2. Obesity
Springer said, “Obesity is really controversial. It borders on ethical discussions. It is really hard to deal with and we as orthopedic surgeons are not good at it.”
“When sitting down and trying to talk to patients about their weight, we tend to try to punt it back to the medical doctors or really not discuss it all even though the data is pretty compelling looking at the preoperative risks, infection risks and revision rates in patients, particularly the morbidly obese patient. But remember, BMI is a continuous variable, so if you extrapolate out complications and BMI, right as you get heavier, your risk goes up. And that inflection point seems to be around 40.”
Springer shared a few important studies on obesity complications in total knee arthroplasty (TKA). In “Primary Total Knee Arthroplasty in Super-obese Patients: Dramatically Higher Postoperative Complication Rates Even Compared to Revision Surgery,” published in the May, 2015 issue of The Journal of Arthroplasty, super obesity was associated with dramatically increased rates of postoperative complications after TKA compared to non-obese, obese, and morbidly obese patients, as well as those undergoing revision TKA.
In “Obesity and Total Joint Arthroplasty: A Literature Based Review” published in the May 2013 issue of the Journal of Arthroplasty, a workgroup of the American Association of Hip and Knee Surgeons (AAHKS) Evidence Based Committee wrote:
“It is our consensus opinion that consideration should be given to delaying total joint arthroplasty in a patient with a BMI [body mass index] > 40, especially when associated with other co-morbid conditions, such as poorly controlled diabetes or malnutrition.”
There is a lot of literature out there on obesity complications. No fewer than 60 articles have been in peer review literature concerning complications related to obesity and total knee arthroscopy since 2010.
Springer said, “We are not doing these patients a service by saying we are going to lose 55 pounds and then when your BMI is lower than 40 we will operate on you. We need to do more than that.”
He added, “We looked at 289 of our own patients who had end stage OA [osteoarthritis] of the hip or knee (76 hip, 213 knees) and a BMI > 40. And only 9% of the patients got their BMI under 40 and had the total joint arthroplasty.”
“I think in some ways we have to risk-stratify all our patients and take into consideration if a higher risk is worth it for patients whose quality of life would be tremendously changed by the surgery like a patient with destructive [osteoarthritis] of hip and wheelchair bound. It is easy to draw lines in the sand, but we have to take these cases individually.”
3. Malnutrition
When it comes to malnutrition, Singer said that a lot of times you don’t know it is there unless you screen for it. In the study “The Effect of Malnutrition on Patients Undergoing Elective Joint Arthroplasty,” published in the September 2013 issue of the Journal of Arthroplasty, malnutrition was found to be prevalent in patients older than age 55 with a significant increase in post-operative complications. Out of 2,161 elective total hip arthroplasty patients, 8.5% were malnourished and the rate of overall complications in the malnourished group was 12% vs. 2.9% in the patients with the control group (p < 0.0001).
Screening can include:
- Total Lymphocyte Count: <1500 mm3
- Serum Albumin: <3.5 g/dl
- Transferrin Level: < 200 mg/dl
Springer said, “Be aware, especially of that obese patient who is malnourished (high calories/low protein) because those patients are really at high risk of developing complications. It is a clustering effect.”
