Joint replacement and obesity

[Bumpa]

dstew42000 sorry to read of your troubles. Unfortunately your husband doesn't look as if he is one of the straightforward cases and the surgeons who have reviewed his case are using the weight as a cop-out. This probably means he needs to go to a centre of excellence where they can look at the whole patient situation. Please let us know the outcome - we, increasingly, have such cases over here. Last week I was at a meeting where a surgeon from Watford and St Albans reported that their review of joint replacement showed that there were no unexpected complications with the heavier patient - just a couple more days in hospital.

 

[Jamie]

dstew.....You need to keep looking to find a surgeon who is willing to operate on overweight patients. They are out there!!! It is very difficult for someone to lose weight when they are not able to move about easily. Not all surgeons "get" that and sadly take the easy route by telling patients to get to a "normal" weight before surgery.

We have many BoneSmarties who had surgery when they were overweight. Use the FIND A CLINIC tab at the top of the page to obtain a list of potential clinics within driving distance from you. Then start calling and ask if they have a surgeon who works with overweight patients. Find several if possible so you can have a choice.

Please let us know how things go. There is a solution....you'll just have to work a bit to get to it!

 

[Bumpa]

More news on obesity:
[FONT=&quot]Obesity: A global epidemic that poses challenges for total joint replacement
[/FONT]

[FONT=&quot]ORLANDO, Fla. — Total joint arthroplasty in obese patients will continue to be an important challenge for orthopedic surgeons as obesity rates are at their highest in 30 years and doubled in the last 20 years among U.S. adults, based on data presented at the Current Concepts in Joint Replacement 2011 Winter Meeting, here. “If you think that [obesity] is a U.S. trend, that is wrong,” Steven J. MacDonald, MD, FRCS(C), said in his presentation. “Most countries are in the clear double digits and many not that far off,” in terms of national obesity rates, he said. Patients with class 3 obesity, where body mass index (BMI) is greater than 40, have an 8.5 times higher risk of needing total hip arthroplasty (THA) and a 32 times higher risk for a total knee arthroplasty (TKA) compared with patients with normal BMI, according to MacDonald. “Obesity in total joint arthroplasty — it increases the number of procedures and the burden. There are increased complication rates,” he said. Infection is a one challenge, MacDonald noted. “Most series powered enough will start to show the trend of increasing infection rates, both superficially — and sometimes deep — with the morbidly obese patient,” he said. However, the difficulty of performing THA or TKA in obese patients is unquestioned, MacDonald said. “There is no evidence that obesity affects implants or survivorship,” he said, noting this may be because obese patients put their prostheses through fewer cycles per year on average. Based on changes between preoperative and postoperative WOMAC, SF-12 and the Hip Society Scores for THA in obese vs. normal weight patients that MacDonald and colleagues studied, “The procedure is doing what it is meant to do,” MacDonald said. [/FONT]
[FONT=&quot]Reference: [/FONT][FONT=&quot][/FONT]
· [FONT=&quot]MacDonald SJ. Patient obesity: Getting to the refrigerator faster. Paper #86. Presented at the Current Concepts in Joint Replacement 2011 Winter Meeting. Dec. 7-10. Orlando, Fla.[/FONT]
· [FONT=&quot]Disclosure[/FONT][FONT=&quot]: MacDonald has no relevant financial disclosures. [/FONT]

 

[rider1960]

I'm an obese person who needs a hip replacement--maybe both. I'm having it done in January.

I have never been told that I need to lose weight in order to have the surgery, although my OS was initially quite persistent (to the point of being annoying!) about weight loss helping relieve pressure on the joint and that I might be able to get by longer with that and conservative treatment. But, he never said--"I won't operate until you lose weight--just suffer with your pain." or the like.

My osteoarthritis was not as bad when I was first diagnosed, not very long ago, as it is now. It's worsened very quickly, and I've gained more weight progressively since my pain initially started a couple of years ago ... mostly due to depression and emotional eating from life changes and dealing with chronic pain and not being able to be as active. Now I walk with a cane and a few hundred feet is a long walk. My life has changed SO much. I was never a couch potato and that's what I've basically turned into.

I haven't always been obese, but I've always been up and down with my weight most of my adult life. I'm at my heaviest so far.

When I first met with my current OS, he was big on weight loss and thought losing significant weight combined with conservative treatment might make me comfortable enough not to need a hip replacement for a while --my joint wasn't in terrible shape at that time, but it was headed in that direction. It amazes me how quickly I've gone downhill.

