Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes

doi:10.1016/j.arth.2014.02.021

The Journal of Arthroplasty

Volume 29, Issue 7, July 2014, Pages 1359-1364

https://doi.org/10.1016/j.arth.2014.02.021 Get rights and content

Abstract

This study compared the total joint arthroplasty (TJA) surgical outcomes of patients who had bariatric surgery prior to TJA to TJA patients who were candidates but did not have bariatric surgery. Patients were retrospectively grouped into: Group 1 (n = 69), those with bariatric surgery > 2 years prior to TJA, Group 2 (n = 102), those with surgery within 2 years of TJA, and Group 3 (n = 11,032), those without bariatric surgery. In Group 1, 2.9% (95% CI 0.0–6.9%) had complications within 1 year compared to 5.9% (95% CI 1.3%–10.4%) in Group 2, and 4.1% (95% CI 3.8%–4.5%) in Group 3. Ninety-day readmission (7.2%, 95% CI 1.1%–13.4%) and revision density (3.4/100 years of observation) was highest in Group 1. Bariatric surgery prior to TJA may not provide dramatic improvements in post-operative TJA surgical outcomes.

Section snippets

Study Design and Sample

A retrospective cohort study was conducted. Inclusion criteria consisted of patients who underwent a primary unilateral TJA for osteoarthritis between 01/01/2005 and 12/31/2011, were 18 years old or over, and had their TJA procedure(s) in 36 hospitals in the two largest geographical regions (Southern and Northern California) of an United States integrated healthcare system [15]. Patients who had multiple procedures within 1 year of each other were excluded. Only the first operation of patients

Results

A total of 11,032 TJA patients fit the criteria for bariatric surgery but had not undergone the procedure, 69 patients that had bariatric surgery > 2 years prior to TJA and 102 had it within 2 years of TJA. There was a higher proportion of females and younger patients who had bariatric surgery (in both groups) compared to those without surgery. There was a higher proportion of TKA as opposed to THA patients in the group who had their bariatric surgery > 2 years before TJA (89.9%) than in groups with

Discussion

In a cohort of patients with bariatric surgery prior to TJA we found a low incidence of post-operative TJA complications. The incidence of complications was comparable between patients with bariatric surgery prior to TJA and those who were candidate for bariatric surgery but did not undergo the procedure. A higher readmission rate was observed in patients who had bariatric surgery > 2 years prior to TJA surgery than in the other groups and higher revision density was observed in patients with

Acknowledgments

The authors would like to thank all Kaiser Permanente orthopedic surgeons and the staff of the Department of Surgical Outcomes and Analysis who have contributed to the success of the National Total Joint Replacement Registry.

References (38)

H. Jia et al.
Trends in quality-adjusted life-years lost contributed by smoking and obesity
Am J Prev Med
(2010)
R.S. Namba et al.
Risk factors for total knee arthroplasty aseptic revision
J Arthroplasty
(2013)
A. Kulkarni et al.
Does bariatric surgery prior to lower limb joint replacement reduce complications?
Surgeon
(2011)
J. Parvizi et al.
Total joint arthroplasty in patients surgically treated for morbid obesity
J Arthroplasty
(2000)
E.P. Severson et al.
Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study
J Arthroplasty
(2012)
E.W. Paxton et al.
Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness
Jt Comm J Qual Patient Saf
(2013)
N.T. Nguyen et al.
Trends in use of bariatric surgery, 2003–2008
J Am Coll Surg
(2011)
T.C. Horan et al.
CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting
Am J Infect Control
(2008)
J.M. Johnson et al.
Effects of gastric bypass procedures on bone mineral density, calcium, parathyroid hormone, and vitamin D
J Gastrointest Surg
(2005)
K.M. Flegal et al.
Prevalence and trends in obesity among US adults, 1999–2008
JAMA
(2010)

A.H. Mokdad et al.

Actual causes of death in the United States, 2000

JAMA

(2004)

R.S. Namba et al.

Risk factors associated with surgical site infection in 30,491 primary total hip replacements

J Bone Joint Surg Br

(2012)

D. Haverkamp et al.

Obesity in total hip arthroplasty—does it really matter? A meta-analysis

Acta Orthop

(2011)

G.M. Kerkhoffs et al.

The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review

J Bone Joint Surg Am

(2012)

J.I. Mechanick et al.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

Obesity (Silver Spring)

(2013)

National Heart Lung and Blood Institute

The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. 2000

Guidelines for reporting results in bariatric surgery. Standards Committee, American Society for Bariatric Surgery

Obes Surg

(1997)

R. Padwal et al.

Bariatric surgery: a systematic review and network meta-analysis of randomized trials

Obes Rev

(2011)

E.W. Paxton et al.

The Kaiser Permanente national total joint replacement registry

Perm J

(2008)

