Traffic in the operating room during joint replacement is a multidisciplinary problem

Background

Door openings disrupt the laminar air flow and increase the bacterial count in the operating room (OR). We aimed to define the incidence of door openings in the OR during primary total joint arthroplasty (TJA) surgeries and determine whether measures were needed and/or possible to reduce OR staff traffic.

Methods

We recorded the number of door openings during 100 primary elective TJA surgeries; the OR personnel were unaware of the observer’s intention. Operating time was divided into the preincision period, defined as the time from the opening of surgical trays to skin incision, and the postincision period, defined as time from incision to dressing application.

Results

The mean number of door openings during primary TJA was 71.1 (range 35–176) with a mean operative time of 111.9 (range 53–220) minutes, for an average of 0.64 (range 0.36–1.05) door openings/min. Nursing staff were responsible for 52.2% of total door openings, followed by anesthesia staff at 23.9% and orthopedic staff at 12.7%. In the preincision period, we observed an average of 0.84 door openings/min, with nursing and orthopedic personnel responsible for most of the door openings. The postincision period yielded an average of 0.54 door openings/min, with nursing and anesthesia personnel being responsible for most of the door openings.

Conclusion

There is a high incidence of door openings during TJA. Because we observed a range in the number of door openings per surgery, we believe it is possible to reduce this number during TJA.     

Operating Room Traffic Increases Aerosolized Particles and Compromises the Air Quality: A Simulated Study

Background

Strategies to prevent bacterial fallout and reduce particle count in the operating room (OR) are key components of preventing periprosthetic joint infection. Although OR traffic control is an important factor, a quantitative study has not been performed to investigate the influence of personnel and door opening on OR air quality. This simulated study aimed to examine the influence of these 2 factors on particle density in OR with and without the laminar air flow (LAF).

The Effect of Laminar Air Flow and Door Openings on Operating Room Contamination

We evaluate the association of laminar airflow (LAF) and OR traffic with intraoperative contamination rates. Two sterile basins were placed in each room during 81 cases, one inside and one outside the LAF. One Replicate Organism Detection and Counting (RODAC) plate from each basin was sent for culture at successive 30-minute intervals from incision time until wound closure. At successive 30-minute intervals more plates were contaminated outside than inside the LAF. A negative binomial model showed that the bacteria colony forming units (CFU) depended on whether there were any door openings (P = 0.02) and the presence of LAF (P = 0.003). LAF decreases CFU by 36.6%. LAF independently reduces the risk of contamination and microbial counts for surgeries lasting 90 minutes or less.     

A retrospective analysis of kidney function and risk factors by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in elderly Chinese patients

Abstract

Chronic kidney disease accounts for much of the increased mortality, especially in the elder population. The prevalence of this disease is expected to increase significantly as the society ages. Our aim was to evaluate the kidney function and risk factors of reduced renal function among elderly Chinese patients. This study retrospectively collected clinical data from a total of 1062 inpatients aged 65 years or over. Estimated glomerular filtration rate (eGFR) was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Renal function and risk factors were also analyzed. For all 1062 subjects, the mean eGFR was 71.0?±?24.8?mL/min/1.73?m², and the incidence rates of reduced renal function, proteinuria, hematuria and leukocyturia were 31.1%, 11.8%, 6.6% and 8.7%, respectively. The eGFR values were 83.4?±?28.4, 72.2?±?22.9, 67.8?±?24.3 and 58.8?±?29.1?mL/min/1.73?m² in the groups of 60–69, 70–79, 80–89 and ≥90 years age group (F?=?15.101, p?=?0.000), respectively; while the incidences of reduced renal function were 12.8%, 27.0%, 37.8% and 51.7% (χ²?=?36.143, p?=?0.000). Binary logistic regression analysis showed that hyperuricemia (OR?=?4.62, p?=?0.000), proteinuria (OR?=?3.96, p?=?0.000), urinary tumor (OR?=?2.92, p?=?0.015), anemia (OR?=?2.45, p?=?0.000), stroke (OR?=?1.96, p?=?0.000), hypertension (OR?=?1.83, p?=?0.006), renal cyst (OR?=?1.64, p?=?0.018), female (OR?=?1.54, p?=?0.015), coronary artery disease (OR?=?1.53, p?=?0.008) and age (OR?=?1.05, p?=?0.000) were the risk factors of reduced renal function. In conclusion, eGFR values decreased by age, while the incidence of reduced renal function, proteinuria, hematuria and leukocyturia increased with age. Treatment and control of comorbidities may slow the decline of renal function in elderly patients.     