Even though this OS was initially quite preachy about wanting me to lose weight, as soon as it became apparent that the conservative measures weren't keeping me comfortable enough, he moved right to recommending a hip replacement--he didn't expect me to suffer in pain just because I'm overweight.

I came right out and asked him if he was comfortable doing a hip replacement on "someone like me", to which he responded with a confused look on his face and said "what do you mean 'someone like you' ". I said "an obese patient". He looked a little surprised and said "I do it frequently! And, I've done hip replacements on some patients that are twice your size! It's a bit more complicated and risky with an overweight patient, but it's certainly doable and I expect that you will be happy with the results." He did tell me that there is a higher infection rate and my prosthesis may not last as long as a thinner person--but even about that, he said losing even 50 pounds will make a huge difference in extending the life of the prosthesis.

I think that study above about the life of the prosthesis not being affected by obesity because the assumption that obese people aren't as active is certainly not true in my case and I'm sure many others. I was a VERY active person before the hip arthritis slowed me down and I plan to return to my usual activities afterwards. Even during my life at times when my weight was up, I could keep up with persons much thinner than I was. And, I expect that it will be much easier for me to lose weight after surgery when I don't have that pain to contend with--easier to be active and also less emotional baggage to cope with day in and day out, so less emotional eating for comfort.

Just my 2 cents ...

 

[Bumpa]

rider196 thanks for sharing your story. I am encouraged by learning of your OS's approach as our surgeons in the UK are looking to reduce costs and delaying surgery - for what ever reason, and being overweight is one of them. That was an error from my part the delay is due to the pressure from primary care GPs who are asked to delay hospital
referrals because we can't afford the NHS as was originally designed. And, sad to say, it will get worse.
Best of luck in your recovery journey.

 

[Josephine]

Oh I agree, Bob. But it's not even the GPs really, it's the PCTs that are to blame.

 

[Bumpa]

Josephine, of course you are right it is the PCTs and now the CCG (Clinical Commissioning Groups). I have tried to have input to the Hertfordshire and Bedfordshire Lower Priority Forum without success - these are the 'officers' who set the hurdles in order to delay referrals!

 

[Josephine]

PCTS, CCGs, ye gods and little fishes! :rolleyespink: Sad that they would therefore seem to be even more deaf than their predecessors.

 

[Tykey]

All these groups involved, but we can't find the culprits.

Other than the banks, of course, for getting us in this pickle

 

[Vikki]

I

My osteoarthritis was not as bad when I was first diagnosed, not very long ago, as it is now. It's worsened very quickly, and I've gained more weight progressively since my pain initially started a couple of years ago ... mostly due to depression and emotional eating from life changes and dealing with chronic pain and not being able to be as active. Now I walk with a cane and a few hundred feet is a long walk. My life has changed SO much. I was never a couch potato and that's what I've basically turned into.

And, I expect that it will be much easier for me to lose weight after surgery when I don't have that pain to contend with--easier to be active and also less emotional baggage to cope with day in and day out, so less emotional eating for comfort.
.

Keep on being positive and it will work for you! I too put on weight as my hip became more painful. And to encourage you, I have lost it steadily since my THR, (with the help of Slimming World's changed attitude to food as a tool to help me). I even lost 2lbs during the two weeks of my initial recovery! I am now one and a half stone lighter than before my THR and active and loving it. I have even joined a gym, something I would never have thought of being able to do pre-op.
It seems like your surgeon realises this and, like mine, saw past the effects of your immobility and pain to the advantages a THR will bring to you.
Best wishes

 

[rider1960]

Thanks Vikki! I appreciate the info and support. I am committed to losing weight and regaining my strength after my hips get better. I realize the surgery will just replace the parts so they work better, but it's my job to strengthen everything else and do the maintenance work to keep my body strong and flexible. The surgeon can only do so much to help me out--I'm responsible after that.

My surgeon is probably as "preachy" about "lose weight, lose weight" as any other, and he would LOVE it if I lose significant weight--he would have preferred to have me lose weight prior to surgery. He emphasizes weight loss at every visit, but he also sees the reality of the situation and knows that I'm in pain and can't live like that. So, we are moving forward with the hip replacement (maybe both eventually).

It's so tough to have mobility compromised--I will never again take mobility for granted.

