Early Surgical Complications of Total Hip Arthroplasty in Patients With Morbid Obesity: Propensity-Matched Cohort Study of 3683 Patients

A Systematic Review and Meta-Analysis of Periprosthetic Joint Infection Rates in Morbidly Obese Patients Undergoing Total Hip Arthroplasty

INTRODUCTION

Periprosthetic joint infection (PJI) is a severe complication associated with higher rates in obese individuals after total hip arthroplasty (THA). Hard cutoffs for body mass index (BMI) levels may lead to restricted access to care; however, a certain level of obesity may warrant these restrictions for patient safety. The purpose of this study was to perform a systematic review and meta-analysis of articles comparing PJI rates in morbidly versus nonmorbidly obese patients undergoing primary THA.

METHODS

A systematic search of PubMed, EMBASE, Cochrane, and Google Scholar databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Original studies comparing PJI rates in morbidly obese (BMI ≥40 kg/m2) and nonobese (BMI <40 kg/m2) THA patients were included. Data extraction, bias assessment, and quantitative synthesis were done.

RESULTS

After exclusion criteria, 10 studies comprising 46,080 THAs were included. Morbidly obese patients were found to have markedly higher rates of PJI compared with nonmorbidly obese patients (odds ratio = 4.332, 95% confidence interval [CI], 2.943 to 6.375, I2 = 0, P-value = 0.901). Analysis of cohorts stratified by BMI showed consistent trends; morbidly obese patients demonstrated markedly increased risk of blood transfusions, postoperative fractures, superficial infections, dislocations, readmission within 90 days, surgical complications, and revision surgery.

CONCLUSION

Morbidly obese patients demonstrate markedly increased risk of PJI and other complications after primary THA. This should be discussed with patients to safely provide the option of THA while minimizing restrictions on access to care.

Does Your Patient Need to Lose Weight? Weight Change Before and After Total Hip Arthroplasty Does Not Affect Health Care Utilization and Achievement of the Minimal Clinically Important Difference

BACKGROUND

Despite the potential negative impact of preoperative obesity on total hip arthroplasty (THA) outcomes, the association between preoperative and postoperative weight change and outcomes is much less understood. Therefore, this study aimed to determine the impact of preoperative and postoperative weight change and preoperative body mass index (BMI) on health care utilization, satisfaction, and achievement of minimal clinically important difference (MCID) for Hip Disability and Osteoarthritis Outcome Score Physical Function Short-Form (HOOS PS) and HOOS Pain.

METHODS

Patients who underwent primary elective unilateral THA between January 2016 and December 2019 were included (N = 2,868). Multivariable logistic regression assessed the association between BMI and preoperative and postoperative weight change on outcomes while controlling for demographic characteristics.

RESULTS

There was no association between preoperative weight change and prolonged length of stay (> 3 days), 90-day readmission, nonhome discharge, patient dissatisfaction at 1 year, or achievement of HOOS Pain or HOOS PS MCID. Postoperative weight loss was an independent risk factor for patient dissatisfaction at 1 year but was not associated with achievement of either HOOS Pain or HOOS PS MCID at 1-year postoperative. Preoperative obesity classes I to III were independent risk factors for nonhome discharge. Nevertheless, preoperative obesity class I and class II were associated with an increased probability of reaching HOOS Pain MCID. Preoperative BMI was not associated with an increased risk of patient dissatisfaction.

CONCLUSIONS

Preoperative weight change does not appear to influence health care utilization, satisfaction, or achievement of MCID in pain and function following THA. Postoperative weight loss may play a role as a risk factor for dissatisfaction following THA. Additionally, patients who had a higher baseline BMI may be more likely to see improvement in pain following THA. Therefore, when counseling obese patients for THA, surgeons must balance the risk of perioperative complications with the expectation of greater improvements in pain.

The Effect of Obesity on Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fractures

Obesity is a well-recognized global epidemic that can lead to longer operative times as well as a greater technical demand. Despite this, the available literature evaluating the impact of obesity on hip hemiarthroplasty (HA) and total hip arthroplasty (THA) when treating fractures about the femoral neck is scarce. Between 2015 and 2018, we retrospectively reviewed all patients that had a HA or THA performed as treatment for an isolated fracture of the femoral neck. Patients were classified as obese and nonobese depending on current body mass index (BMI) when the index procedure was performed. Preoperative and postoperative variable were obtained from the electronic medical record. A total of 157 patients underwent hip HA or THA for an isolated fracture of the femoral neck. In those patients undergoing HA, obesity was associated with an increase in operative times (P = 0.021) and was associated with a nonsignificant increase in total operating room time (P = 0.088) and duration of anesthesia (P = 0.14). In those patients undergoing THA, obesity was associated with longer operative times (P = 0.043), total operating room time (P = 0.032), and duration of anesthesia (P = 0.045). There were no significant differences in complication rates postoperatively between obese and non-obese patients undergoing either procedure. The treatment of isolated fractures of the femoral neck with HA or THA leads to an increase in operative time without an increase in postoperative complications in obese patients.

