Does bariatric surgery prior to lower limb joint replacement reduce complications?

doi:10.1016/j.surge.2010.08.004

The Surgeon

Volume 9, Issue 1, February 2011, Pages 18-21

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Abstract

Obesity is an increasing health concern in developed world. Bariatric surgery is considered in super-obese patients. Many of these patients will also require lower limb arthroplasty. This study was performed to investigate the complications of hip and knee replacement in patients who had bariatric surgery either before or after their joint replacement. Hospital episode statistics data for English NHS patients undergoing lower limb arthroplasty and bariatric surgery between 2005 and 2009 were analysed. The joint replacement-specific and general medical complications were compared between those undergoing joint replacement prior to bariatric surgery and vice versa, and also with the general English arthroplasty patient. One hundred and forty-three patients underwent bariatric surgery and joint replacement. Bariatric surgery was performed first in 53 and arthroplasty first in 90 patients. The mean age of obese patients was 9 years younger than the general arthroplasty population. Mean in-hospital stay was similar but general medical complications in obese patients appear to be less, possibly because of the lower age at the time of the procedure. Hip dislocation rate at 18 months was higher. Within the two obese groups wound infection rate was 3.5 times lower and readmission to hospital at 30 days appeared to be 7-times lower in patients who had bariatric surgery prior to joint replacement (p = 0.06). In this patient group, the risk of complications following joint replacement appears to be lower if bariatric surgery is performed first.

Introduction

Obesity is increasing to epidemic levels across the developed world. In a recent study of obesity in the United States, the age-adjusted prevalence was 33.8%.¹ About half the adults in England and Wales are overweight and about a quarter are obese.² The number of obese people has trebled in the last 20 years.³ This has proven general health risks including Type 2 diabetes, hypertension, dyslipidaemia, fatty liver, cardiovascular, cerebro-vascular and peripheral vascular disease and obstructive sleep apnoea.⁷ Obesity is classified on the basis of Body Mass Index (BMI) thresholds from overweight to super-obese (Table 1). A 5-point increase in BMI over 25 has been shown to be associated with 30% increased risk of overall mortality.⁷

There are non-surgical treatments for weight loss such as dietary modification, drug therapy, increasing exercise levels and behavioural changes. These are effective in a proportion of highly motivated individuals.17, 18 Bariatric surgery has been shown to produce effective long-term weight loss.18, 19 Cost effectiveness is proven⁷ and the UK National Institute for Health and Clinical Excellence (NICE) guidelines suggest bariatric surgery is beneficial for patients with a BMI over 40, and could be used as a first line treatment for those with BMI over 50.4, 9 Currently only 1–3% of obese patients have bariatric surgery.²¹ This is likely to increase.

Bariatric surgery, particularly involving bilio-pancreatic diversion, carries a risk of malnutrition and a dietary regime of supplementation is necessary to avoid micronutrient deficiency.⁷ Gastric banding is most commonly performed procedure. It has 22–35% risk of late complications and failure. Overall risk of mortality from all types of bariatric surgery is 0.28%.⁷

The Canadian joint replacement registry¹⁰ demonstrates that increasing body mass index is a risk factor for requirement of joint arthroplasty. Degenerative joint disease reduces mobility of these patients and makes it difficult to lose weight.¹¹ Joint replacement in obese patients has shown improvement in pain and function independent of BMI12, 13 and Parvizi et al.⁸ showed significant improvement in function over two to eleven years in patients who had bariatric surgery and then lower limb joint replacement. Joint replacement for pain however does not necessarily mean patients loose weight. Dowsey et al.⁶ in their study of 529 knee replacements in obese patients, found at 12 months that 12.6% patients lost weight, but 21% gained weight. Arthroplasty in morbidly obese patients is technically more difficult, it takes longer to perform and may increase the risk of early complications.5, 6, 14, 15, 16

The aim of this study was to investigate the complications of hip and knee replacement in patients who had bariatric surgery either before or after their joint replacement. Peri- and post-operative complications in these patients were also compared to an unselected unmatched arthroplasty population.