 

[Bumpa]

Here's another pointer to help patients who are very heavy to reduce weight - even a little!

Morbidly obese THA patients show increased risk of instability, dislocation

• September 19, 2012

Morbidly obese patients who have total hip arthroplasty risk hip instability and dislocation because of their size compared to patients with a normal body mass index, and researchers from the University of Iowa suggest the procedure should be modified for larger patients, according to a study in Clinical Orthopaedics and Related Research.
“We have shown that morbidly obese patients’ thighs are so large they are actually pushing each other outward and forcing the implant out of its socket,” Jacob M. Elkins, MS, a graduate student from the University of Iowa, stated in a press release. “Studies have shown up to a 6.9-fold higher dislocation rate for morbidly obese patients compared to normal weight patients.”
In 146 healthy adults and six cadaver pelves, Elkins and colleagues measured a variety of hip implants in patients performing movements such as sitting and standing. They assessed dislocation risk with 28-mm and 36-mm heads, for multiple cup abduction angles and in normal and high-offset necks, according to the abstract.
Patients increased their risk of dislocation if they had a body mass index of 40 or greater. While larger diameter heads did not decrease the dislocation rate, implants with high-offset necks were effective, according to the abstract.
Reference:
Elkins JM, Daniel M, Pedersen DR, et al. Morbid obesity may increase dislocation in total hip patients: a biomechanical analysis. Clin Orthop Rel Res. Published online ahead of print Aug. 21, 2012. doi:10.1007/s11999-012-2512-3.

 

[Josephine]

That's very interesting, Bob. I thought it was going to be about the size of the femoral implant!

I'm sure you remember back in the old days when Charnleys ruled the nest, there were only 4 sizes of stem; standard, heavy, X heavy and XX heavy. I was a big girl at the time and asked our hip guru, John Read (one of Charnley's early registrars) what criteria he used to select them. He replied that up to 11 stone would be standard, 11-13 stone, a heavy, 13-15 stone an X heavy and then he looked at me and said with a cheeky grin "For you, an XX heavy"!

 

[Bumpa]

Jo, thanks for that story. It made me laugh. In 1975 I bought Charnley and his wife a drink in the Royal Hotel in Copenhagen (EFFORT Congress) and from then we got on fine. I always thought 'XXXs' were kisses!

 

[bottomshollow]

Bumpa said, "I always thought 'XXXs' were kisses"

 

[Bumpa]

This has just been published in the British Edition of the Journal of Bone & Joint Surgery and gives a positive view for those who are well built and likely to undergo knee replacement. At least in Scotland and Australia!

Does obesity influence clinical outcome at nine years following total knee replacement?

1. broken link removed: https://www.bjj.boneandjoint.org.uk/search?author1=R.+A.+Collins&sortspec=date&submit=Submit, BMedSci (Hons), 5th year Medical Studentbroken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract#aff-1 broken link removed: https://orthodox.boneandjoint.org.uk/viewprofileinfo.aspx?authorid=1005852;
2. broken link removed: https://www.bjj.boneandjoint.org.uk/search?author1=P.+J.+Walmsley&sortspec=date&submit=Submit, MBChB, FRCSEd(Orth), Consultant Orthopaedic Surgeonbroken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract#aff-2;
3. broken link removed: https://www.bjj.boneandjoint.org.uk/search?author1=A.+K.+Amin&sortspec=date&submit=Submit, MBChB, PhD, FRCSEd(Tr&Orth), Fellowbroken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract#aff-3;
4. broken link removed: https://www.bjj.boneandjoint.org.uk/search?author1=I.+J.+Brenkel&sortspec=date&submit=Submit, BSc, FRCSEd, Consultant Orthopaedic Surgeonbroken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract#aff-2; and
5. broken link removed: https://www.bjj.boneandjoint.org.uk/search?author1=R.+A.+E.+Clayton&sortspec=date&submit=Submit, BSc(Hons), MBChB(Hons), FRCSEd (Tr&Orth), Consultant Orthopaedic Surgeonbroken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract#aff-2

broken link removed: https://www.bjj.boneandjoint.org.uk/content/94-B/10/1351.abstract Author Affiliations

1. 1University of Edinburgh College of Medicine & Veterinary Medicine, Chancellor’s Building, Little France, Edinburgh, EH14 6SA, UK.
2. 2Victoria Hospital Kirkcaldy, Department of Orthopaedics, Hayfield Road, Kirkcaldy KY2 5AH, UK.
3. 3The Austin Hospital, 145 Studley Road, PO Box 5555, Heidelberg, Victoria 3084, Australia.