Unique characteristics of patients who choose an intensive lifestyle medicine program to address chronic musculoskeletal pain

INTRODUCTION

Factors that motivate musculoskeletal patients to pursue an intensive, lifestyle medicine-based approach to care are poorly understood.

OBJECTIVE

To determine whether, compared to patients seeking musculoskeletal care through traditional pathways, patients who choose an intensive lifestyle medicine program for musculoskeletal pain endorse greater physical dysfunction, worse psychological health, and/or more biopsychosocial comorbidities.

DESIGN

Cross-sectional analysis of existing medical records from 2018 to 2021.

SETTING

Orthopedic department of one academic medical center.

PATIENTS

Fifty consecutive patients who enrolled in an intensive lifestyle medicine program to address a musculoskeletal condition. Comparison groups were the following: (1) 100 patients who presented for standard nonoperative musculoskeletal care, and (2) 100 patients who presented for operative evaluation by an orthopedic surgeon and qualified for joint arthroplasty.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes were age-adjusted, between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS) physical and psychological health measures. Secondary outcomes were between-group differences in sociodemographic and medical history characteristics.

RESULTS

Patients who enrolled in the intensive lifestyle medicine program were more racially diverse (non-White race: lifestyle cohort 34% vs. comparison cohorts 16%-18%, p ≤ .029) and had a higher prevalence of obesity and diabetes than both comparison groups (mean body mass index: lifestyle cohort 37.6 kg/m2 vs. comparison cohorts 29.3-32.0, p < .001; diabetes prevalence: lifestyle cohort 32% vs. comparison cohorts 12%-16%, p ≤ .024). Compared to standard nonoperative patients, there were no clear between-group differences in PROMIS physical or psychological health scores. Compared to standard operative evaluation patients, patients in the lifestyle program reported worse anxiety but less pain interference (PROMIS Anxiety: B = 3.8 points [95% confidence interval, 0.1 to 7.4], p = .041; Pain interference: B = -3.6 [-6.0 to -1.2], p = .004).

CONCLUSIONS

Compared to musculoskeletal patients who sought care through traditional pathways, patients who chose an intensive lifestyle medicine pathway had a higher prevalence of metabolic comorbidities, but there was substantial overlap in patients' physical, psychological, and sociodemographic characteristics.

Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review

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Obesity, defined as body mass index (BMI) ≥30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly.

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From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI ≥40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI ≥30) or morbidly obese (BMI ≥40).

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In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI ≥40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision.

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The current literature on the role that bariatric weight loss surgery before TJA has on improving surgical outcomes is split and referral to a bariatric surgeon should be a shared-decision between patient and surgeon on a case-by-case basis.

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Despite the increased risk profile of TJA in the morbidly obese cohort, these patients consistently show improvement in pain and physical function postoperatively that should be considered when deciding for or against surgery.

Should patient age thresholds dictate fixation strategy in total hip arthroplasty?

AIMS

Total hip arthroplasty (THA) is a very successful and cost-effective operation, yet debate continues about the optimum fixation philosophy in different age groups. The concept of the 'cementless paradox' and the UK 'Getting it Right First Time' initiative encourage increased use of cemented fixation due to purported lower revision rates, especially in elderly patients, and decreased cost.

METHODS

In a high-volume, tertiary referral centre, we identified 10,112 THAs from a prospectively collected database, including 1,699 cemented THAs, 5,782 hybrid THAs, and 2,631 cementless THAs. The endpoint was revision for any reason. Secondary analysis included examination of implant survivorship in patients aged over 70 years, over 75 years, and over 80 years at primary THA.

RESULTS

Cemented fixation had the lowest implant survival in all age groups, with a total ten-year survivorship of 97.0% (95% confidence interval (CI) 95.8 to 97.8) in the cemented group, 97.6% (95% CI 96.9 to 98.1) in the hybrid group, and 97.9% (95% CI 96.9 to 98.6) in the cementless group. This was not statistically significant (p = 0.092). There was no age group where cemented fixation outperformed hybrid or cementless fixation.

CONCLUSION

While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. We recommend that surgeons should carefully monitor their own outcomes and use fixation techniques that they are familiar with, and deliver the best outcomes in their own hands. Cite this article: Bone Joint J 2022;104-B(2):206-211.