Section snippets

Materials and methods

Procedural and diagnosis data is collected on all NHS patients (in the form of OPCS and ICD-10 codes), and collated nationally to form the Hospital Episode Statistics (HES) database in England. Surgical codes specific to various bariatric procedures, arthroplasty procedures and complications were sought (Table 2). All patients who underwent bariatric surgery and a hip or knee arthroplasty in the NHS in England between 2005 and 2009 were included if they carried the diagnosis code for obesity.

Results

Following HES data matching, we identified 519,297 lower limb joint replacement procedures which were performed between 2005 and 2009. There were 227,390 hip replacements, 23,092 hip resurfacing arthroplasties and 268,815 knee replacements.

There were 53 (19 THR, 3 hip resurfacing and 31 TKR) at least six months before bariatric surgery and 90 joint replacement procedures (37 TKR and 53 THR) performed at least six months after bariatric surgery. The comparison of complications between the

Discussion

Obese patients are present for arthroplasty at a younger age. This may explain the shorter in-patient stay and lower risk of myocardial or cerebro-vascular complications observed in these patients.

The 90-day mortality following TJR in unselected English arthroplasty patients was 0.37% compared to 0.7% in the bariatric surgery patients. Given the small number of the patients and lack of further information it is difficult to conclude that obese patients, or indeed patients who have bariatric

Conclusion

In patients being considered for both bariatric surgery and lower limb joint replacement the risk of complications following joint replacement appears to be lower if bariatric surgery is performed first.

