There is controversy in the literature regarding the justification of performing total knee replacement (TKR) in obese patients in view of their increased risk of poor outcomes and how those poorer outcomes impact the health care system overall.
Questions/Purposes
Is TKR justifiable in the obese patient? Can the negative impact of continuing to perform TKR in the obese be quantified?
Methods
A Cochrane Library, PubMed (MEDLINE), and Google Scholar search related to the justification of TKR in the obese patient and its impact on the health care system was analyzed. The main criteria for selection were that the articles were focused in the aforementioned questions.
Results
Two thousand one hundred seventy-three articles were found, but only 50 were selected and reviewed because they were focused on the questions of this paper. Although some articles (with low grade of evidence) did not find that obesity adversely affected the outcome of TKR, most of them found that obesity adversely affected the results of TKR. Regarding complications rates and survival rates, obesity has shown to have a negative influence on outcome after TKR. The improvements in patient-reported outcome measures, however, were similar irrespective of body mass index. Regarding the impact of TKR in obese patients, an extra cost of US$3,050 has been reported per patient. Considering that 50% of the US population is obese and that 600,000 TKRs are implanted per year, the impact for the US health system could be as much as 915 million dollars (300,000 × 3,050).
Conclusion
TKR in obese patients may be justifiable because the functional improvements appear equivalent to those of patients with a lower BMI. However, in obese patients, the risk of complications is higher and the prosthetic survival is lower. Moreover, TKR in obese patients has a huge impact on the health system which should be considered.
AminAKClaytonRAEPattonJTGastonMCookREBrenkelIJTotal knee replacement in morbidly obese patients. Results of a prospective matched studyJ Bone Joint Surg (Br)200688-B1321–610.1302/0301-620X.88B10.17697
2.
BakerPPetheramTJamesonSReedMGreggPDeehanDThe association between body mass index and the outcomes of total knee arthroplastyJ Bone Joint Surg Am2012941501–810.2106/JBJS.K.01180
3.
BakerPMuthumayandiKGerrandCKleimBBettinsonKDeehanDInfluence of body mass index (BMI) on functional improvements at 3years following total knee replacement: a retrospective cohort studyPLoS One20138e59079360251510.1371/journal.pone.0059079
4.
Bin Abd RazakHRChongHCTanAHObesity does not imply poor outcomes in Asians after total knee arthroplastyClin Orthop Relat Res20134711957–63370665010.1007/s11999-012-2721-9
5.
BordiniBSteaSCremoniniSVicecontiMDe PalmaRToniARelationship between obesity and early failure of total knee prosthesesBMC Musculoskelet Disord20091029266089610.1186/1471-2474-10-29
6.
BourneRBMcCaldenRWMacDonaldSJMoketeLGuerinJInfluence of patient factors on TKA outcomes at 5 to 11years followupClin Orthop Relat Res200746427–31
7.
Bozic KJ, Lau E, Ong K, Chan V, Kurtz S, Vail TP, Rubash HE, Berry DJ. Risk factors for early revision after primary TKA in Medicare patients. Clin Orthop Relat Res 2013; 10.
8.
ChalidisBEPetsatodisGChristodoulouAGChristoforidisJPapadopoulosPPPournarasJIs obesity a contraindication for minimal invasive total knee replacement? A prospective randomized control trialObes Surg2010201633–4110.1007/s11695-009-9968-6
9.
CollinsRAWalmsleyPJAminAKBrenkelIJClaytonRADoes obesity influence clinical outcome at nine years following total knee replacement?J Bone Joint Surg (Br)2012941351–510.1302/0301-620X.94B10.28894
10.
DeshmukhRGHayesJHPinderIMDoes body weight influence outcome after total knee arthroplasty? A 1-year analysisJ Arthroplasty200217315–910.1054/arth.2002.30776
11.
Dowsey MM, Choong PF. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009; 467: 1577-81.
12.
