A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Does body mass index affect outcomes following arthroscopic superior capsular reconstruction using fascia lata autograft for massive irreparable rotator cuff tear?

PURPOSE

This study aimed to evaluate the effect of increased body mass index (BMI) on patient-reported outcomes (PROs) and clinically significant outcomes (CSOs) obtained > two years postoperatively following arthroscopic superior capsular reconstruction (ASCR).

METHODS

A retrospective study was conducted on patients who underwent ASCR with a minimum two year follow-up. All patients were divided into normal (BMI < 25.0), overweight (BMI 25-30.0), and obese (BMI ≥ 30) according to preoperative BMI. Patients were assessed using the PROs preoperatively and at six months, one year, and two years postoperatively, including the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant-Murley scores. The time required to achieve each CSO was analyzed and compared. Multivariate analyses evaluated the predictor variables and time required to achieve CSOs.

RESULTS

This study included 63 patients with a mean age of 64.8 ± 8.6 years, including 31 normal BMI, 25 overweight, and seven obese patients. Significant improvements in VAS and ASES scores after ASCR were observed in all three groups. Normal and overweight patients had significant improvements in the Constant score; however, no difference was observed in obese patients. No significant difference was observed in the probability distributions of CSOs between the BMI groups. Similarly, no significant differences were observed in the probability distributions of the CSOs, ASES, and Constant scores at each time point, among the BMI groups.

CONCLUSION

Patients in the normal and overweight groups had significant improvements in the VAS, ASES, and Constant scores after ASCR. Patients in the obese group had a significant improvement in VAS score; however, there is no difference for the ASES and Constant scores in the obese group. However, no differences were observed in all PROMs and the likelihood of achieving CSOs among the different BMI groups.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories.

METHODS

We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model.

RESULTS

285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30).

CONCLUSIONS

Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

The aim of our study was to identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories.

METHODS

We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model.

RESULTS

285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30).

CONCLUSIONS

Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. However, future research should consider incorporating PASS anchor questions to determine whether obesity truly carries a risk of delayed achievement of a satisfactory state of health as it pertains to the hip.

LEVEL OF EVIDENCE

III, retrospective comparative study.

The effect of obesity on complications following isolated posterior cruciate ligament reconstruction

BACKGROUND

This study assessed the risk of 30-day complications for obese patients compared to non-obese patients undergoing isolated posterior cruciate ligament (PCL) reconstruction.

METHODS

From 2006 to 2019, the National Surgical Quality Improvement Program database was queried for patients undergoing isolated PCL reconstruction. Two patient cohorts were defined: patients with obesity (BMI ≥ 30.0 kg/m²) and patients without obesity (BMI < 30 kg/m²). Patients' baseline demographics and medical comorbidities were collected and compared between the cohorts. Postoperative outcomes were assessed using bivariate and multivariate analyses.

RESULTS

414 patients underwent PCL reconstruction. 258 patients (62.3%) were non-obese and 156 patients (37.7%) were obese. Obese patients were more likely to be older, have a higher American Society of Anesthesiologists classification, and have hypertension compared to non-obese patients (p < 0.05 for all). The rates of superficial surgical site infections, wound dehiscence, transfusion necessity, deep vein thrombosis, and re-operation were not significant between obese and non-obese patients. Following adjustment on multivariate analyses, relative to patients without obesity, those with obesity had an increased risk of admission to the hospital overnight (OR 1.66; p = 0.048).

CONCLUSIONS

To our knowledge, this is the first study to evaluate obesity on complications in isolated PCL reconstruction. Our results and the heterogeneity in the literature indicate that obesity significantly impacts the rates of hospital readmission for PCL reconstruction. Therefore, surgeons should carefully weigh the risks and benefits of operating on obese patients and plan accordingly as obese patients may require postoperative hospital admission after PCL reconstruction.

LEVEL OF EVIDENCE

III.

Cystoscopy as a tool for hip arthroscopy for treating morbidly obese patients: a case report of treating a Sumo wrestler

Sports medicine surgeons sometimes encounter morbidly obese athletes with femoroacetabular impingement, such as Sumo wrestlers. In such cases, traditional arthroscopic equipment will not reach the joint. This case report describes the use of a cystoscope to perform arthroscopy to treat borderline developmental dysplasia of the hip combined with cam impingement in a morbidly obese athlete. The cystoscope enables hip arthroscopy to be performed when traditional instruments are not of sufficient length to access the hip and/or an extra-long arthroscope is not available. The use of the cystoscope provides a practical, feasible and minimally invasive option to treat non-arthritic intraarticular hip pathology in the morbidly obese or extremely muscular athletes.

Body Mass Index Screening in Knee Arthroscopy: An Analysis Using the National Surgical Quality Improvement Database

PURPOSE

To analyze patients undergoing knee arthroscopy stratified by body mass index (BMI) and assess the tradeoffs in complications avoided versus access to care that occur when instituting BMI eligibility criteria.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent knee arthroscopy from 2015 to 2016. Patients were categorized by BMI, and differences in complication rates between BMI categories were assessed. The positive predictive value (PPV) was calculated for various BMI cutoffs, with further analysis performed to identify the number of surgeries that would be denied to avoid a single complication.

RESULTS

There were 44,153 knee arthroscopy cases identified and an overall complication rate of 1.7%. There was no significant difference found in major complication rate between those with a BMI >40 kg/m² and those with a BMI <40 (1.7% vs 1.7%, P = .70), and no significant associations between increased complications and a higher BMI were found on binary logistic regression. Instituting a BMI cutoff of 40 has a PPV of 1.7% and would result in the avoidance of 11% of complications while denying 10% of otherwise uncomplicated surgeries. This cutoff would deny 57 surgeries for every complication avoided.

CONCLUSION

In patients undergoing knee arthroscopy, this study failed to detect a significant increased risk of major complications associated with having a BMI >40. The institution of BMI eligibility cutoffs would result in low PPVs and a high number of denials for surgery that would otherwise be complication free.

LEVEL OF EVIDENCE

Level IV, retrospective cohort-based database study.