Clinical Pathways of Patients Denied Total Knee Arthroplasty Due to an Institutional BMI Cutoff

Abstract

Out of concern for the increased risk of complications with morbid obesity, institutional body mass index (BMI) cutoffs for total knee arthroplasty (TKA) have become commonplace. We sought to answer the questions: what percentage of morbidly obese patients with knee osteoarthritis who present to an arthroplasty clinic will, within 2 years, undergo TKA at (1) a BMI less than 40 kg/m² or (2) at a BMI greater than 40 kg/m²? Of those who do not undergo surgery, (3) what percentage lose enough weight to become TKA-eligible, and (4) what percentage do not? We performed an observational study of 288 patients, of which 256 had complete follow-up. Institutional electronic medical record review and patient follow-up by telephone were conducted to determine which patients underwent surgery, and at what BMI. For those that did not undergo TKA, BMI was examined to see if the patient ever lost enough weight to become TKA eligible. Twelve of 256 patients (4.7%) underwent TKA at a BMI less than 40 kg/m², 64 patients (25%) underwent TKA at a BMI greater than 40 kg/m², and 7 patients (2.7%) underwent surgery at an outside hospital. The average BMI at the time of surgery was 42.3 kg/m². Thirty-seven of 256 patients (14.4%) lost enough weight to become TKA-eligible within 2 years of the initial visit but did not undergo surgery, while 136 patients (53.1%) neither underwent TKA nor became eligible. Strict enforcement of a BMI cutoff for TKA is variable among surgeons. In the absence of weight loss protocols, 19.1% of morbidly obese patients may be expected to reach the sub-40 kg/m² BMI milestone.

Keywords

BMI cutoff - obesity - total knee arthroplasty - knee arthroplasty - weight loss

Ethical Approval

Ethical approval was provided by Baylor Scott & White Research IRB (Project ID 018–534, Reference Number: 315799).