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An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty
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Obesity and lower-extremity arthritis are challenging problems to address as they are often mutually exacerbating. Due to the known perioperative risk of morbid obesity, the modality and timing of weight loss prior to arthroplasty is debated. We present a case of a 55-year-old nonambulatory female patient with an initial body mass index of 80.3 kg/m². This individual underwent a staged bariatric and joint replacement surgical pathway employing personnel of differing treatment disciplines. Our patient successfully lost a substantial amount of weight and has been able to ambulate, exercise, and engage in new, strenuous physical activities. In the care of the nonambulatory bariatric patient, employing a multidisciplinary treatment plan can produce successful results.
Does bariatric surgery really benefit patients before total knee arthroplasty? A systematic review and meta-analysis
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In comparison with the control group, patients with prior bariatric surgery had a higher risk of blood transfusion (OR = 1.83, 95% CI = 1.68 to 2.00, p < 0.00001), with no heterogeneity (I2 = 0%) (Fig. 5) (Table 3). Only 3 studies (n = 52156) reported on the risk of mortality within 30 days postoperatively [15,19,21]. No significant differences were found in both groups (OR = 0.99, 95% CI = 0.08 to 12.48, p = 1.00), with high heterogeneity (I2 = 81%) (Fig. 6) (Table 3).
At present, whether bariatric surgery before total knee arthroplasty (TKA) affects the prognosis of subsequent TKA has been a topic of debate in the academic community. The primary purpose of this systematic review and meta-analysis was to investigate the effect of previous bariatric surgery on prosthetic revisions and postoperative complications after TKA.
We included prospective and observational studies published in English involving patients who had undergone bariatric surgery prior to TKA and compared them with morbidly obese patients with no history of bariatric surgery. The Newcastle-Ottawa Scale was used to assess the methodological quality of non-randomized case-control studies. The outcomes included revisions, infections, venous thromboembolism (VTE), blood transfusion, mortality, stiffness or manipulation under anesthesia (MUA), and medical complications.
Of the 9 included studies with 166047 patients, 4 were matched cohort studies, 2 were unmatched cohort, and 3 were database studies. Methodological quality was high in ten studies and moderate in thirteen studies. Our analysis demonstrated that patients with TKA who had undergone prior bariatric surgery were associated with increased risks of long-term revision, long-term infection, long-term stiffness or MUA and blood transfusions, whereas prior bariatric surgery did not increase the risk of short-term complications and short-term revision.
This meta-analysis highlights the risks of bariatric surgery prior to TKA and suggests that prior bariatric surgery may increase the risk of perioperative blood transfusion and also the risk of revision and infection in long-term follow-up. Surgeons can use this information to help counsel patients undergoing bariatric surgery before primary TKA.
Preoperative assessment and prehabilitation in patients with obesity undergoing non-bariatric surgery: A systematic review
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The orthopaedic studies were all cohort studies and mainly reported on preoperative bariatric surgery as a method of prehabilitation. They reported no difference or worse outcomes [29,39,47,49–52]. The two general surgical studies were both randomised controlled trials: one used a dietary intervention and showed no difference between groups, and the study reporting a multi-disciplinary intervention showed improved outcomes in some but not all study measures [7,41].
The optimal methods of preoperative assessment and prehabilitation specific to patients with obesity undergoing non-bariatric surgery have not been described. We investigated two questions: 1) which methods of preoperative assessment in patients with obesity are associated with improved patient management, and 2) which methods of prehabilitation in patients with obesity are associated with improved patient outcomes?
Systematic review.
Preoperative assessment and optimisation, and postoperative outcomes.
Patients with obesity scheduled for surgery of any type.
We searched six electronic databases for clinical studies addressing either preoperative assessment or preoperative optimisation.
The primary outcome measure for the assessment review was any impact on preoperative disease diagnosis or progression, or postoperative complications. The primary outcome measure for the prehabilitation review was any postoperative change in disease or health status, or any medical or surgical complications.
Twenty one papers were included in the assessment review (total of 5090 participants) and twenty five for prehabilitation (30,170 participants). Approximately two thirds of papers reported on bariatric surgery populations. In the assessment review, studies reported on either the preoperative detection of comorbidities or the prediction of postoperative complications. The only assessment tool with any suggestion of benefit was polysomnography. A range of methods of prehabilitation were found for question 2. Forty eight percent of papers reported improvement in some or all study outcomes. The most successful intervention was exercise, with 4 of 5 exercise-based trials showing improvement in either some or all postoperative outcomes.
There is a limited body of work addressing preoperative assessment and prehabilitation specific to surgical patients with obesity, especially when undergoing non-bariatric surgery. Preoperative polysomnography was shown to improve both the diagnosis of obstructive sleep apnoea and the prediction of postoperative complications. Half of the prehabilitation studies showed evidence of benefit. From this review, we were unable to make strong recommendations as to best practice in patients with obesity presenting for non-bariatric surgery.
Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?
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There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA.
The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m² and age of 72 years, and 60% of whom were female.
We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m², tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001).
Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient.
IV.
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Obesity is a risk factor for complications after total joint arthroplasty (TJA). This study analyzed the impact of individual surgeon demographics, financial concerns, and other factors in determining patient candidacy for TJA based on body mass index (BMI).
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For TJA procedures, 49.9% of surgeons had a BMI cutoff at 40, 24.5% at 45, and 8.3% at 50. At a BMI cutoff of 40, 23.8% of surgeons felt their patient volume would be adversely affected, whereas at a BMI cutoff of 35, 50% of surgeons felt their patient volume would be adversely affected. Surgeons were more likely to not perform total hip arthroplasty on patients with morbid obesity than total knee arthroplasty (P = .037). Significantly more academic surgeons did not have cutoffs for total hip arthroplasty (P = .003) or total knee arthroplasty (P < .001) compared with all other practice settings.
There are myriad factors that affect surgeon BMI thresholds for offering elective TJA including poor outcomes, hospital thresholds, financial considerations, and the well being of the patient. Further work should be performed to minimize the risks associated with TJA while providing the best possible care to patients with morbid obesity.

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Does bariatric surgery prior to lower limb joint replacement reduce complications?

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

J Arthroplasty

J Arthroplasty

Surg Obes Relat Dis

Lancet

Prevalence and trends in obesity among US adults, 1999–2008

J Am Med Assoc

Prevalence of obesity in Great Britain

Obes Rev

Health survey for England 2004: updating of trend tables to include 2004 data

Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children

Obesity in total hip replacement

JBJS Br

Early outcomes and complications following joint arthroplasty in obese patients: a review of the published reports

ANZ J Surg