Joint Replacement and Obesity: A Surgeon’s Dilemma

Joint replacement surgery is common–even very common in the U.S., with more than 700,000 major joint replacements performed annually.  It’s also very expensive, with total costs exceeding $10 billion.  It’s highly successful in most patients and dramatically improves their quality of life.  However, complications can be disastrous and very costly.

Recently, a study was published in the journal Clinical Orthopaedics and Related Research identified the medical conditions that predispose patients to complications after joint replacement surgery.  For a single disease process, these researchers found that patients with obesity had the highest risk for post-surgical complications with the incidence of complications increasing by more than 40%.  Furthermore, the percentage of patients requiring admission to a rehabilitation center after surgery increased 45% when a patient was obese.

As a result of this study and other studies like it, “Some surgeons are now refusing to operate unless an obese patient first loses a significant amount of weight,” according to an article in the Wall Street Journal (February 28, 2006).  Another article from The Boston Globe, July 18, 2006, quoted Dr. Richard Scott, chief of joint-replacement services at Brigham and Women’s Hospital, as telling high-risk, obese patients “If you lose so much weight . . . then I will fill my end of the bargain, and we’ll go ahead with your surgery. If you don’t do it, you’re telling me you’re not motivated.”  The problem here, of course, is that many obese people simply can’t lose the weight.

This dilemma is obvious since obesity itself is rapidly becoming the main cause of chronic joint disease.  One study from Canada found that 90% of patients undergoing knee replacements and 70% who had hip replacements in 2004 were overweight.  Clearly, obesity is a substantial additional risk for patients undergoing joint replacement and significant weight loss in an obese patient will lower the risk of complications.  For severely obese patients, delaying joint replacement for 6-to-12 months in order to permit them to undergo bariatric surgery and lose their excess body weight may be the difference between a rapid, uncomplicated recovery and a disastrous outcome.  Coordination between orthopedic surgeons and bariatric surgeons in the management of severely obese patients may be the best answer.

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