Total knee arthroplasty in the obese patient: Tips and quips

doi:10.1054/arth.2002.33265

The Journal of Arthroplasty

Volume 17, Issue 4, Supplement 1, June 2002, Pages 69-70

https://doi.org/10.1054/arth.2002.33265 Get rights and content

Abstract

As defined by body mass index, 1 of every 3 Americans is overweight. The excuses and reasons for this situation are genetic, dietary, cultural, and physiologic. Scandinavian literature has shown a higher incidence of gonarthrosis in obese patients and some indication of decremental surgical results. Patient selection requires identification of the distribution of the obesity and its implications for knee surgery. Anesthetic techniques should stress regional approaches, oxygenation, and modified postoperative regimens. Surgical incisions should be midline, should be longer than normal, and should involve eversion of the patella within its fat envelope. Increased tourniquet length and width are mandatory. Although wound complications are more common, the overall statistics from total knee arthroplasty in obese patients are not discouraging. Greater pressure is placed on the surgeon to achieve perfect alignment and balance because the patient's weight could unmask the imperfections of the arthroplasty. Only 18% of obese people lose weight after joint replacement. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Surgical procedure

Although the use of a tourniquet has been a given in TKA for many years, this may not be possible in the obese patient without such high pressures that neurologic or vascular damage might ensue. Special wider tourniquets are available for this situation, but the surgeon should be prepared to operate without a tourniquet at all. In this instance, as much of the knee surgery as possible should be performed with the limb in flexion because bleeding about the knee is reduced radically in this

Postoperative considerations

Postoperatively, it is prudent to restrict the range of the continuous passive motion machine to avoid reduced oxygen tension in the healing skin incision; to avoid antithrombotic stockings, which are unlikely to fit the heavy leg; and to avoid limited ambulation, often leading to postphlebitic syndrome, which is more common in obese women.

The incidence of disruption of the anterior fibers of the medial collateral ligament is distinctly higher in TKAs in obese patients, and the surgeon must be

Conclusion

Although only 18% of obese TKA patients achieve or maintain significant weight reduction after their surgery, they are among the least complaining and most satisfied of all TKA recipients. Although special precautions and considerations are necessary, the end result is likely to be quite satisfying for all.

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Cited by (25)