Patients' risk factors for periprosthetic joint infection in primary total hip arthroplasty: a meta-analysis of 40 studies

BACKGROUND

Periprosthetic joint infection (PJI) is a catastrophic complication after total hip arthroplasty (THA). Our meta-analysis aimed to identify the individual-related risk factors that predispose patients to PJI following primary THA.

METHODS

Comprehensive literature retrieval from Pubmed, Web of Science, and the Cochrane Library was performed from inception to Feb 20th, 2021. Patient-related risk factors were compared as per the modifiable factors (BMI, smoke and alcohol abuse), non-modifiable factors (gender, age), and medical history characteristics, such as diabetes mellitus (DM), avascular necrosis (AVN) of femoral head, femoral neck fracture, rheumatoid arthritis (RA), cardiovascular disease (CVD), and osteoarthritis (OA) etc. The meta-analysis was applied by using risk ratios with 95% corresponding intervals. Sensitivity analysis and publication bias were performed to further assess the credibility of the results.

RESULTS

Overall, 40 studies with 3,561,446 hips were enrolled in our study. By implementing cumulative meta-analysis, higher BMI was found associated with markedly increased PJI risk after primary THA [2.40 (2.01-2.85)]. Meanwhile, medical characteristics including DM [1.64 (1.25-2.21)], AVN [1.65 (1.07-2.56)], femoral neck fracture [1.75 (1.39-2.20)], RA [1.37 (1.23-1.54)], CVD [1.34 (1.03-1.74)], chronic pulmonary disease (CPD) [1.22 (1.08-1.37)], neurological disease [1.19 (1.05-1.35)], opioid use [1.53 (1.35-1.73)] and iron-deficiency anemia (IDA) [1.15 (1.13-1.17)] were also significantly correlated with higher rate of PJI. Conversely, dysplasia or dislocation [0.65 (0.45-0.93)], and OA [0.70 (0.62-0.79)] were protective factors. Of Note, female gender was protective for PJI only after longer follow-up. Besides, age, smoking, alcohol abuse, previous joint surgery, renal disease, hypertension, cancer, steroid use and liver disease were not closely related with PJI risk.

CONCLUSION

Our finding suggested that the individual-related risk factors for PJI after primary THA included high BMI, DM, AVN, femoral neck fracture, RA, CVD, CPD, neurological disease, opioid use and IDA, while protective factors were female gender, dysplasia/ dislocation and OA.

Association of Surgical Experience With Risk of Complication in Total Hip Arthroplasty Among Patients With Severe Obesity

IMPORTANCE

Severe obesity is a risk factor for major early complications after total hip arthroplasty (THA).

OBJECTIVE

To determine the association between surgeon experience with THA in patients with severe obesity and risk of complications.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study was performed in Ontario, Canada, from April 1, 2007, to March 31, 2017, with data analysis performed from March 2020 to January 2021. A cohort of patients who received a primary THA for osteoarthritis and who also had severe obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] ≥40) at the time of surgery was defined. These patients were identified using the Canadian Institute for Health Information Discharge Abstract Database and physician claims from the Ontario Health Insurance Plan. Generalized estimating equations were used to determine the association between overall THA and severe obesity-specific THA surgeon volume and the occurrence of complications after controlling for potential confounders. The study hypothesized that surgeon experience specific to patients with severe obesity could further reduce the risk of complications.

EXPOSURES

Primary THA.

MAIN OUTCOMES AND MEASURES

Complications were considered as a composite outcome (revision, infection requiring surgery, or dislocation requiring reduction), within 1 year of surgery. This was defined before the study, as was the study hypothesis.

RESULTS

A total of 4781 eligible patients was identified. The median age was 63 (interquartile range [IQR], 56-69) years, and 3050 patients (63.8%) were women. Overall, 186 patients (3.9%) experienced a surgical complication within 1 year of surgery. The median overall THA surgeon volume was 70 (IQR, 46-106) cases/y, whereas the median obesity-specific surgeon volume was 5 (IQR, 2-9) cases/y. After controlling for patient and hospital factors, greater obesity-specific THA surgeon volume (adjusted odds ratio per additional 10 cases, 0.65 [95% CI, 0.47-0.89]; P = .007), but not greater overall THA surgeon volume (adjusted odds ratio per 10 additional cases, 0.97 [95% CI, 0.93-1.02]; P = .24), was associated with a reduced risk of complication.

CONCLUSIONS AND RELEVANCE

Increased surgeon experience performing THA in patients with severe obesity was associated with fewer major surgical complications. These findings suggest that surgeon experience is required to mitigate the unique anatomical challenges posed by surgery in patients with severe obesity. Referral pathways for patients with severe obesity to surgeons with high obesity-specific THA volume should be considered.