Predictors of Left Ventricular Hypertrophy in Patients with Chronic Kidney Disease

The aim of the present study is to determine the prevalence and predictors of left ventricular hypertrophy in patients with stage 3 or 4 chronic kidney disease. Thirty-four patients were included. In addition to hematological and biochemical evaluations, echocardiography and ambulatory blood pressure monitoring were performed both at the beginning and at the end of the first year. Echocardiographic left ventricular mass was calculated and indexed to body surface area to calculate left ventricular mass index (LVMI). Left ventricular hypertrophy was diagnosed if LVMI >131 g/m² in male and >100 g/m² in female patients. During the follow-up period, estimated glomerular filtration rate decreased from 36.6±11.7 to 31.0±14.0 mL/min (p = 0.03), while LVMI increased from 130.2±35.6 to 140.5±30.5 g/m² (p = 0.055). Left ventricular hypertrophy was detected in 67.6% of the patients at the baseline and in 89.7% at the end of the study (p = 0.011). The independent predictors of the final LVMI were age (p = 0.035), baseline day-time systolic blood pressure (p = 0.01), baseline C-reactive protein (p = 0.001), and the decrease in glomerular filtration rate during the follow-up (p = 0.002). Left ventricular hypertrophy is quite frequent among patients with stage 3 or 4 chronic kidney disease, and its prevalence increases while glomerular filtration rate decreases during the follow-up. The early detection of left ventricular hypertrophy and both prevention of the deterioration of renal function and aggressive blood pressure control may help to achieve a decrease in cardiovascular morbidity and mortality in these patients.     

Effects and safety of atmospheric low‐temperature plasma on bacterial reduction in chronic wounds and wound size reduction: A systematic review and meta‐analysis

The use of atmospheric low‐temperature plasma (AP) on chronic wounds and its effect on microbial bioburden in open wounds has not been explored with a systematic review and meta‐analysis. PRISMA guidelines were followed and PubMed, Embase, CENTRAL, and CINAHL databases searched for randomised controlled trials (RCTs), which compared AP with no AP for the management of open, chronic wounds. The primary outcomes of reduction of bioburden or wound size were included. Meta‐analyses were performed; odds ratio (OR) and 95% confidence intervals (CIs) were extracted and pooled in a random effects model. Four RCTs investigated the effect of AP on chronic wound healing. Chronic wounds treated with AP did not show a significant improvement in healing (AP vs control: OR = 1.46; 95% CI = 0.89‐2.38; P = 0.13). Five further RCTs investigated the reduction of bioburden in wounds, but AP demonstrated no significant reduction of bioburden (AP vs control: OR = 0.85; 95% CI = 0.45‐1.62; P = 0.63). All nine RCTs recorded the presence of any severe adverse events (SAEs) in the 268 patients studied, with only one unrelated SAE identified in each group (AP vs control: OR = 1.00; 95% CI = 0.05‐19.96; P = 1.00). Use of AP in wound care is safe, but the retrieved evidence and meta‐analysis show that there is no clinical benefit of AP in chronic open wounds using currently available AP device settings.     

Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty May Experience Higher Rates of Venous Thromboembolism When Prescribed Direct Oral Anticoagulants vs Aspirin

BackgroundMorbidly obese (body mass index [BMI] >40 kg/m²) patients undergoing total joint arthroplasty (TJA) are at high risk for postoperative venous thromboembolism (VTE); however, there is debate surrounding the optimal pharmacologic agent for prevention of VTE after TJA in this patient subset. Current guidelines recommend against direct-acting oral anticoagulants (DOACs) in patients of BMI >40 kg/m² due to low quality evidence justifying their use. We evaluated whether patients of BMI >40 kg/m² undergoing primary unilateral TJA would have increased risk of postoperative VTE if prescribed DOACs compared to non-DOAC agents such as aspirin.MethodsThis retrospective study analyzed 897 patients of BMI >40 kg/m² undergoing primary unilateral TJA. Demographic and comorbidity-related variables were collected. The association between postoperative VTE and prophylactic pharmacologic agent prescribed was evaluated by multivariate logistic regression.ResultsAfter controlling for comorbidities, we found that the sole use of DOACs, specifically apixaban, for VTE prophylaxis was associated with an increased risk of developing VTE compared to prophylaxis with aspirin alone in patients of BMI >40 kg/m² (odds ratio 2.962, P = .016). Regardless of VTE prophylactic agent, patients with BMI >40 kg/m² undergoing TKA had at least 4.5-fold increased odds of developing VTE compared to patients undergoing THA (OR 4.830, P = .019).ConclusionIn our retrospective study of a large sample size of patients with BMI >40 kg/m², we found that the use of DOACs, specifically apixaban, for VTE prophylaxis following TJA was associated with increased odds of a VTE complication compared to the use of aspirin alone.     

Racial Differences in Bariatric Surgical Approach: a Cross-Sectional National Inpatient Sample Analysis

Purpose

Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups:?<?40.0 kg/m², 40.0–44.9 kg/m², 45.0–49.9 kg/m², and?≥?50.0 kg/m².

Results

Within the final cohort (N?=?86,053), 73.0% (N?=?62,779) underwent LSG, and 27.0% (N?=?23,274) underwent LRYGB. Patients with BMI 45.0–49.9 kg/m² (OR?=?0.85) and BMI?≥?50.0 kg/m² (OR?=?0.80) were less likely to undergo LSG than patients with BMI 40.0–45.0 kg/m² (all p?<?0.001). However, Black (OR?=?1.74) and White Hispanic patients (OR?=?1.30) were more likely to undergo LSG than White non-Hispanic patients (all p?<?0.005). In the BMI?≥?50.0 kg/m² group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR?=?1.69, p?<?0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR?=?0.41, p?<?0.05).

Conclusion

In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities.

Graphical abstract

     