Abstract
A total of 445 consecutive primary total knee replacements (TKRs) were followed up prospectively at six and 18 months and three, six and nine years. Patients were divided into two groups: non-obese (body mass index (BMI) < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). The obese group was subdivided into mildly obese (BMI 30 to 35 kg/m2) and highly obese (BMI ≥ 35 kg/m2) in order to determine the effects of increasing obesity on outcome. The clinical data analysed included the Knee Society score, peri-operative complications and implant survival. There was no difference in the overall complication rates or implant survival between the two groups.
Obesity appears to have a small but significant adverse effect on clinical outcome, with highly obese patients showing lower function scores than non-obese patients. However, significant improvements in outcome are sustained in all groups nine years after TKR. Given the substantial, sustainable relief of symptoms after TKR and the low peri-operative complication and revision rates in these two groups, we have found no reason to limit access to TKR in obese patients.

 

[Josephine]

That's great, Bob. Thanks for posting it.

 

[Bumpa]

Josephine, on the other hand (or is it knee!):

Obese patients have higher infection rates, complications after TKA surgery

• October 24, 2012

Obese patients have double the rate of infection and a greater risk of complications in general following total knee arthroplasty than patients with a normal body mass index, according to researchers from Amsterdam.
“Orthopedic operations can technically be more difficult in obese people and it is important for us to know whether there is a higher complication rate in the obese and if the long-term outcome is worse,” Gino M.M.J. Kerkhoffs, MD, PhD, lead author and orthopedic surgeon at the Academic Medical Center Amsterdam at University of Amsterdam, stated in a press release.
Kerkhoffs and colleagues identified 14 total knee arthroplasty (TKA) studies with 15,276 patients where infection was recorded. Overall infection had an odds ratio of 1.90 for obese patients to patients with a normal body mass index (BMI), while the odds ratio for deep infection in obese patients compared to normal BMI patients was much higher, at 2.38, according to the abstract. The researchers also noted that revision TKA for any reason, recorded in 11 studies with 12,101 patients, occurred more often in obese patients with an odds ratio of 1.30.
While Kerkhoffs and colleagues do not recommend against performing TKA in obese patients, they suggest surgeons inform their patients of the potential complications that could arise from the procedure.
“Although these results are not surprising, for the obese patient, this literature sheds new light on treatment options for symptomatic knee osteoarthritis: a total knee replacement is not the easy solution,” Kerkhoffs stated.
Reference:
Kerkhoffs GMMJ. J Bone Joint Surg Am. 2012;doi:10.2106/JBJS.K.00820.

 

[Bumpa]

This UK paper does tend to endorse that operations should not be delayed in severe osteoarthritis:
Delaying THR in osteoarthritic patients is costly, decreases quality of life

• February 8, 2013

A United Kingdom researcher has found that delaying total hip replacement in patients with severe osteoarthritis significantly decreases their quality of life and often costs more than if the procedure had been performed immediately.
“This research clearly suggests that the cost savings to national health systems in Europe brought about by delaying [broken link removed: https://www.healio.com/orthopedics/search?q=%22total%20hip%20replacement%22&requiredfields=specialty:Orthopedics] THR may not justify the large quality of life losses to patients,” Rubén E. Mújica Mota, BSc, MSc, PhD, senior lecturer of health economics at the University of Exeter and lead author, stated in a press release.
Mújica Mota conducted a literature review using the Italian National Health Service of patients with osteoarthritis who underwent THR performed immediately, nonsurgical therapy followed by THR after osteoarthritis progression or drug therapy. At 65 years old, the broken link removed: https://www.healio.com/orthopedics/search?q=%22cost%20per%20quality-adjusted%20life-year%22&requiredfields=specialty:Orthopedics was €987 for men and €466 in women for THR compared to patients who delayed THR, according to the abstract. For patients who delayed THR rather than underwent drug therapy, the cost per quality-adjusted life-year was €463 for men and €82 in women.
Though the cost savings was greater for patients who immediately underwent THR, Mújica Mota wrote in the review that women may benefit from delayed THR because of their longer life expectancy.
Reference:
Mújica Mota RE. Value Health. 2013;doi:10.1016/j.jval.2012.10.020.