DowseyMMLiewDChoongPFEconomic burden of obesity in primary total knee arthroplastyArthritis Care Res2011631375–8110.1002/acr.20563
13.
ErsozluSAkkayaTOzgurAFSahinOSenturkITandoganRBilateral staged total knee arthroplasty in obese patientsArch Orthop Trauma Surg2008128143–810.1007/s00402-007-0356-1
14.
EstesCSSchmidtKJMcLemoreRSpangehlMJClarkeHDEffect of body mass index on limb alignment after total knee arthroplastyJ Arthroplasty2013288 Suppl101–510.1016/j.arth.2013.02.038
15.
ForanJRHMontMAEtienneGJonesLCHungerfordDSThe outcome of total knee arthroplasty in obese patientsJ Bone Joint Surg Am200486-A1609–15
16.
FriedmanRJHessSBerkowitzSDHomeringMComplication rates after hip or knee arthroplasty in morbidly obese patientsClin Orthop Relat Res20134713358–6610.1007/s11999-013-3049-9
17.
GillespieGNPorteousAJObesity and knee arthroplastyKnee20071481–610.1016/j.knee.2006.11.004
18.
GuanZChenYSongYInfluence of body mass index and age on deep vein thrombosis after total hip and knee arthroplasty [Article in Chinese]Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi200620611–5
19.
HamouiNKantorSVinceKCrookesPFLong-term outcome of total knee replacement: does obesity matter?Obes Surg20061635–810.1381/096089206775222140
20.
IllingworthKDMihalkoWMParviziJSculcoTMcArthurBel BitarYSalehKJHow to minimize infection and thereby maximize patient outcomes in total joint arthroplasty: a multicenter approach: AAOS exhibit selectionJ Bone Joint Surg Am2013958e5010.2106/JBJS.L.00596
21.
IssaKPivecRKapadiaBHShahTHarwinSFDelanoisREMontMADoes obesity affect the outcomes of primary total knee arthroplasty?J Knee Surg20132689–9410.1055/s-0033-1341408
22.
JacksonMPSextonSAWalterWLWalterWKZicatBAThe impact of obesity on the mid-term outcome of cementless total knee replacementJ Bone Joint Surg (Br)200991-B1044–810.1302/0301-620X.91B8.22129
23.
JärvenpääJKettunenJKrögerHMiettinenHObesity may impair the early outcome of total knee arthroplastyScand J Surg20109945–9
24.
JärvenpääJKettunenJSoininvaaraTMiettinenHKrögerHObesity has a negative impact on clinical outcome after total knee arthroplastyScand J Surg2012101198–20310.1177/145749691210100310
25.
JonesCACoxVJhangriGSSuarez-AlmazorMEDelineating the impact of obesity and its relationship on recovery after total joint arthroplastiesOsteoarthr Cartil201220511–810.1016/j.joca.2012.02.637
26.
JonesRERussellRDHuoMHWound healing in total joint replacementBone Joint J201395-B11 Suppl A144–710.1302/0301-620X.95B11.32836
27.
KerkhoffsGMServienEDunnWDahmDBramerJAHaverkampDThe influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature reviewJ Bone Joint Surg Am2012941839–44348906810.2106/JBJS.K.00820
28.
KimSHMorbid obesity and excessive hospital resource consumption for unilateral primary hip and knee arthroplastyJ Arthroplasty2010251258–6610.1016/j.arth.2009.09.005
29.
LiabaudBPatrickDAJrGellerJAHigher body mass index leads to longer operative time in total knee arthroplastyJ Arthroplasty201328563–510.1016/j.arth.2012.07.037
30.
Lizaur-UtrillaAMiralles-MuñozFASanz-ReigJCollados-MaestreICementless total knee arthroplasty in obese patients: a prospective matched study with follow-up of 5-10yearsJ Arthroplast2013
31.