Radionuclide Staging of Renal Function in Type 1 Diabetes Mellitus

Aim. The aim of this study was to assess renal function in different stages of type 1 diabetes mellitus by radionuclide methods. Additionally, glomerular and tubular functions were correlated with urinary albumin (UAER) and N-acetyl-β-D-glucosaminidase (NAGA) excretion rates. Patients and methods. Fifty-three patients with diabetes mellitus were classified into four groups: normoalbuminuric (NA, 18 patients), microalbuminuric (MiA, 12 patients), macroalbuminuric (MaA, 13 patients), and chronic renal failure group (CRF, 10 patients). Glomerular filtration rate (GFR) was estimated by diethylenetriamine pentaacetic acid-technetium 99m (^99mTc-DTPA) clearance rate while tubular function was calculated as a percentage of net injected activity fixed in both kidneys, 4 h after intravenous injection of dimercaptosuccinate acid-technetium 99m (^99mTc-DMSA). Additionally, ^99mTc-DTPA clearance was correlated with estimated GFR (eGFR) by using modified Modification of Diet in Renal Disease (MDRD) Study Group formula. Results. ^99mTc-DTPA clearance and ^99mTc-DMSA fixation were found significantly higher in normoalbuminuric group (p < 0.05 and p < 0.02, respectively), unchanged in microalbuminuric group (p > 0.05, p > 0.05), and decreased in both macroalbuminuric (p < 0.0001, p < 0.00001) and chronic renal failure group (p < 0.0001, p < 0.00001). Renal function was denoted as normal, increased (hyperfunction), or decreased (hypofunction). It was found normal in a high percentage of patients with normalbuminuria (filtration 44.4%, fixation 72.2% pts) and microalbuminuria (66.7% and 66.7%). Renal hyperfunction was not only found frequent in normalbuminuric group (55.6% and 27.8%), but was also recorded in microalbuminuric group (8.3% and 8.3%). Renal hypofunction was present in all macroalbuminuric patients and in one-quarter of those with microalbuminuria as well. Such distribution of renal function conditions indicated normalbuminuric and microalbuminiric groups functionally heterogeneous. Regression analysis showed a significant correlation between ^99mTc-DTPA clearance and eGFR in MaA and CRF groups only. Although urinary NAGA excretion rate was shown as a less sensitive staging parameter, being significantly increased when compared to control group only in MaA and CRF groups (p < 0.05), it significantly correlated with ^99mTc-DTPA clearance rate (r = ?0.485, p = 0.0004) and ^99mTc-DMSA tubular fixation (r = ?0.526, p = 0.0002). Conclusions. The results of this study favor the performance of radionuclide studies together with the determination of urinary albumin excretion rate in patients with type 1 diabetes mellitus in order to achieve more reliable staging of diabetic kidney disease. The demonstration of glomerular hyperfiltration and tubular hyperfunction by radiopharmaceuticals contributes to the early detection of diabetic kidney disease, while the quantification of renal function enables the follow-up of the progressive function loss in the later course of the disease.     

Association of Rurality and Neighborhood Level Socioeconomic Deprivation with Perioperative Health Status in Total Joint Arthroplasty Patients: Analysis from a Large,Tertiary Care Hospital

BackgroundIndividual socioeconomic status (SES) is associated with disparities in access to care and worse outcomes in total joint arthroplasty (TJA). Neighborhood-level SES measures are sometimes used as a proxy for individual-level SES, but the validity of this approach is unknown. We examined neighborhood level SES and rurality on perioperative health status in TJA.MethodsThe study population comprised 46,828 TJA surgeries performed at a tertiary care hospital. Community area deprivation index (ADI) was derived from the 2015 American Census Survey. Logistic regression was used to examine perioperative characteristics by ADI and rurality.ResultsCompared to patients from the least deprived neighborhoods, patients from the most deprived neighborhoods were likely to be female (odds ratioOR 1.46, 95% confidence interval CI: 1.33-1.61), non-white (OR 1.36, 95% CI: 1.13-1.64), with education high school or less (OR 4.85, 95% CI: 4.35-5.41), be current smokers (OR 2.20, 95% CI: 1.61-2.49), have BMI>30 kg/m² (OR 1.43, 95% CI: 1.30-1.57), more limitation on instrumental activities of daily living (OR 1.75, 95% CI: 1.55-1.97) and American Society of Anesthesiologists (ASA) score > II (OR 2.0, 95% CI: 1.11-1.37). There was a progressive association between the degree of area level deprivation with preexisting comorbidities. Patients from rural communities were more likely to be male, white, have body mass index (BMI)>30 kg/m² and lower education levels. However, rurality was either not associated or negatively associated with comorbidities.ConclusionTJA patients from lower SES neighborhoods have worse behavioral risk factors and higher comorbidity burden than patients from higher SES neighborhoods. Patients from rural communities have worse behavioral risk factors but not comorbidities.     

Foot and ankle injuries during the Athens 2004 Olympic Games

Background

The purpose of this study was to assess the level of air contamination with bacteria after surgical hydrodebridement and to determine the effectiveness of hydro surgery on bacterial reduction of a simulated infected wound.

