Any conversation about obesity brings up some painful emotions. As medical professionals, it is our duty – our sworn obligation – to help you heal as well as possible. Unfortunately, for many of our patients, creating the ideal physical environment for optimum healing requires losing weight before surgery.
When we advise patients to lose weight before embarking on a treatment plan, it is not to make you feel ashamed of your body. Quite the opposite, in fact! We want you to have the best chance of an excellent outcome. We want you to heal quickly and recover more completely than you would while carrying excess weight.
If you are carrying some extra weight, i’m sure that you have heard all the usual lines about how obesity is an epidemic, how it’s costing us countless billions of dollars per year in lost productivity and medical bills…. We’re not here to nag you. Which is why we have compiled a fluff-free list that gets down to brass tacks:
How Does Obesity Affect Orthopedic Surgery?
Obese patients have a much higher risk of arthritis of the hip and knee, as well as a much higher risk of lifetime disability due to back pain and arthritis and spinal stenosis. Younger obese patients have a higher risk of deformities of the hip and knee.
When Does Obesity Become a Surgery Risk?
Even though obese surgical patients can have good results from orthopedic surgery, they have a much higher risk of complications in the operating room and after surgery including:
In the operating room:
- Increased blood loss
- Increased length of surgery
- Increased technical difficulty performing surgery
- Higher risk of anesthetic complications during surgery
- Increased costs
After surgery:
- Increased risk of wound infections and wound non-healing
- Hip or knee implant complications such as pain, loosening and infection
- Spine implant breakage and non-unions of fusion due to increased loads
- Postoperative pneumonia
- Blood clots and pulmonary embolism
- Heart attacks, strokes
- Peripheral swelling
- Lengthy recovery periods and poorer progress in rehabilitation
- Increased need for personal assistance after surgery
In spine surgery:
Morbid obesity was associated with 97% higher in-hospital complication rates (13.6% vs. 6.9%), sustained across nearly all complication types (cardiac, renal, pulmonary, wound complications, among others). Mortality among the morbidly obese was slightly higher, as were average hospital costs and length of stay.
Morbid obesity is the most significant predictor of complications. Both obese and non-obese patients had improvement in preoperative symptoms, but the obese patients improved less than half compared to the non-obese patients.
In total knee replacements, infection occurred more often in obese patients, with an increase of 90%. Deep infection requiring surgical debridement was reported with an increase of 200%. Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, occurred more often in obese patients, with an increase of 130% compared to non-obese patients.
52% of total knee replacement and 36% of total hip replacement patients were obese (body mass index ≥30). The obese patients were significantly younger, with a higher proportion of obese total knee replacement patients being women. Higher rates of diabetes and hypertension were found in obese patients. Higher postoperative infection rates were observed in patients with BMI 35 or higher.
The risk was 6.7 times higher risk for infection in obese total knee replacement patients, and 4.2 times higher for obese hip arthroscopy patients. The increased risk of infection in obese patients undergoing total joint arthroplasty must be realized by both the patient and surgeon.
What about the expectation that patients will lose their excess weight after a joint replacement surgery?
An analysis of 3,893 total hip arthroplasties and 3036 total knee arthroplasties demonstrated that 73% of patients who had undergone total hip arthroplasty and 69% of patients who had undergone total knee arthroplasty had no weight change two years after total joint arthroplasty. However, further analysis demonstrated 14% of patients had lost weight, 65% of patients had remained the same weight, and 21% of patients had gained weight by one year after surgery for joint replacement. After total hip arthroplasty, weight loss was associated with improved clinical outcomes and weight gain was associated with inferior clinical outcomes.
So, what can I do to safely lose weight before a surgery – and keep it off?
It is rare to find an overweight person who truly does not know what they ‘should’ and ‘should not’ eat and do. Most people know that portion control, eating a balanced diet and regular exercise are the keys to a long, healthy life. Obesity is generally a chronic condition, however, and like most chronic conditions, requires the help and guidance of trained professionals. Nutritionists, physical therapists, counselors and exercise specialists can help you get started, and provide you with the support system needed to get the best outcome from your surgery – and indeed life in general.
There is so much health related science to support the link between obesity and health problems and obesity and poor surgical outcomes. When your surgeon tells you that you need to lose weight before surgery, your surgeon is not fat-shaming you, but fat-facting you. Your surgeon is trying to protect you by weighing risk appropriately, and improve your chances of a good outcome. Listen to your doctor’s suggestions – they will help you improve your health and may save your life.