McElroyMJPivecRIssaKHarwinSFMontMAThe effects of obesity and morbid obesity on outcomes in TKAJ Knee Surg20132683–8
MedingJBReddlemanKKeatingMEKlayARitterMAFarisPMBerendMETotal knee replacement in patients with diabetes mellitusClin Orthop Relat Res2003416208–1610.1097/01.blo.0000093002.90435.56
34.
MarcacciMIaconoFZaffagniniSVisaniALoretiIPetittoANeriMPKonETotal knee arthroplasty without patellar resurfacing in active and overweight patientsKnee Surg Sports Traumatol Arthrosc19975258–6110.1007/s001670050060
35.
MoonHKHanCDYangIHChaBSFactors affecting outcome after total knee arthroplasty in patients with diabetes mellitusYonsei Med J200849129–37261525810.3349/ymj.2008.49.1.129
36.
MulhallKJGhomrawiHMMihalkoWCuiQSalehKJAdverse effects of increased body mass index and weight on survivorship of total knee arthroplasty and subsequent outcomes of revision TKAJ Knee Surg200720199–204
37.
NambaRSPaxtonLFithianDCStoneMLObesity and perioperative morbidity in total hip and total knee arthroplasty patientsJ Arthroplasty2005207 Suppl 346–5010.1016/j.arth.2005.04.023
38.
NúñezMLozanoLNúñezESastreSLuis Del ValJSusoSGood quality of life in severely obese total knee replacement patients: a case-control studyObes Surg2011211203–810.1007/s11695-010-0197-9
39.
OdumSMSpringerBDDennosACFehringTKNational obesity trends in total knee arthroplastyJ Arthroplasty2013288 Suppl148–5110.1016/j.arth.2013.02.036
40.
PatelADAlbrizioMRelationship of body mass index to early complications in knee replacement surgeryArch Orthop Trauma Surg20081285–910.1007/s00402-007-0364-1
41.
PruzanskyJSBronsonMJGrelsamerRPStraussEMouchaCSPrevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospitalJ Arthroplast2013
42.
RajgopalVBourneRBChesworthBMMacDonaldSJMcCaldenRWRorabeckCHThe impact of morbid obesity on patient outcomes after total knee arthroplastyJ Arthroplasty200823795–80010.1016/j.arth.2007.08.005
43.
SamsonAJMercerGECampbellDGTotal knee replacement in the morbidly obese: a literature reviewANZ J Surg201080595–910.1111/j.1445-2197.2010.05396.x
44.
SchwarzkopfRThompsonSLAdwarSJLiublinskaVSloverJDPostoperative complication rates in the “super-obese” hip and knee arthroplasty populationJ Arthroplasty201227397–40110.1016/j.arth.2011.04.017
45.
SinghJAGabrielSELewallenDGHigher body mass index is not associated with worse pain outcomes after primary or revision total knee arthroplastyJ Arthroplasty201126366–74293093310.1016/j.arth.2010.02.006
46.
SpicerDDPomeroyDLBadenhausenWESchaperLAJrCurryJISuthersKESmithMWBody mass index as a predictor of outcome in total knee replacementInt Orthop200125246–9362083510.1007/s002640100255
47.
Stevens-LapsleyJEPettersonSCMiznerRLSnyder-MacklerLImpact of body mass index on functional performance after total knee arthroplastyJ Arthroplasty2010251104–9289141010.1016/j.arth.2009.08.009
48.
SuleimanLIOrtegaGOng'utiSKGonzalezDOTranDDOnyikeATurnerPLFullumTMDoes BMI affect perioperative complications following total knee and hip arthroplasty?J Surg Res20121747–1110.1016/j.jss.2011.05.057
49.
YasunagaHTsuchiyaKMatsuyamaYOheKAnalysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: nationwide web-based surveyJ Orthop Sci20091410–610.1007/s00776-008-1294-7
50.
YeungEJacksonMSextonSWalterWZicatBWalterWThe effect of obesity on the outcome of hip and knee arthroplastyInt Orthop201135929–34310395210.1007/s00264-010-1051-3