Methods

Four porcine samples were scored then infected with a broth culture containing a variety of organisms and incubated at 37°C for 24 hours. The infected samples were then debrided with the hydro surgery tool (Versajet, Smith and Nephew, Largo, Florida, USA). Samples were taken for microbiology, histology and scanning electron microscopy pre-infection, post infection and post debridement. Air bacterial contamination was evaluated before, during and after debridement by using active and passive methods; for active sampling the SAS-Super 90 air sampler was used, for passive sampling settle plates were located at set distances around the clinic room.

Results

There was no statistically significant reduction in bacterial contamination of the porcine samples post hydrodebridement. Analysis of the passive sampling showed a significant (p < 0.001) increase in microbial counts post hydrodebridement. Levels ranging from 950 colony forming units per meter cubed (CFUs/m³) to 16780 CFUs/m³ were observed with active sampling of the air whilst using hydro surgery equipment compared with a basal count of 582 CFUs/m³. During removal of the wound dressing, a significant increase was observed relative to basal counts (p < 0.05). Microbial load of the air samples was still significantly raised 1 hour post-therapy.

Conclusion

The results suggest a significant increase in bacterial air contamination both by active sampling and passive sampling. We believe that action might be taken to mitigate fallout in the settings in which this technique is used.     

Prevalence of different types of wound infection in subjects with Parkinson's disease and total joint arthroplasty: A meta-Analysis

A meta-analysis study to assess the influence of Parkinson's disease (PD) on different types of wound infection (WI) in total joint arthroplasty (TJA) patients. A comprehensive literature examination till January 2023 was implemented and 1976 linked studies were appraised. The picked studies contained 76 661 subjects with TJA in the picked studies' baseline, 19 188 of them were PD, and 57 473 were non-PD. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of PD on different types of WI in TJA patients by the dichotomous and continuous styles and a fixed or random model. PD had a significantly higher postoperative surgical site WI (OR, 1.76; 95% CI, 1.15–2.67, P = .009), superficial WI (OR, 3.36; 95% CI, 1.41–7.99, P = .006), and periprosthetic WI (OR, 4.89; 95% CI, 2.13–11.22, P < .001) compared to the non-PD in TJA patients' post-surgery wounds. PD had a significantly higher postoperative surgical site WI, superficial WI, and periprosthetic WI compared to the non-PD in TJA patients' post-surgery wounds. Though precautions should be taken when commerce with the consequences since some of the picked studies for this meta-analysis was with low sample sizes.     

Live donor study – implications of kidney donation on cardiovascular risk with a focus on lipid parameters including lipoprotein a

In this prospective observational cohort study, we evaluate the change in cardiovascular risk parameters, with a focus on lipids, in live kidney donors 1 year post donation. Body mass index, systolic/diastolic blood pressure, kidney function (chromium‐51 ethylenediaminetetraacetic acid estimated glomerular filtration) and lipid parameters were measured at baseline and 1 year. Data on 87 live kidney donors were collected. Body mass index increased from 26.5 ± 2.7 pre to 27.4 ± 3.0 kg/m² post donation (p < 0.0001). Chromium‐51 ethylenediaminetetraacetic acid estimated glomerular filtration decreased from 111.8 ± 20.0 pre to 72.1 ± 13.1 mL/min/1.73 m² post donation (p < 0.0001). Serum triglyceride levels increased from 0.8 (interquartile range 0.6–1.3) pre to 1.0 mmol/L (interquartile range 0.7–1.6) post donation (p = 0.0004). Statin use increased from 11.5% pre to 21% post donation (p < 0.005). Low‐density lipoprotein remained stable, and other lipids (high‐density lipoprotein, apolipoprotein B and lipoprotein a) did not change post donation.     

