin, said patients who are obese now constitute a greater part of the population in Europe, and Europe is now trailing the United States only slightly in terms of the extent of its obese population.

“If we look at obesity, it is a little bit more than just the physical problem to get to the joint,” he said.

There are trauma risk factors to consider related to obesity, Pfitzner said.

He cited a study in which an increased risk of hip fractures was observed among obese women who were minimally active. Other studies have shown increased risks of calcified tissue and vertebral fractures among patients who are obese.

A patient’s absolute weight may not be the only predictor of traumatic fractures. These patients can also have low or normal muscle volume, which affects their fracture risk, according to Pfitzner.

In addition, there are distinct surgical considerations for patients who are obese. Both patient positioning and approach are more critical in these cases.

“We have an increased 90-day mortality in obese patients. We have increased risk of complications, like pulmonary embolism, and we have a problem of lower survival in these patients,” Pfitzner said.

Sebastien Lustig, MD, PhD, of Lyon, France, who discussed how obesity affects patients who undergo total hip arthroplasty (THA), noted that regarding anesthesia, added intubation and ventilation problems can ensue.

Obese patients are also at higher risk of thromboembolism.

“But, when you look at the recommendation for anti-coagulation, for these patients the recommendation is standard. We do not have to change what you usually do,” Lustig said.

However, “what is crucial for these patients is the mechanical prophylaxis.”

To avoid hip dislocation in THA, he proposed increasing neck offset and decreasing cup abduction.

Aseptic loosening rates are five times higher among obese patients after THA vs. normal weight patients. In addition, orthopaedists should be aware of an increased risk of wound healing in patients who are obese, according to Lustig.

“Obese patients should not be denied to have hip replacement solely on their BMI,” he said. – by Susan M. Rapp

Reference:

Parratte S, et al. Symposium: Obesity in orthopaedics and trauma surgery. Presented at: 17th EFORT Annual Congress—A combined programme in partnership with swiss orthopaedics; 1-3 June 2016; Geneva.

Disclosures: Lustig reports he is a paid consultant and presenter/speaker for Tornier. Parratte reports no relevant financial disclosures. Pfitzner reports he is a paid consultant to DePuy Synthes.