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Do you think patients who are morbidly obese are able to undergo TJR with limited complications? How do you address these patients?
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Address complications
Javad Parvizi
It is a fact that any surgical procedure, including TJA, performed in obese patients carries a higher risk for complications. With the increase in the number of obese patients in North America and the association between obesity and arthritis, it is not uncommon to find obese patients seeking TJA. Based on many studies, more than half of patients undergoing TJA are obese. The questions are, can TJA be performed in obese patients and what, if any, risk mitigation strategies can be implemented to reduce the risk of complications in these patients?
I think TJA can be performed in obese patients, and the outcome is rewarding most of the time. However, when complications occur, these are challenging to address. The reason for higher complications may relate to the technical difficulty of performing TJA in obese patients and the higher risk for postoperative failures.
Thus, it is important to ensure all steps are taken to minimize complications in obese patients undergoing TJA. To reduce the risk of medical and orthopedic complications, all obese patients should be medically optimized prior to surgery. The latter is particularly important in patients with metabolic syndrome (hypertension, hyperglycemia, dyslipidemia). Intraoperatively, a longer incision, specialized instruments and an additional assistant may be needed to improve visualization and avoid component malpositioning. A prosthesis implanted in these patients may require additional reinforcement, such as the use of stems during TKA and so on, to reduce the probability for subsidence or periprosthetic fracture. The wound needs to be managed carefully (I prefer to use an occlusive dressing), and any wound-related complications should be treated aggressively. It may also be prudent to ask obese patients to protect weight-bearing on uncemented components to improve osseointegration. It is critical that a surgeon defines a limit for obesity and does not perform elective arthroplasty in patients who are beyond the defined limit (BMI greater than 40 kg/m2). This allows us to engage the patients preoperatively and have them be accountable for their health issues.
Javad Parvizi, MD, FRCS, is the James Edwards Professor of Orthopedic Surgery at the Sidney Kimmel Medical College and Rothman Institute at Thomas Jefferson University Hospital in Philadelphia.
Disclosure: Parvizi receives research support from 3M, Aesculap/B.Braun, AO Spine, Biomet, Cempra, CeramTec, DePuy Synthes, Integra, Myoscience, National Institutes of Health (NIAMS and NICHD), NDRI, Norvartis, OREF, Orthospace, Pfizer, Rotation Medical, Simplify Medical, Smith & Nephew, StelKast, Stryker, TissueGene, Tornier and Zimmer Biomet; has stock or stock options in Alphaeon, CD Diagnostics, Ceribell, Corentec, Hip Innovation Technology, Joint Purification Systems, MedAp, MicroGenDx and Parvizi Surgical Innovations; is a paid consultant for CeramTec, ConvaTec, Ethicon, TissueGene and Zimmer; receives publishing royalties, financial or material support from Corentec, Datatrace, Elsevier, Jaype Publishers, SLACK Incorporated and Wolters Kluwer Health – Lippincott Williams & Wilkins; is a board or committee member for Eastern Orthopaedic Association and the Muller Foundation; and is on the editorial or governing board for the Journal of Arthroplasty, Journal of Bone & Joint Surgery and The Bone & Joint Journal.
Too many risks
Depending on an individual surgeon’s definition and acceptance level of complications, the answer to this question may vary. As an adult reconstruction-trained surgeon who is 12 years into his private practice, I have developed a low tolerance for creating complications. I have had the opportunity to treat a full gamut of complications and, thus, do whatever I can to avoid these.
The definition of obesity based on BMI may be complicated in certain individuals, but serves as the best current guide for us to try and standardize care based upon clinical guidelines established by available research. We have learned that patients with a BMI of greater than 40 have significant increased rates of complications, as reported at the recent American Association of Hip and Knee Surgeons Annual Meeting. Several studies reported similar findings of complications rates 4- to 5-fold higher than compared to those of lower weight cohorts.
The ever-increasing transition of risk to us, as surgeons, is also important. Whether it is financial responsibility or interpersonal records of patient satisfaction, we are being asked to provide the highest quality care we can to each patient with limited to no complications. A known impossibility, as a specialty, we have always prided ourselves with providing the best possible care to our individual patients as we are capable.
Can morbidly obese patients undergo hip or knee arthroplasties? Sure, but are we willing to take that risk or whatever risk to potentially have a negative impact on someone’s life? Based on the compelling information provided to us through research during the past few years, I have made every effort to not only intentionally postpone or altogether deny procedures in this population, but also have been trying to educate and standardize care amongst community colleagues not otherwise focused on arthroplasty. By doing so, we hope to eliminate pressure to perform procedures on individuals who we fear may find another surgeon to do their joint replacement. Cultivating this confidence amongst colleagues allows us to improve local population health while reduce surgical risks and complications. We are trying to create pathways with our bariatricians, bariatric surgeon colleagues and their associates, which allow patients to improve their health quality prior to entering into the large responsibility of joint replacement surgery.
I heard a comment at a recent meeting that has resonated with me during clinics, as I have had this conversation frequently. By following best practice guidelines to provide high-quality care with the lowest possible complications, we can redirect health responsibility back to patients who will have to improve their general medical health (including weight reduction) prior to getting procedures they eagerly await that will vastly improve their functional quality of life. Improving the chances that patients will receive their new joints with lower risks, we are not only continuing to try and do the best for our patients, but also being better stewards of health care dollars by reducing preventable complications as much as possible.
Matthew D. Olin, MD, is an orthopedic surgeon at Greensboro Orthopaedics in Greensboro, NC.
Disclosure: Olin reports no relevant financial disclosures.