Preoperative Nonsurgical Weight Loss Interventions Before Total Hip and Knee Arthroplasty: A Systematic Review

BackgroundAn upcoming total joint arthroplasty (TJA) may motivate patients with severe obesity (body mass index [BMI] > 40 kg/m²) to lose weight. Weight loss can optimize outcomes following TJA, and many surgeons use a 40 kg/m² cut-off for undergoing TJA to reduce the risk of complications. However, few patients who are denied TJA for severe obesity successfully lose weight. This is the first systematic review of nonsurgical weight loss interventions before TJA.MethodsFive electronic databases were searched for articles on January 11, 2021. Studies that utilized preoperative nonsurgical weight loss interventions for patients with obesity (BMI ≥ 30 kg/m²) scheduled for or awaiting TJA of the hip or knee were included. Two reviewers independently screened articles, assessed methodological quality, and extracted data.ResultsWe retrieved 1943 unique records, of which 7 met inclusion criteria including 2 randomized clinical trials and 5 single-arm case series. Overall, weight loss ranged from 5.0 to 32.5 kg. Four interventions reduced BMI by 3 kg/m² at 3-5 months, while 1 reduced BMI by 12.7 kg/m². Other weight outcomes and those related to pain, function, complications, and adverse events were inconsistently reported.ConclusionAlthough larger trials are needed, particularly randomized controlled trials that measure preoperative weight loss in a control group, nutritional status, and postoperative complications, the available evidence indicates that short-term, nonsurgical, preoperative weight loss interventions before TJA produce both statistically significant weight loss and reduced BMI before surgery. It remains unknown if the amount of weight loss from these interventions is clinically significant and sufficient to improve outcomes after TJA.     

Operating Room Traffic is a Major Concern During Total Joint Arthroplasty

Background  

Periprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty (TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, and may lead to increased rates of infection.     

Association between Decreased Kidney Function and Endotoxin Receptor CD14 C-159T Polymorphism among Japanese Health Check-up Examinees

Background. A recently identified promoter polymorphism of the endotoxin receptor (CD14 C-159T) was shown to be associated with atherosclerotic diseases such as myocardial infarction. This study was conducted to determine whether this polymorphism is associated with decreased kidney function. Methods. A total of 281 male and 522 female health check-up examinees, aged 39–88 years, were genotyped for CD14 C-159T. The glomerular filtration rate (GFR) was estimated by the Modification of Diet in Renal Disease (MDRD) Study equation. Estimated GFR (eGFR) and the proportion of subjects with mildly decreased eGFR (eGFR under 90 mL/min/1.73 m²) were compared among the genotypes. Results. Subjects carrying the T allele showed decreased age- and sex-adjusted eGFR compared with those with CC genotype (101±22 vs. 105±23 mL/min/1.73 m²; mean±SD, p?=?0.012). The proportion of subjects with mildly decreased eGFR was higher in T allele carriers (34.2% for TT+CT and 26.3% for CC genotype, p?=?0.041), but not statistically significant when adjusted for age and sex (odds ratio [OR] 1.41, 95% CI 0.97–2.05, p?=?0.076). In subjects under 65 years, T allele carriers had a significantly increased risk for mildly decreased eGFR (27.1% for TT+CT and 18.0% for CC; age- and sex-adjusted OR 1.82, 95% CI 1.06–3.12, p?=?0.030). Conclusion. CD14-159T allele was associated with decreased eGFR compared with CC genotype, and with a higher prevalence of mildly decreased eGFR in younger subjects under 65.     

Surgical Case Order Has an Effect on the Risk of Subsequent Periprosthetic Joint Infection

Background

Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) is a serious complication with multiple etiologies. Prior spine literature has shown that later cases in the day were more likely to develop surgical site infection. However, the effect of case order on PJI after TJA is unknown. This study aims to determine the influence of case order, prior infected case, and terminal cleaning on the risk for a subsequent PJI.