Management of the Bariatric Patient. What Are the Implications of Obesity and Total Joint Arthroplasty: The Orthopedic Surgeon's Perspective?
2019, Journal of Arthroplasty
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There is no question that obese patients are at higher risk for the development of complications following total joint replacement and represent a large segment of the population that need or receive total joint replacement [6,8]. Obesity, and particular, morbid obesity (BMI >40 kg/m2) has been shown in numerous peer-reviewed publications to be an independent risk factor for the development of peri-prosthetic joint infection and early failure of total joint replacement [15–18]. Odds ratios for risk of major complications increase up to 8× when BMI is above 40 and up to 25× when BMI is greater than 50 kg/m2 [19].
Obesity in the United States has reached epidemic proportions. It is associated with multiple higher rates of osteoarthritis of the hip and knee and thus an increasing need for total hip and knee arthroplasty. The demand for total joint arthroplasty among obese patients has increased and outpaces that of a non-obese cohort. The complications associated with obese patients undergoing hip or knee replacement is well defined in the literature.
Many practices have set restriction on body mass index (BMI) prior to elective total join arthroplasty. We review the implications of these BMI cutoffs as it is related to access to care for morbidly obese patients in need of hip and knee arthroplasty.
Of the 289 patients who presented with BMI >40, only 19% of patients underwent total hip or knee arthroplasty at a minimum of 2 years of follow-up.
This symposium discusses the implications of withholding surgery in the morbidly obese and sets the stage for the development of more collaborative work to ensure optimal care and optimal outcome for the morbidly obese.
Intra-operative and short term outcome of total knee arthroplasty in morbidly obese patients
2014, Knee
Longer operation times, poorer patient outcomes and increased early post-operative complications are reasons cited for not undertaking Total Knee Arthroplasty (TKA) on morbidly obese patients. This study tests the hypothesis that there is no difference in intra-operative parameters between morbidly obese and non-obese patients, and no difference in patient outcome.
Intra-operative parameters, post-operative complications, patient outcomes and knee range of motion were compared between morbidly obese patients (BMI > 40 kg/m²) and individually age and gender matched non-obese patients (BMI < 30 kg/m²) undergoing cementless rotating platform TKA.
Anaesthetic times and length of hospital stay were not significantly different between the morbidly obese and non-obese patients. Surgical time was significantly greater in morbidly obese patients. Improvements in patient outcomes following TKA were not significantly different between the morbidly obese and non-obese patients at early and short-term follow-up.
In contrast to previous studies, post-operative complication rates within three months of surgery and up to one year post-operatively were not significantly higher for morbidly obese patients.
III
Effect of body mass index on limb alignment after total knee arthroplasty
2013, Journal of Arthroplasty
Prior studies have reported increased failure rates in obese patients with postoperative limb mal-alignment. This study was undertaken to determine if a relationship exists between postoperative limb alignment and BMI in patients undergoing primary TKA performed with mechanical instruments. An IRB-approved retrospective review of 196 knees was undertaken. Limb alignment was determined on full-length, standing, hip-to-ankle x-rays, preoperatively and postoperatively. The effects of gender, side, preoperative mechanical alignment and BMI on postoperative alignment were analyzed via multivariate regression analysis. Both preoperative mechanical limb alignment (P < 0.001) and BMI (P = 0.009) had a significant effect on postoperative limb alignment following TKA performed with mechanical instruments.
Patient obesity: A growing concern of successful total knee arthroplasty
2010, Seminars in Arthroplasty JSES
Citation Excerpt :
As most surgeons will appreciate, knee arthroplasty in obese patients poses certain technical difficulties, such as inability to apply the tourniquet leading to a bleeding operating field, difficult access, alignment estimation, and wound closure. Recommendations for preoperative and perioperative measures have been described,41 and the higher risk of surgical complications should be discussed with patients. Intraoperative sizing may be more accurate than radiographic templating because of reduced magnification.
The study reviews the outcome of total knee arthroplasty in obese patients. Knee arthroplasty in obese patients is a more technically challenging procedure. It carries a higher risk of postoperative infection, and the final functional score may not be as good as that of the nonobese patient. However, the pain relief and improvement in knee function are significant, and implant survival is equivalent to nonobese patients. Knee arthroplasty should not be denied to obese patients despite the concerns, as the overall improvement of quality of life is highly significant.
Effects of obesity on inpatient rehabilitation outcomes following total knee arthroplasty
2008, Physiotherapy
Citation Excerpt :
Traditionally, obese patients have been considered at risk for poor surgical outcome. Difficulties with anaesthesia, baseline pulmonary dysfunction, hypercoagulability, technical challenges during surgery and the large tissue mass at the incision site have been hypothesised to contribute to higher complication rates in overweight patients [9,12,18]. Despite these concerns, long-term outcome studies have shown that obese TKA patients do as well as their non-obese counterparts in terms of patient satisfaction, quality of life and wear of the implanted components [4,9,13,19].
To investigate the effects of obesity on inpatient rehabilitation outcomes following total knee arthroplasty.
Two hundred and thirty-nine total knee arthroplasty patients (12 men and 227 women).
Patients were divided in two groups (non-obese and obese) according to pre-operative body mass index (BMI). After surgery, all patients received standard post-operative treatment from a physiotherapist, including continuous passive motion, active-assistive and active range of motion exercises, isometric and isotonic strengthening exercises, gait training and transfer training.
Patients were evaluated pre-operatively and at discharge using BMI, knee function score [Hospital for Special Surgery (HSS) score], pain and range of motion of knee flexion. Functional activities were evaluated using the Iowa Level of Assistance Scale, and walking speed was evaluated using the Iowa Ambulation Velocity Scale.
There were no statistically or clinically significant differences between the two groups of patients at discharge, with obese patients recording a mean HSS score of 62.6 points (95% confidence interval 61.3 to 63.9) and non-obese patients recording a mean HSS score of 62.6 (95% confidence interval 61.6 to 63.7, P = 0.950). Both groups improved in all parameters at the time of discharge compared with pre-operative values, with the exception of walking speed and the range of knee flexion. There was no significant difference in length of hospital stay between obese (median 9 days, interquartile range 4–22) and non-obese (median 9 days, interquartile range 4–23) patients.
Obesity had no negative effects on inpatient rehabilitation outcomes following total knee arthroplasty. This finding is significant given implementation of the prospective payment system in rehabilitation hospitals in parts of Turkey, and the effect that this will have on length of hospital stay for patients who have undergone total knee arthroplasty.
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^☆: No benefits or funds were received in support of this study.

^☆☆: Reprint requests: Robert E. Booth, Jr., MD, 3B Orthopaedics, 800 Spruce Street, Philadelphia, PA 19107.

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Total knee arthroplasty in the obese patient: Tips and quips☆,☆☆

Abstract

Section snippets

Surgical procedure

Postoperative considerations

Conclusion