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Go Big or Go Home: Obesity and Total Joint Arthroplasty
2023, Journal of Arthroplasty
Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.
Bariatric surgery prior to elective shoulder arthroplasty: a Nationwide Inpatient Sample analysis
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Obesity has been linked to adverse outcomes after various orthopedic procedures, and bariatric surgery is an effective surgical treatment for morbid obesity. This study assesses whether prior bariatric surgery is associated with differences in hospital length of stay (LOS), discharge destination, and inpatient complication rate for elective shoulder arthroplasty.
The Nationwide Inpatient Sample database was queried from years 2003 to 2014 for all elective anatomic and reverse total shoulder arthroplasty cases. Two groups were defined: morbidly obese without prior bariatric surgery (MO cohort) and prior bariatric surgery without morbid obesity (BS cohort). Outcome measures were LOS (extended if greater than the 75th percentile), discharge destination (home or non-home), and any inpatient complication. Patients under age of 18 years and those with missing information were excluded. National estimates were calculated using weights provided by the Nationwide Inpatient Sample database. Chi-squared tests were performed for demographics and comorbidities. Binomial multivariate logistic regression was performed using significant demographics and comorbidities.
A weighted-total of 19,877 patients were included in the study, of which 2783 were in the BS cohort and 17,094 were in the MO cohort. The BS group was younger (62.9 years vs. 66.0 years), had more females (73% vs. 69%), and was more likely to be anemic (15% vs. 10%). The MO group was more likely to have diabetes (40% vs. 22%), hypertension (83% vs. 65%), and peripheral vascular disease (3% vs. 1%). Multivariate analysis showed that the BS cohort had decreased odds of extended LOS (odds ratio [OR], 0.68), non-home discharge destination (OR, 0.67), and developing any inpatient complication (OR, 0.42).
In the setting of anatomic and reverse total shoulder arthroplasties, patients with prior bariatric surgery and without morbid obesity had more favorable hospital LOS, discharge destination, and inpatient complication rate than morbidly obese patients with no prior bariatric surgery. Further studies are warranted to better elucidate the relationship between bariatric surgery and shoulder arthroplasty.
Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index
2023, Journal of Shoulder and Elbow Surgery
Bariatric surgery (BS) is a debated, yet commonly used, management strategy in the treatment of morbidly obese patients. Despite recent advances in BS techniques, there is limited data on the potential impact of prior BS in patients undergoing shoulder arthroplasty. This investigation evaluated the outcomes of primary shoulder arthroplasty (SA) in patients with prior BS when compared to matched controls.
Over a 31-year period (1989-2020), 183 primary SA (12 hemiarthroplasties [HAs], 59 anatomic total shoulder arthroplasties [aTSAs], and 112 reverse shoulder arthroplasties [RSAs]) in patients with prior BS and a minimum of 2-year follow-up had been performed at a single institution. This cohort was matched 1:1:1 according to age, sex, diagnosis, implant, American Society of Anesthesiologists score, Charlson Comorbidity Index, and SA surgical year to separate control groups of SA with no history of BS and a BMI of either <40 (low BMI group) or ≥40(high BMI group). Surgical complications, medical complications, reoperations, revisions, and implant survivorship were assessed. The mean follow-up time was 6.8 years (range, 2-21 years).
The bariatric surgery cohort had a higher rate of any complication (29.5% vs. 14.8% vs. 14.2%; P < .001), surgical complications (25.1% vs. 12.6% vs. 12.6%; P = .002), and noninfectious complications (20.2% vs. 10.4% vs. 9.8%; low P = .009 and high P = .005) relative to both low and high BMI groups. For BS patients, the 15-year survivorship free of any complication was 55.6 (95% confidence interval [CI], 43.8%-70.5%) compared with 80.3% (95% CI, 72.3%-89.3%) in the low BMI group and 75.8% (65.6%-87.7%) in the high BMI group (P < .001). Comparisons of the bariatric and matched groups demonstrated no statistical differences between the risk of reoperation or revision surgery. When SA was performed within 2 years of BS, higher rates of complications (50% vs. 27.0%; P = .030), reoperations (35.0% vs. 8.0%; P = .002), and revisions (30.0% vs. 5.5%; P = .002) were observed.
Primary shoulder arthroplasty in patients with prior bariatric surgery demonstrated an elevated complication profile when compared to matched cohorts of patients with no history of BS and either low or high BMI. These risks were more pronounced when shoulder arthroplasty was performed within 2 years of bariatric surgery. Care teams should be aware of the potential implications of the postbariatric metabolic state and investigate whether further perioperative optimization is warranted.
An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty
2023, Orthopedic Clinics of North America
A Multidisciplinary Approach to the Nonambulatory Bariatric Patient With Bilateral Knee Osteoarthritis
2023, Arthroplasty Today
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.
2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery
2022, Surgery for Obesity and Related Diseases
Major updates to 1991 National Institutes of Health guidelines for bariatric surgery
- •
  Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) ≥35 kg/m², regardless of presence, absence, or severity of co-morbidities.
- •
  MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m².
- •
  BMI thresholds should be adjusted in the Asian population such that a BMI ≥25 kg/m² suggests clinical obesity, and individuals with BMI ≥27.5 kg/m² should be offered MBS.
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  Long-term results of MBS consistently demonstrate safety and efficacy.
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  Appropriately selected children and adolescents should be considered for MBS.

View all citing articles on Scopus

: Work performed at: Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA.

: The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2014.02.021.

View full text

Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes

Abstract

Section snippets

Study Design and Sample

Results

Discussion

Acknowledgments

Am J Prev Med

J Arthroplasty

Surgeon

J Arthroplasty

J Arthroplasty

Jt Comm J Qual Patient Saf

J Am Coll Surg

Am J Infect Control

J Gastrointest Surg

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

JAMA

Actual causes of death in the United States, 2000

JAMA

Risk factors associated with surgical site infection in 30,491 primary total hip replacements

J Bone Joint Surg Br

Obesity in total hip arthroplasty—does it really matter? A meta-analysis

Acta Orthop

The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review

J Bone Joint Surg Am

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

Obesity (Silver Spring)

The practical guide: identification, evaluation, and treatment of overweight and obesity in adults. 2000

Guidelines for reporting results in bariatric surgery. Standards Committee, American Society for Bariatric Surgery

Obes Surg

Bariatric surgery: a systematic review and network meta-analysis of randomized trials

Obes Rev

The Kaiser Permanente national total joint replacement registry

Perm J