Total Joint Arthroplasty in the Morbidly Obese: How Body Mass Index ≥40 Influences Patient Retention,Treatment Decisions,and Treatment Outcomes

BackgroundThe United States is in an obesity epidemic. Obesity has multiple common comorbid conditions, including lower extremity arthritis. We sought to examine the course of treatment for a population with body mass index (BMI) ≥40 kg/m² and osteoarthritis (OA) of the hip or knee. We investigated decision criteria that influenced arthroplasty surgeons to recommend nonoperative management vs total joint arthroplasty (TJA). For those patients who ultimately received TJA, we compared outcomes in this population to those with BMI <40 kg/m².MethodsThis study retrospectively reviewed 158 new patients with BMI ≥40 kg/m² and moderate/severe OA of the hip or knee. Demographics, comorbidity profiles, and weight loss were compared between groups that underwent TJA and those that did not. The arthroplasty database was used to identify patients who underwent TJA during 2016-2018 (N = 1473). Comorbidities, readmissions, surgical site infections, and overall complications were compared between those with BMI ≥40 kg/m² and BMI <40 kg/m².ResultsAbout 51.3% of new patients with BMI ≥40 kg/m² and moderate/severe OA did not return for a second clinic visit. Of those who did return, 42.9% eventually underwent surgery. BMI was higher in single visit patients vs those with multiple visits (49.5 vs 46.3 kg/m², P < .001), no difference in those scheduled on an “as-needed” basis vs a specific return date (P = .18), and did not change significantly during the 2-year follow-up (P = .41). Patients who underwent TJA had a lower mean BMI at presentation than their nonoperative counterparts (44.5 vs 47.6 kg/m², P < .01) and demonstrated significant weight loss prior to surgery (44.5 vs 42.6 kg/m², P < .05). When comparing patients with BMI ≥40 kg/m² vs BMI <40 kg/m², overall complications were not higher in the BMI ≥40 kg/m² group, although surgical site infections were higher in those undergoing total hip arthroplasty with BMI ≥40 kg/m² (0.3% vs 3.1%, P < .05).ConclusionA majority of patients with BMI ≥40 kg/m² and moderate/advanced OA will be lost to orthopedic follow-up. A relatively lower BMI indicates a greater chance of retention in care, and ultimately surgery, but does not influence surgeons’ recommendations to continue orthopedic management. Patients who persist in seeking treatment, lose significant weight, and exhaust nonoperative alternatives may be suitable for TJA despite a BMI ≥40 kg/m², with an overall complication rate of 4.3%. However, only 9% of patients at 2-year follow-up achieved BMI <40 kg/m² and only 20% of surgeries were performed on patients who had achieved this proposed cutoff.     

The Fate of Morbidly Obese Patients With Joint Pain: A Retrospective Study of Patient Outcomes

BackgroundThe number of obese patients seeking a total joint arthroplasty (TJA) continues to increase. Weight loss is often recommended to treat joint pain and reduce risks associated with TJA. We sought to determine the effectiveness of an orthopedic surgeon’s recommendation to lose weight.MethodsWe identified morbidly obese (body mass index (BMI) 40-49.9 kg/m²) and super obese (BMI ≥50 kg/m²) patients with hip or knee osteoarthritis. Patients with less than 3-month follow-up were excluded. Patient characteristics (age, gender, BMI, comorbidities), disease characteristics (joint affected, radiographic osteoarthritis grading), and treatments were recorded. Clinically meaningful weight loss was defined as weight loss greater than 5%.ResultsTwo hundred thirty morbid and 50 super obese patients were identified. Super obese patients were more likely to be referred to weight management (52.0% vs 21.7%, P < .001) and were less likely to receive TJA (20.0% vs 41.7%, P = .004). Each 1 kg/m² increase in BMI decreased the odds of TJA by 10.9% (odds ratio = 0.891, 95% confidence interval: 0.833-0.953, P = .001). Forty (23.0%) of the nonoperatively treated patients achieved clinically meaningful weight loss, and 19 (17.9%) patients who underwent TJA lost weight before surgery. After surgery, the number of patients who achieved a clinically meaningful weight loss grew to 32 (30.2%).ConclusionIn morbid and super obese patients, increasing BMI reduces the likelihood that a patient will receive TJA, and when counseled by their orthopedic surgeon, few patients participate in weight-loss programs or are otherwise able to lose weight. Weight loss is an inconsistently modifiable risk factor for joint replacement surgery.