Publikationsverlauf

Eingereicht: 12. Juni 2020

Angenommen: 02. Januar 2021

Artikel online veröffentlicht:
19. Februar 2021

• References

• 1 Bourne R, Mukhi S, Zhu N, Keresteci M, Marin M. Role of obesity on the risk for total hip or knee arthroplasty. Clin Orthop Relat Res 2007; 465 (465) 185-188
• 2 Wendelboe AM, Hegmann KT, Biggs JJ. et al. Relationships between body mass indices and surgical replacements of knee and hip joints. Am J Prev Med 2003; 25 (04) 290-295
• 3 Adhikary SD, Liu WM, Memtsoudis SG, Davis III CM, Liu J. Body mass index more than 45 kg/m(2) as a cutoff point is associated with dramatically increased postoperative complications in total knee arthroplasty and total hip arthroplasty. J Arthroplasty 2016; 31 (04) 749-753
• 4 Boyce L, Prasad A, Barrett M. et al. The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature. Arch Orthop Trauma Surg 2019; 139 (04) 553-560
• 5 Dowsey MM, Liew D, Stoney JD, Choong PF. The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients. J Bone Joint Surg Br 2010; 92 (04) 513-520
• 6 Everhart JS, Altneu E, Calhoun JH. Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty. Clin Orthop Relat Res 2013; 471 (10) 3112-3119
• 7 Prohaska MG, Keeney BJ, Beg HA. et al. Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty. Knee 2017; 24 (03) 634-640
• 8 Si HB, Zeng Y, Shen B. et al. The influence of body mass index on the outcomes of primary total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1824-1832
• 9 Sisko ZW, Vasarhelyi EM, Somerville LE, Naudie DD, MacDonald SJ, McCalden RW. Morbid obesity in revision total knee arthroplasty: a significant risk factor for re-operation. J Arthroplasty 2019; 34 (05) 932-938
• 10 Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI. J Arthroplasty 2015; 30 (9, Suppl): 42-46
• 11 Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty 2013; 28 (05) 714-721
• 12 McElroy MJ, Pivec R, Issa K, Harwin SF, Mont MA. The effects of obesity and morbid obesity on outcomes in TKA. J Knee Surg 2013; 26 (02) 83-88
• 13 Dowsey MM, Liew D, Choong PF. Economic burden of obesity in primary total knee arthroplasty. Arthritis Care Res (Hoboken) 2011; 63 (10) 1375-1381
• 14 Girardi FM, Liu J, Guo Z, Valle AGD, MacLean C, Memtsoudis SG. The impact of obesity on resource utilization among patients undergoing total joint arthroplasty. Int Orthop 2019; 43 (02) 269-274
• 15 Kremers HM, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. The effect of obesity on direct medical costs in total knee arthroplasty. J Bone Joint Surg Am 2014; 96 (09) 718-724
• 16 Urish KL, Qin Y, Li BY. et al. Predictors and cost of readmission in total knee arthroplasty. J Arthroplasty 2018; 33 (09) 2759-2763
• 17 Shapiro JA, Narayanan AS, Taylor PR, Olcott CW, Del Gaizo DJ. Fate of the morbidly obese patient who is denied total joint arthroplasty. J Arthroplasty 2020; 35 (6S): S124-S128
• 18 Springer BD, Roberts KM, Bossi KL, Odum SM, Voellinger DC. What are the implications of withholding total joint arthroplasty in the morbidly obese? A prospective, observational study. Bone Joint J 2019; 101-B (7_Supple_C): 28-32
• 19 Texas Comptroller of Public Accounts. “The Central Texas Region 2018 Regional Report.” The Central Texas Region, 2018, comptroller.texas.gov/economy/economic-data/regions/central.php
• 20 Le A, Judd SE, Allison DB. et al. The geographic distribution of obesity in the US and the potential regional differences in misreporting of obesity. Obesity (Silver Spring) 2014; 22 (01) 300-306
• 21 Springer BD. Management of the bariatric patient. what are the implications of obesity and total joint arthroplasty: the orthopedic surgeon's perspective?. J Arthroplasty 2019; 34 (7S): S30-S32
• 22 Gandler N, Simmance N, Keenan J, Choong PF, Dowsey MM. A pilot study investigating dietetic weight loss interventions and 12 month functional outcomes of patients undergoing total joint replacement. Obes Res Clin Pract 2016; 10 (02) 220-223
• 23 Liljensøe A, Laursen JO, Bliddal H, Søballe K, Mechlenburg I. Weight loss intervention before total knee replacement: a 12-month randomized controlled trial. Scand J Surg 2019; 1457496919883812: 1457496919883812
• 24 Yázigi F, Espanha M, Vieira F, Messier SP, Monteiro C, Veloso AP. The PICO project: aquatic exercise for knee osteoarthritis in overweight and obese individuals. BMC Musculoskelet Disord 2013; 14: 320
• 25 Iannaccone F, Dixon S, Kaufman A. A review of long-term pain relief after genicular nerve radiofrequency ablation in chronic knee osteoarthritis. Pain Physician 2017; 20 (03) E437-E444
• 26 McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-effectiveness of bariatric surgery prior to total knee arthroplasty in the morbidly obese: a computer model-based evaluation. J Bone Joint Surg Am 2016; 98 (02) e6
• 27 Rishi L, Bhandari M, Kumar R. Can bariatric surgery delay the need for knee replacement in morbidly obese osteoarthritis patients. J Minim Access Surg 2018; 14 (01) 13-17
• 28 Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. J Arthroplasty 2015; 30 (10) 1705-1709
• 29 Biernikiewicz M, Taieb V, Toumi M. Characteristics of doctor-shoppers: a systematic literature review. J Mark Access Health Policy 2019; 7 (01) 1595953
• 30 Gudzune KA, Bleich SN, Richards TM, Weiner JP, Hodges K, Clark JM. Doctor shopping by overweight and obese patients is associated with increased healthcare utilization. Obesity (Silver Spring) 2013; 21 (07) 1328-1334
• 31 Baker P, Petheram T, Jameson S, Reed M, Gregg P, Deehan D. The association between body mass index and the outcomes of total knee arthroplasty. J Bone Joint Surg Am 2012; 94 (16) 1501-1508
• 32 Hakim J, Volpin G, Amashah M. et al. Long-term outcome of total knee arthroplasty in patients with morbid obesity. Int Orthop 2020; 44 (01) 95-104
• 33 Keeney BJ, Austin DC, Jevsevar DS. Preoperative weight loss for morbidly obese patients undergoing total knee arthroplasty: determining the necessary amount. J Bone Joint Surg Am 2019; 101 (16) 1440-1450
• 34 Li S, Luo X, Sun H, Wang K, Zhang K, Sun X. Does prior bariatric surgery improve outcomes following total joint arthroplasty in the morbidly obese? A meta-analysis. J Arthroplasty 2019; 34 (03) 577-585
• 35 Werner BC, Kurkis GM, Gwathmey FW, Browne JA. Bariatric surgery prior to total knee arthroplasty is associated with fewer postoperative complications. J Arthroplasty 2015; 30 (9, Suppl): 81-85
• 36 Inacio MC, Kritz-Silverstein D, Raman R. et al. The impact of pre-operative weight loss on incidence of surgical site infection and readmission rates after total joint arthroplasty. J Arthroplasty 2014; 29 (03) 458-64.e1
• 37 Smith TO, Aboelmagd T, Hing CB, MacGregor A. Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis. Bone Joint J 2016; 98-B [phone]
• 38 Lee GC, Ong K, Baykal D, Lau E, Malkani AL. Does prior bariatric surgery affect implant survivorship and complications following primary total hip arthroplasty/total knee arthroplasty?. J Arthroplasty 2018; 33 (07) 2070-2074.e1
• 39 Lui M, Jones CA, Westby MD. Effect of non-surgical, non-pharmacological weight loss interventions in patients who are obese prior to hip and knee arthroplasty surgery: a rapid review. Syst Rev 2015; 4: 121
• 40 Meller MM, Goodman S, Gonzalez MH, Lau E. Does bariatric surgery normalize risks after total knee arthroplasty? Administrative Medicare data. J Am Acad Orthop Surg Glob Res Rev 2019; 3 (12) e19.00102
• 41 Benotti PN, Still CD, Craig Wood G. et al; SWIFT Trial Investigators. Surgical weight-loss to improve functional status trajectories following total knee arthroplasty: SWIFT trial: rationale, design, and methods. Contemp Clin Trials 2018; 69: 1-9